F0697

D

Failure to Provide Prescribed Opioid Pain Medication During Pharmacy Transition

Florissant, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide prescribed opioid pain medication to a resident for four days following a pharmacy change, despite an active physician order for scheduled oxycodone. The resident had a history of pain related to neuropathy, bilateral lower extremity pain, and a left tibia fracture, with care plan goals for adequate pain relief and interventions that included administering analgesia as ordered and monitoring and reporting pain complaints. The physician order, in place since 11/19/25, directed that oxycodone 5 mg, two tablets by mouth every four hours, be given for pain related to the left tibia fracture, and the March MAR showed this medication scheduled at six times per day. Documentation showed the medication was administered at midnight and 4:00 a.m. on 3/1/26, but all subsequent scheduled doses from later that morning through at least the morning of 3/5/26 were marked as not administered.

Nursing progress notes repeatedly documented that the oxycodone was not available or not in stock, and that a pharmacy change and need for new prescriptions were preventing administration. Notes on 3/1/26 indicated the medication needed a prescription and was not in stock, and multiple entries on 3/2/26 and 3/3/26 stated that the medication was not available due to a pharmacy change, that new e-prescriptions were required, and that the facility was awaiting medication from the new pharmacy. Additional notes on 3/4/26 continued to document that the oxycodone was not available. During this period, the facility’s own policies required that physician orders be transcribed and implemented in accordance with professional standards and that medications be ordered to ensure prompt delivery, including use of emergency drug supplies or an automatic dispensing unit for first doses when available. The pain management policy also required systematic recognition, evaluation, treatment, and monitoring of pain, and directed nursing to notify the practitioner if pain was not controlled by the current regimen.

Resident interviews and staff statements further described the impact of the unavailability of the ordered pain medication. On 3/4/26, the resident, who was in a wheelchair with a boot on the left foot, reported being out of oxycodone for several days since the pharmacy switch and stated they were hurting without the pain pill because of the broken foot. On 3/5/26, the resident was observed in the hallway in a wheelchair, crying and not wearing the boot, and stated feeling overwhelmed and in a lot of pain, reporting that they had asked for pain medication overnight and instead received anxiety medication. A CMT reported giving the resident PRN Tylenol and stated that the resident did not seem to be in pain and had asked for anxiety medication rather than pain medication, while an LPN acknowledged that the resident did seem to be in pain and that the oxycodone was not in the new pharmacy system, but was unsure how long the resident had been without it. The Administrator and the RN consultant both stated that residents should not be without pain medications for four days, and the RN consultant confirmed that the prescription was not received by the pharmacy until 3/4/26 and that being out of the medication since 3/1/26 was not acceptable.