Failure to Ensure Availability and Administration of Ordered Pain Medication
Penalty
Summary
Surveyors identified a failure to ensure ordered pain medications were available and administered as prescribed for Resident #58. The resident was admitted on 09/01/24 with diagnoses including rheumatoid arthritis, failure to thrive, depression, and post cholecystectomy syndrome. A quarterly MDS dated 01/07/26 documented intact cognition, dependence on staff for toileting and transfers, and the presence of pain managed with scheduled and PRN pain medications. Physician orders for January 2026 included Oxycodone 15 mg every four hours and Acetaminophen 500 mg every six hours as needed. Review of the January 2026 MAR showed that on 01/20/26, multiple scheduled Oxycodone doses at 6:00 A.M., 10:00 A.M., 2:00 P.M., and 6:00 P.M. were marked as not administered with directions to see progress notes. Progress notes on 01/20/26 at 10:07 A.M., 1:13 P.M., and 5:42 P.M. documented that Oxycodone doses were not given because the facility was waiting for the pharmacy to deliver the medication. Further review of the MAR revealed additional missed Oxycodone doses on 01/25/26 at 10:00 P.M. and on 01/26/26 at 2:00 A.M., 6:00 A.M., and 2:00 P.M., which were left blank with no explanatory documentation. In an interview on 01/29/26 at 5:00 P.M., the DON confirmed that Oxycodone was not administered on 01/20/26, 01/25/26, and 01/26/26 due to delays in pharmacy delivery and acknowledged there were no notes explaining the missed doses on 01/25/26 and 01/26/26. Facility policy on administering medications, revised December 2012, required medications to be administered safely, timely, and in accordance with prescribed orders, including required time frames. This deficiency was cited under Complaint Number 2711748.
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