Repeated Medication Unavailability and Delayed Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely ordering, receipt, and administration of prescribed medications, including controlled substances for pain management, for multiple residents. One resident was admitted after a left total knee replacement with hospital discharge orders for several pain medications, including hydrocodone, hydromorphone (Dilaudid), morphine, and tizanidine, for chronic pain, morbid obesity, and osteoarthritis status post total knee arthroplasty. Hospital documentation indicated that controlled substance prescriptions were sent with the discharge packet and that the next morphine dose was due at 9:00 PM, with the last Dilaudid dose given at 4:00 PM prior to transfer. Nursing documentation showed that by 1:10 AM the following day, the resident’s prescribed pain medications had not been delivered by the pharmacy and were not available in the emergency supply. The LPN caring for the resident reported that the resident complained of severe left knee pain multiple times between 11:00 PM and 1:00 AM and confirmed the resident had not received any pain medication since admission. The LPN stated the pharmacy informed her they had not received the faxed controlled substance prescriptions, and she did not fax them until approximately 1:00 AM, after discovering they had only been sent with the admission packet, contrary to the facility’s admission checklist requiring orders to be faxed within two hours of arrival. Additional deficiencies were identified for another resident whose MAR documented multiple missed doses of medications due to unavailability from the pharmacy. These included missed doses of Wellbutrin XL for depression and morbid obesity, oxcarbazepine for multiple sclerosis, and estradiol cream for postmenopausal atrophic vaginitis on various dates. Each missed dose was documented as “unavailable” or “medication not available,” with corresponding administration notes confirming the lack of medication. This resident reported having a “big problem” with medications and stated that the facility was “always out of something,” indicating repeated interruptions in medication availability. A third resident, cognitively intact and documented as experiencing occasional moderate pain that frequently interfered with activities and sleep, also had missed doses of medications due to pharmacy unavailability. The MAR and administration notes showed that labetalol for atherosclerotic heart disease and duloxetine for depression were not administered because they were out of stock or there was “no medication.” The Assistant DON acknowledged that medications were not always ordered in advance as required and that delays from both nursing and pharmacy had resulted in missed doses. The pharmacist stated the pharmacy expects three to five days’ notice before medications run out, typically fills prescriptions within two days, and can provide same-day delivery for urgent needs. The DON confirmed that two residents’ medications were out of stock and acknowledged ongoing issues with timely medication delivery and ordering practices, despite facility policies requiring an effective medication distribution system and timely faxing of new admission orders to the pharmacy.
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