Failure to Provide Ordered PRN Pain Medication After Supply Depletion
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident with significant pain needs. The resident was admitted with a right tibia and fibula fracture stabilized with an external fixator and had diabetes. A physician’s order dated 10/23/25 directed that the resident receive oxycodone 5 mg every four hours as needed for pain. The admission MDS Pain CAA indicated that pain interventions were to be administered per provider orders. The controlled substance record showed the last oxycodone dose was given on 10/25/25 at 7:35 PM, with zero tablets remaining afterward. On 10/27/25 at 6:00 AM, the Treatment Administration Record documented the resident reported a pain level of nine, yet the Medication Administration Record showed no oxycodone 5 mg was administered that day. On 10/27/25, an LPN documented that the resident complained of pain and requested oxycodone 5 mg, but the facility was out of the medication. The LPN contacted the pharmacy to reorder and requested a Cubex pull code, which the pharmacy denied because remaining oxycodone from the original prescription was already packaged for delivery and a new prescription was required for further refills. The LPN left a voicemail for the on-call provider, and later documented that the provider faxed a new prescription and that three additional tablets would be delivered, with approval to pull from Cubex if needed. The medical record contained no documentation of when the oxycodone was actually delivered and no documentation of any additional pain-management interventions provided to the resident after the reported pain level of nine. A pharmacy technician later stated that four tablets of oxycodone 5 mg were delivered to the facility on 10/27/25 at 3:55 PM, and the DNS confirmed the resident’s oxycodone supply had been depleted on 10/25/25 and was not reordered timely.
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