F0755

J

Failure to Maintain Opioid Availability and Controlled Substance Accountability

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

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure effective pharmacy services and continuous availability of prescribed opioid pain medication for a resident with chronic pain and long-term morphine therapy. The resident had diagnoses including chronic pain syndrome, an above-the-knee amputation, post‑traumatic osteoarthritis with contracture, and PTSD, and was cognitively intact but dependent on staff for transfers and toileting. He had MD orders for morphine IR 15 mg four times daily on a scheduled regimen and morphine IR 7.5 mg twice daily PRN. On one day, the day‑shift RN recognized that the resident’s supply of scheduled morphine IR 15 mg tablets would be insufficient but did not contact the provider for a new prescription before the end of the shift, citing time constraints, and only verbally informed the oncoming nurse without verifying that a prescription was obtained.

Later that day, the scheduled afternoon and evening 15 mg morphine doses were not administered because the drug was not available, and only a single 7.5 mg PRN dose was given in place of a full scheduled dose. The evening RN attempted multiple times to reach the on‑call NP through a triage nurse and was told by the NP later that she had signed the order in the electronic system but did not verify that the prescription reached the pharmacy and refused to resend it that night, stating she would address it in the morning. The NP did not provide alternative pain management orders, did not order monitoring for opioid withdrawal symptoms, and did not inquire whether doses had already been missed. Pharmacy records confirmed that no morphine prescription from the NP was received that day, and the pharmacy indicated that no calls from the facility were logged during the reported time frame, despite staff documentation that the pharmacy had been contacted multiple times.

The following morning, the resident’s early scheduled morphine dose was again not administered due to lack of medication, and the day‑shift RN was not informed by night staff that multiple doses had been missed. She did not contact the on‑call provider until after mid‑morning, when she discovered the resident was out of morphine, at which time the triage RN and a PA became involved to send a new prescription and authorize use of the e‑kit. The resident reported that during the period without his scheduled morphine he experienced pain at 10/10, could not get out of bed, had decreased appetite, and his anxiety worsened; his spouse observed him sweating, unusually quiet, confused, and unable to operate the TV remote as usual. Documentation showed that the resident went approximately 24 hours without a full scheduled 15 mg dose and about 20.5 hours with only a partial 7.5 mg PRN dose instead of his ordered regimen, with no comprehensive assessment for opioid withdrawal symptoms and no enhanced monitoring for increased pain.

In addition to the failure to maintain medication availability, the facility failed to ensure proper reconciliation, transcription, and accountability of controlled substances for the same resident’s morphine. Review of the controlled substance book and medication cart revealed incomplete documentation and discrepancies between the narcotic record, bubble packs, and pharmacy packing slips. One controlled substance sheet documented receipt of 24 tablets of morphine 15 mg without listing the RX number, prescriber name, or directions, and the corresponding bubble pack was no longer present for verification. Another sheet documented receipt of 12 tablets for PRN morphine, while the pharmacy packing slip for the same RX and label indicated delivery of only 6 tablets, and the controlled substance sheet again lacked RX number, prescriber, and directions. These inconsistencies and omissions compromised the facility’s ability to accurately track, verify, and ensure availability of the resident’s ordered controlled substances.

The DON stated she was unaware that the resident had missed multiple scheduled morphine doses and acknowledged that this represented a significant medication error that could place the resident at risk for acute withdrawal and significant pain. She confirmed that the provider had not been notified about the missed doses at the time, that no medication error report had been completed, and that there were no orders in place during the gap to control the resident’s pain or to monitor for withdrawal symptoms. The consultant pharmacist and medical director both confirmed, based on record review and interviews, that the resident went without morphine for an extended period, that there were no comprehensive assessments or monitoring for pain or acute opioid withdrawal during that time, and that missing scheduled doses of IR morphine would be expected to result in increased pain and potential withdrawal signs such as sweating and nausea. The surveyors determined that these failures in ordering, communication, monitoring, and controlled substance documentation resulted in severe unmanaged pain and possible early opioid withdrawal symptoms for the resident and constituted immediate jeopardy beginning when the facility first failed to ensure the resident’s prescribed morphine was available for administration.