Failure to Provide Ordered Pain Medication Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that ordered pain medication, specifically methadone, was available for administration to a resident with chronic pain syndrome and opioid dependence. The resident missed multiple doses of methadone over several days due to issues with pharmacy dispensing, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. Documentation showed that the resident missed a total of nine doses over three days, resulting in increased pain and withdrawal symptoms, which led the resident to call 911 and be transferred to the emergency room for treatment. Medical record review and staff interviews revealed that the resident had a history of chronic pain, recent surgeries, and opioid dependence, and was prescribed methadone three times daily. Despite this, there were repeated instances where the medication was not available due to the pharmacy's inability to fill prescriptions with an opioid dependence diagnosis, insurance issues, and delays in obtaining updated prescriptions from the provider. Staff interviews indicated inconsistent practices in reordering medications, lack of timely follow-up with the pharmacy or provider, and inadequate documentation regarding missed doses and communication with the provider. The facility's own policy required that pain medications be administered as ordered and that staff monitor for withdrawal symptoms and communicate with the provider if pain or side effects were not controlled. However, the resident experienced actual harm, including increased pain and withdrawal symptoms, due to the facility's failure to ensure the availability of methadone. The deficiency affected at least one resident and was substantiated by medical records, staff and resident interviews, and pharmacy documentation.