Failure to Provide Ordered Fentanyl Patch for Pain Management
Penalty
Summary
The facility failed to ensure that a scheduled opioid pain medication was available and administered as ordered for a resident with significant pain-related conditions. The resident, who was cognitively intact, had diagnoses including diabetes mellitus, repeated falls, unspecified protein calorie malnutrition, and a stage 3 pressure ulcer, and had a pain care plan indicating use of pain medication for cancer of the left breast, chronic pain syndrome, and arthritis, with interventions to administer analgesics as ordered. A physician’s order directed that a fentanyl 50 mcg/hr transdermal patch be applied every 72 hours for pain, but the Medication Administration Records for November and December showed that the fentanyl patch was not administered on multiple scheduled dates, with Order Administration notes documenting that the medication was unavailable, a prescription refill was needed, or there was no script, despite indications that a new prescription had been obtained but not received by the pharmacy. During interview, the DON stated that the Nurse Practitioner should have been notified and a prescription obtained, and acknowledged that although a new prescription was received, the pharmacy did not receive it, resulting in missed doses of the ordered fentanyl patch.
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