Failure to Provide Ordered Pain Medication and Accurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received ordered pain medication, to use the backup medication supply when the primary supply was exhausted, and to accurately document medication administration. The resident, who had diagnoses including muscle weakness and low back pain, was admitted in November 2025 and had a care plan for chronic and acute pain related to arthritis and chronic back and shoulder pain, with interventions including administration of pain medications as ordered and monitoring effectiveness. A physician’s order dated 11/19/25 directed that acetaminophen-codeine 300-30 mg be given by mouth every 4 hours for pain. On 11/27/25, nursing documentation indicated that at the start of a shift the nurse was informed the resident was in pain due to not receiving scheduled Tylenol #3 because the prescription had not been refilled. The nurse documented contacting the supervisor, who in turn contacted the physician for authorization to pull medication from the backup supply, after which the nurse obtained the medication from backup and administered it at approximately 11:30, with the resident later reporting relief of pain. However, the controlled substance log showed that the last pill from the pharmacy supply was administered at midnight on 11/27/25, leaving no remaining doses for the rest of that day. Review of the electronic backup dispensing log showed that no codeine tablets were removed from the backup supply until 7:33 a.m. on 11/27/25, indicating that no medication was removed for the scheduled 4:00 a.m. dose. The November 2025 MAR showed the 4:00 a.m. dose as administered by a nurse, but there was no corresponding documentation on the controlled substance sheet or in the electronic backup dispensing log to support that the dose was removed or given. The DON stated that staff are expected to reorder medications before running out and to use the electronic backup machine and notify pharmacy and the provider if medication is not available, and acknowledged that the 4:00 a.m. dose appeared to have been missed and that the nurse likely made a documentation error by recording the dose as given without having medication available or documented removal from backup, contrary to facility policy on timely medication administration and documentation.
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