F0710

F

Failure to Obtain Timely Practitioner Orders and Morphine Refill for Pain Management

Red Wing, Minnesota Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure timely practitioner orders and provision of prescribed narcotic pain medication when a resident’s scheduled morphine was not available. The resident had an order dated 11/28/23 for morphine IR 15 mg to be administered four times daily for chronic pain syndrome at 6:30 a.m., 11:30 a.m., 4:00 p.m., and 8:00 p.m. The February 2026 MAR showed that on 2/2/26 the 4:00 p.m. and 8:00 p.m. scheduled doses were not administered because the medication was not available, and only a single 7.5 mg PRN dose was given at 5:03 p.m. On 2/3/26, the 6:30 a.m. scheduled dose was not administered and the 11:30 a.m. dose was given late at 1:36 p.m., again due to unavailability of the ordered morphine.

Progress notes and interviews documented repeated but unsuccessful efforts by nursing staff to obtain a new prescription and supply of morphine. On the evening of 2/2/26, staff contacted the on-call provider and pharmacy multiple times and documented that the medication was not available. The nurse practitioner reported she had sent the morphine prescription to the pharmacy at 7:00 p.m., but the pharmacy could not locate it, and she declined to fax or resend the prescription that night, stating she might do so the following morning. She did not provide alternative pain management orders, did not give instructions to monitor for opioid withdrawal symptoms, and did not direct staff on how to address increased pain. The charge RN confirmed she attempted to reach the NP multiple times between mid-afternoon and late evening, could not use the MAR reorder function because a new prescription was required, and identified the failure to obtain a timely prescription as the root cause of the missed doses.

The resident reported that after running out of morphine in the afternoon, he did not receive his scheduled doses for almost a full day, during which he experienced pain rated 10/10, inability to get out of bed, decreased appetite, and worsened anxiety with difficulty swallowing. The pharmacist stated the pharmacy did not receive a morphine prescription from the NP on 2/2/26 and only received a new prescription from a certified physician assistant the following day, which included authorization to obtain a dose from the e-kit. The pharmacist explained that after-hours procedures allowed for emergency verbal prescriptions for controlled substances and characterized the lack of medication in this situation as an omission medication error. The facility’s Physician Services policy required that a physician, NP, or PA provide orders for residents’ immediate care needs, ensure 24-hour availability of physician services in case of emergency, and maintain residents under physician care with timely communication and documentation of orders, which was not met in this case when timely orders and medication were not secured for the resident’s pain management.