F0760

G

Multiple Missed Gabapentin Doses for Neuropathic Pain

Lenoir, North Carolina Survey Completed on 02-05-2026

Penalty

Fine: $54,560

Summary

The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when multiple scheduled doses of Gabapentin, prescribed for diabetic polyneuropathy, were not administered over a four-day period. The resident had diabetes mellitus with diabetic polyneuropathy and an order for Gabapentin 800 mg by mouth three times daily. The admission MDS documented that the resident was cognitively intact and experienced frequent pain that interfered with activities, with a pain intensity of 6/10 during the assessment period. In January, the MAR showed Gabapentin 800 mg TID for diabetes mellitus, with eight doses marked as not administered on specific dates and times by various staff, including medication aides and nurses.

On the first missed day, a medication aide reported that the Gabapentin was not in the medication cart and stated she reordered it in the electronic charting system but did not recall whom she informed about the missed dose. On subsequent evening shifts, a nurse documented additional missed doses, stating the medication was not in the cart and that the automated medication dispensing machine did not have enough Gabapentin to cover the prescribed dosage. She did not reorder the medication from the pharmacy, explaining that day-shift staff typically handled reorders, and she did not recall the resident reporting severe pain or leg twitching during her shifts. Another nurse documented a missed morning dose when the medication was again not in the cart and reported trying to piece together doses from the dispensing machine; she stated the resident later refused a noon dose, so she did not attempt to obtain it from the machine. She also stated the facility was having issues with the pharmacy obtaining medications, that she was unaware the resident had missed several doses, and that she had not personally contacted the pharmacy about the medication status.

A medication aide observed preparing the resident’s noon medications stated that the Gabapentin had been missing from the cart for at least three days, that she reordered it that day, and that she informed the nurse on duty. She confirmed the resident missed his morning and noon doses that day because the medication was unavailable and noted that the resident was alert and aware he was not receiving it. The MAR showed the resident was also receiving scheduled and PRN Oxycodone-Acetaminophen, with documented pain ratings ranging from 0 to 9 on a 0–10 scale during the same period. When interviewed, the resident reported not receiving Gabapentin for about a week, stated he took it for neuropathic pain, and described his leg pain as extremely bad, rating it 10/10 day and night, with twitching that kept him awake for at least three nights. He stated he had never refused his medication, had asked staff about it, and was told they would check on it but they did not return with information.

The unit manager stated no staff had informed her that the resident was missing medication and that she could have pulled medication from the dispensing machine or contacted the Nurse Practitioner or Medical Director and followed up with the pharmacy if she had been notified. The pharmacist reported that a 30-day supply of 90 Gabapentin tablets had been sent earlier in the month, sufficient through the following month, and that a refill request on one of the dates in question was too early for insurance but could have been filled and billed to the facility if staff had called; he stated no one from the facility contacted the pharmacy about the medication status. The regional pharmacy consultant stated that missing several doses of Gabapentin for diabetic nerve pain would result in recurrence of pain and that the drug’s sedating and calming effects meant mood, behavior, and sleep could be disrupted without it. The Nurse Practitioner and Medical Director both stated they were unaware of the missed doses and indicated that missing Gabapentin would affect the resident’s pain level, with the Nurse Practitioner noting that the missed doses would be significant for pain control and that Gabapentin and Oxycodone act on different nerve receptors.