Failure to Administer Scheduled Pain Medication Due to Medication Unavailability
Penalty
Summary
The facility failed to administer scheduled medications as ordered for one resident who was admitted with diagnoses of radiculopathy and cervical spinal stenosis. Upon admission, an order was entered for the resident to receive Lyrica 25 mg, two capsules by mouth twice daily for pain management. However, the medication was not administered as scheduled for at least two days following admission, as documented in the Medication Administration Record (MAR) and confirmed by nurse notes indicating the medication was unavailable or pending from the pharmacy. Multiple staff members, including medication aides and nurses, documented the unavailability of the medication and reported attempts to notify the pharmacy and the charge nurse. The resident reported increased pain due to not receiving the prescribed medication and communicated this to a family member. The family member also inquired about the missed doses and was informed by staff that the facility had not received the order from the transferring facility on the day of admission. Documentation and interviews revealed that the pharmacy was contacted, but there were delays in response and delivery, and the resident did not receive the medication for several scheduled doses. Further review showed that the facility did not have a written policy outlining the process for acquiring medications when not immediately available. The Director of Nursing was not notified of the missed doses and stated that she would have intervened had she been aware. The facility's policy required nurses to reorder and ensure an adequate supply of medications, but this process was not effectively followed, resulting in the resident missing multiple doses of a routine pain medication.