F0755

D

Failure to Timely Obtain and Provide Ordered Controlled Pain Medication

Mount Vernon, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to obtain and provide ordered controlled pain medication (oxycodone) in a timely manner for a newly admitted resident with multiple fractures and end stage renal disease. The resident was admitted on 02/14/26 with diagnoses including a right femoral neck fracture, displaced trimalleolar and bimalleolar fractures of the right lower leg, cellulitis of the right lower limb, and end stage renal disease. The resident’s MDS and admission/re-admission observation documented that she was cognitively intact, dependent for most mobility and transfer tasks, and experiencing significant pain, with an admission pain score of 8/10 in the right leg. The admission assessment and pain care planning documentation identified oxycodone and acetaminophen as treatments, with PRN oxycodone noted as a coping measure for pain and interventions directing staff to administer analgesia per orders, anticipate pain needs, and respond immediately to complaints of pain.

Despite this documentation, the facility did not have the resident’s oxycodone available for several days after admission. Progress notes from 02/16/26 show that nursing staff called the pharmacy three times that day to check on the oxycodone prescription and also contacted the physician provider company multiple times, with a note that the request was sent to a nurse practitioner at 3:35 PM and that the pharmacy cutoff was 6:00 PM. Interviews revealed conflicting and incomplete actions: the DON stated the new pharmacy was problematic, that oxycodone was not in the emergency medication bank kit, and that the resident arrived after the pharmacy cutoff, but also acknowledged she did not know why staff did not call her and admitted they “dropped the ball” on obtaining the medication. The ADON reported attempts to contact the pharmacy and believed the resident’s allergy to hydrocodone limited use of other narcotics, while also stating she told a nurse to request an emergency run and was under the impression oxycodone was not in the emergency kit.

Additional interviews and pharmacy records further demonstrated that the facility did not timely secure the controlled medication. The administrator and vice president of operations stated that staff could have contacted on-call providers for a prescription and used the emergency medication bank or an emergency run, but this was not done. The family member reported that the resident arrived from the hospital in horrible pain and did not receive oxycodone for about two days, receiving only Tylenol, which the family member stated did not relieve the pain. Nursing staff described repeated calls to the pharmacy and providers, the resident crying with pain rated 10/10, and reliance on Tylenol because oxycodone was not available. Pharmacy representatives stated that an active prescription for oxycodone 5 mg was not received until 02/16/26 and that the medication was not delivered until 02/17/26, with no record of any emergency run request or request to access oxycodone from the emergency medication bank, which they confirmed contained oxycodone 5 mg IR. The resident’s MAR showed oxycodone administration only beginning on 02/19/26. Facility and pharmacy policies required that when a medication is not available, staff must call the pharmacy and notify the physician, and that STAT/emergency medications, including controlled substances, can be obtained via emergency kits and STAT delivery within four hours, but the documented actions and interviews show these processes were not effectively used to ensure timely access to the resident’s ordered controlled pain medication.

The facility’s own staff accounts were inconsistent regarding the availability of oxycodone in the emergency medication bank and the steps taken to access it. One agency LPN reported being told by the ADON that the medication could be pulled from the emergency medication bank but stated she did not have access as an agency nurse and instead gave Tylenol after being shown standing orders. Another RN believed she had requested an emergency run and possibly removed oxycodone from the emergency kit, but pharmacy and emergency bank representatives reported no such requests or withdrawals. The provider group confirmed that the first request for an oxycodone prescription from the facility occurred on 02/16/26 at 3:49 PM, with the prescription sent to the pharmacy at 4:47 PM, and no earlier requests documented. Collectively, the records and interviews show that from admission on 02/14/26 until at least 02/16/26–02/17/26, the resident with documented severe pain and an identified need for opioid therapy did not receive the ordered controlled pain medication because the facility did not timely secure a valid prescription, did not effectively use available emergency medication systems, and did not coordinate with the pharmacy and providers in accordance with facility and pharmacy policies for controlled substances and STAT/emergency medication access.