Failure to Provide Ordered Pain Medication Due to Communication and Refill Delays
Penalty
Summary
A resident admitted with right hip pain and a fractured thigh bone was prescribed hydrocodone-acetaminophen for pain management, to be administered every eight hours as needed for up to five days. Despite these orders, there were multiple documented instances where the resident did not receive the prescribed narcotic pain medication due to it being not available (NA) on the medication administration record (MAR). Specifically, doses were missed on several occasions, and staff notes indicated that the resident experienced severe pain during this period without access to the ordered medication. The deficiency was further compounded by communication issues between facility staff, the provider, and the pharmacy. Staff reported delays in reordering the medication and acknowledged that not all nurses had access to the provider communication system, making it the responsibility of Unit Managers to follow up on medication orders. The Director of Nursing confirmed that a refill for the narcotic medication was not sent to the pharmacy as required, and staff were expected to escalate such issues to management for resolution. These lapses resulted in the resident being without necessary pain medication for an extended period.