Failure to Ensure Continuous Availability of Ordered Narcotic Pain Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of drugs for one resident. The resident had rheumatoid arthritis and a history of spinal compression fractures, required maximum assistance for activities of daily living, and had intact cognition. A physician’s order dated 10/01/2025 directed that a narcotic pain medication be administered every six hours for rheumatoid arthritis. Review of the January 2026 MAR showed multiple missed doses of this narcotic pain medication on 01/27/2026 and 01/28/2026, as well as the midnight dose on 01/29/2026. During observation and interview, the resident reported that the facility did not have their narcotic pain medication available, resulting in six missed doses, and described pain throughout their body, including hands, back, feet, and elbows. The resident stated staff told them the medication had run out and the pharmacy would not refill it until a new prescription was written, and that there was no backup supply available from the emergency supply. Staff interviews confirmed that the facility’s processes for refilling and administering medications were not followed. An LPN explained that the standard process was to request refills when the medication card reached the blue section, indicating seven doses remaining, and that if a medication ran out before the refill arrived, a dose could be obtained from the emergency backup supply using a pharmacy authorization code. For this resident, the LPN stated there was a problem receiving the narcotic from the pharmacy, and although the provider was contacted and a new prescription sent, staff were unable to obtain an authorization code from the pharmacy due to confusion with the order, resulting in the resident going without the narcotic pain medication until the pharmacy resolved the issue. The DON stated that narcotic refills were to be requested at least seven days before the resident ran out and acknowledged that the process for refilling and administering medications was not followed. The Administrator stated that licensed nurses were responsible for communicating with the provider and pharmacy to ensure residents had needed medications and to request refills before medications were depleted.
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