Failure to Prevent Significant Medication Error in Pain Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to scheduled pain management. A cognitively intact resident with chronic pain, including right knee and back pain, had a long-standing order for oxycodone 10 mg at bedtime for chronic pain, with no PRN pain medications. The resident reported that her pain was very bad without the scheduled dose and that she relied on one pain pill at bedtime. In January, the resident stated that the facility did not have her pain medication in the building, the pharmacy would not send it, and staff were obtaining doses from a backup supply box. She reported that on one night she did not receive her pain medication at all, her pain escalated to 10/10, was unbearable, and she did not get much sleep. Record review showed the last tablet from the resident’s primary oxycodone supply was given on 1/6, and backup oxycodone 10 mg tablets were pulled on 1/7, twice on 1/9, and on 1/10 and 1/12, with no backup tablet pulled on 1/8 or 1/11. The January MAR documented the 10 mg oxycodone as held on 1/8 with a note that a new prescription was needed and that the physician was aware. The LPN who made this entry later stated she likely held the dose because it was not available, then gave it late from the backup supply but failed to document the late administration or correct the original “held” entry. The DON confirmed that the last regular tablet was given on 1/6, that backup doses were used on specific subsequent days, and that there was no clear source for the dose documented as given on 1/11, concluding it appeared the resident did not receive a dose that night despite documentation indicating otherwise. Pharmacy records showed a new supply of oxycodone was not delivered until later in the month, supporting that there was at least one missed scheduled dose of oxycodone associated with the resident’s reported severe pain and sleep difficulty.
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