Failure to Timely Reorder and Administer Physician-Ordered Medication
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident with diagnoses including spinal stenosis and pain. The resident had physician orders for tizanidine HCl 2 mg tablets to be administered three times daily and as needed for muscle spasms, as well as oxycodone for pain. Documentation showed that the resident's tizanidine was not administered as ordered because the medication was not available; progress notes indicated the facility was out of the medication, and the pharmacy was not contacted for a refill until after the resident had already missed doses. The Medication Administration Record (MAR) and staff interviews confirmed that the resident experienced increased pain and breakthrough pain due to the unavailability of the muscle relaxant. Staff interviews revealed that nurses, including agency staff, were responsible for reordering medications but did not consistently do so in a timely manner. There was a lack of clarity among staff regarding who was responsible for monitoring medication reorders, and ongoing issues were reported with timely ordering of non-narcotic medications. The pharmacist confirmed that the facility did not request a refill for the resident's tizanidine until after the medication had run out. The resident reported increased pain and distress during the period when the medication was unavailable.