F0755

D

Failure to Ensure Availability of Prescribed Pain Medication

Cupertino, California Survey Completed on 02-23-2026

Penalty

No penalty information released

Summary

The facility failed to provide pharmaceutical services to meet the needs of a resident when prescribed diclofenac sodium was not available for administration for two scheduled doses. The resident had multiple arthritis-related diagnoses, including ankylosing spondylitis of the spine, rheumatoid arthritis, osteoarthritis, other chronic pain, and arthropathy, and was cognitively intact with a BIMS score of 15. The resident had an active order for diclofenac sodium 25 mg, three tablets by mouth twice daily for rheumatoid arthritis. The MAR for the relevant period showed code 9 entries for the scheduled diclofenac doses, indicating "Other/See Progress Notes" for one evening and one morning administration time.

Nursing progress notes documented that during medication pass on one evening, the resident’s prescribed diclofenac was unavailable, and that the medication remained unavailable the following morning. In an interview, the resident confirmed missing two doses of diclofenac sodium and stated he badly needed the medication for rheumatoid arthritis, adding that nurses did not give the medication and blamed the pharmacy. An LVN confirmed not administering the morning dose because the medication was not available and stated that nurses should order medications several days before they are consumed and that the pharmacy should deliver within 24 to 48 hours. The DON stated nurses should order medications three days prior to running out and confirmed the resident missed two doses because the medication was not available, further stating that diclofenac had been ordered from the pharmacy on two prior dates and was not delivered on time. The facility’s medication administration policy required medications to be administered as prescribed to ensure compliance with dose guidelines.