F0755

D

Failure to Ensure Timely Availability and Administration of Controlled Medications

Saint Petersburg, Florida Survey Completed on 01-08-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely provision of ordered controlled substances and other scheduled medications for three residents, despite clear evidence of ongoing pain and anxiety and existing physician orders. One resident with a displaced bimalleolar fracture of the right lower leg, cognitively intact with a BIMS score of 15, reported pain at 9/10 and stated she had not received her prescribed pain medication during the night or that morning. Her MAR for oxycodone-acetaminophen 10-325 mg every 6 hours showed multiple missed doses on several days, coded as “other/see nurse notes,” while concurrent pain monitoring entries documented pain scores of 8 on multiple shifts. Progress notes documented that a new prescription was needed, that the medication was on order or not on site, and that the provider was aware, but the resident continued to experience pain without receiving the ordered narcotic until a new order for a different strength was written later in the day.

Another resident with an acquired tracheostomy, dysphagia, and other neurologic sequelae, cognitively intact with a BIMS score of 13, communicated pain in her left arm and back by writing and nodding. She indicated concern about a lapse in her pain medication and activated her call light. The assigned LPN stated that pain medication had been given “not too long ago” and that the resident was not due again until 1:00 p.m. However, the MAR for oxycodone-acetaminophen 10-325 mg every 4 hours showed that on one date, four consecutive scheduled doses (1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m.) were not administered and were coded as “other/see nurse notes.” When nurses’ progress notes for the relevant period were requested, none were available for this resident, despite the missed doses and the resident’s care plan directing staff to administer pain medication and observe for effectiveness.

A third resident with epilepsy, type 2 diabetes, anxiety disorder, and major depressive disorder, also cognitively intact with a BIMS score of 15, had an order for clonazepam 0.5 mg four times daily for anxiety. During a medication pass, the assigned LPN reported that she was able to administer the clonazepam that day but had been unable to do so the previous day because there was no medication available, requiring a call to the pharmacy for a refill. The MAR documented that all four scheduled clonazepam doses on that date were not administered and were coded as “hold/see nurse notes,” while progress notes repeatedly stated that the facility was “waiting on pharmacy to deliver” and “awaiting from pharmacy,” including after pharmacy notification that delivery would occur on the next run. Interviews with the consultant pharmacist, pharmacy representatives, and the DON confirmed that narcotic and controlled substance prescriptions required valid orders and timely refill requests, that emergency supplies could be accessed under certain conditions, and that low-count warnings existed on medication cards, but these mechanisms were not effectively used to prevent lapses in medication availability and administration for the affected residents.

For the resident with the right leg fracture, pharmacy staff reported that on one date the physician telephoned in an order for a three-day supply of oxycodone-acetaminophen 10-325 mg, explaining that a telephone order could only be filled for three days, and that there were no current orders visible after that supply. A pharmacy representative later confirmed that another three-day supply was called in and that an electronic order for a month’s supply had been received but only a three-day supply would be sent until the order was clarified. For the resident with the tracheostomy, a customer service technician stated that a prescription from a pain management provider was dated in mid-December but was not faxed from the facility until the first of the following month and could not explain why the resident missed medications on that date despite having a prescription. The DON described the facility’s process for nurses to request narcotic refills and contact physicians when no refills remained, and acknowledged unawareness of a red warning column on blister packs intended to alert nurses to refill needs, while the facility’s written policy outlined requirements for valid controlled substance prescriptions, emergency verbal authorizations, and use of the emergency supply kit, which were not effectively implemented to ensure uninterrupted access to ordered controlled medications for these residents.