Failure to Provide Timely Pain Medication Due to Inadequate Pharmacy Coordination
Penalty
Summary
Nursing staff failed to provide a resident with routine and emergency pharmaceutical services as required by physician orders. Specifically, the staff did not ensure timely administration of Lyrica, a pain medication, from 10/10/25 to 10/15/25. The medication was not administered for five consecutive days, and documentation showed either missing initials or notes indicating the medication was pending delivery. During this period, the resident received PRN pain medications, but not the scheduled Lyrica as ordered. The resident had a history of unspecified cirrhosis of the liver and type 2 diabetes, with frequent pain episodes documented in his care plan and MDS assessment. The care plan required staff to administer medications as ordered and notify the physician as needed. Despite these directives, nursing staff did not contact the pharmacy promptly to inquire about the delayed delivery of Lyrica, nor did they consult the resident's primary care provider (PCP) to obtain a one-time order for the medication from the facility's Pyxis system, even though the medication was available in-house. Interviews with facility leadership, including the ADON and DON, confirmed that staff did not follow established policies for medication reordering and notification of changes in treatment. Both leaders stated that staff should have reordered medications in advance, followed up with the pharmacy within 24 hours of a missed delivery, and notified the PCP to ensure continuity of care. The nurse responsible for the resident's care acknowledged not considering obtaining the medication from the Pyxis or contacting the PCP, resulting in the resident not receiving prescribed pain management for several days.