Failure to Timely Obtain and Administer Ordered Pregabalin for Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely acquisition and administration of a prescribed controlled medication for pain. A resident with an original admission date of 12/24/25 and a readmission date of 01/22/26 had multiple chronic conditions, including fibromyalgia, rheumatoid arthritis, multiple sclerosis, COPD, and osteoporosis. The admission MDS showed moderately impaired cognition (BIMS score 12), frequent pain with interference in sleep and daily activities, and a reported pain level of 7/10. The physician’s order, reflected on the Order Summary Report dated 01/23/26, prescribed Pregabalin (Lyrica) 50 mg orally three times daily for pain. Review of the January 2026 MAR showed that Pregabalin doses scheduled for 7:00 a.m., 1:00 p.m., and 7:00 p.m. on 01/21/26, 01/22/26, and 01/23/26 were not administered, with code 8 entered directing staff to see progress notes. Nursing progress notes on 01/22/26 and 01/23/26, documented by LVNs and a medication aide, repeatedly stated that the Pregabalin was “med not available” or “pending.” A note on 01/24/26 at 7:43 a.m. again documented that the Pregabalin was not available from the pharmacy. Despite these repeated notations of unavailability over several days, the medication was not obtained and administered as ordered. Interviews and record reviews identified that the failure to obtain the medication was related to breakdowns in the ordering process for controlled substances. The medical director, who was the attending physician, stated he was not notified that the resident had not received Pregabalin for several days and noted that a designated agent at the facility could order controlled substances once a physician order was received. Pharmacy customer service staff reported that the Pregabalin order had not been faxed to the pharmacy and that narcotics are not dispensed without physician confirmation, which they obtain after receiving a faxed order from nursing that includes the physician’s contact information. The DON and ADON confirmed that licensed staff were responsible for faxing controlled substance orders to the vendor pharmacy so the pharmacy could obtain authorization and dispense the medication, and the MAR confirmed that Pregabalin was not administered as ordered on 01/21/26, 01/22/26, 01/23/26, and 01/24/26.
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