Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A resident with chronic pain, obesity, depression, and severe osteoarthritis of the left hip was admitted to the facility and required physician-ordered pain management, including Norco (hydrocodone-acetaminophen). Despite having clear physician orders for Norco, the resident did not receive the medication for 11 consecutive days. During this period, the resident reported severe, uncontrolled pain, rating it as 10 out of 10, and stated that alternative pain medications such as Tylenol and Ibuprofen were not effective. The resident indicated that staff were aware of the missing Norco and repeatedly informed him that the pharmacy had not shipped the medication yet. Review of the resident's medical records and medication administration records confirmed that Norco was not administered from the start date of the order through the period in question. Progress notes documented ongoing issues with obtaining the medication, including references to awaiting supply, missing scripts, and delays attributed to the Thanksgiving holiday. Staff interviews revealed that delays in receiving medications from the pharmacy were not uncommon, and several nurses believed that facility management was aware of the issue. However, both the DON and NHA stated they were not aware of the resident missing Norco until the ombudsman intervened. Further interviews with facility leadership and the prescribing physician highlighted communication breakdowns and procedural lapses. The DON reported that the pharmacy did not receive the necessary script and that there was difficulty getting the physician to provide it due to the holiday. The physician acknowledged he could have sent the script electronically but did not recall the specifics of the situation. The facility's policy required providing care and services according to established guidelines, but the resident's pain management needs were not met due to these failures in medication procurement and communication.