Failure to Ensure Continuous Supply and Administration of Ordered Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered pain medication as prescribed for a cognitively intact resident with chronic pain and spinal stenosis. Facility policy stated that pharmacy services were available 24/7 and that residents would have a sufficient supply of prescribed medications and receive them in a timely manner. The resident had physician orders for oxycodone 10 mg six times per day and an additional 10 mg every six hours as needed for pain. The MAR for the month reviewed showed multiple missed scheduled oxycodone doses on several dates, including missed doses at midnight, early morning, afternoon, and evening times. Progress notes documented that oxycodone was not available on at least one date due to awaiting pharmacy delivery, and on another date only one tablet was available when two were ordered, with the remainder on order. Additional progress notes showed repeated unavailability of oxycodone in the automated medication storage systems (Pixis/Omnicell), with documentation that staff lacked access to the system at one point and that the pharmacy had been informed of the missing medication on another. Notes also indicated that oxycodone doses were pending pharmacy delivery on multiple occasions. During interview, the resident reported that the facility continually ran out of oxycodone, resulting in missed doses on their every‑four‑hour regimen, and described receiving various explanations from staff, including that the medication was not ordered, agency nurses did not order it, there were mix‑ups between shifts, the physician did not sign the prescription, or insurance would not cover it. A medical provider stated they expected licensed nurses to administer medications per order. The DON reported that an internal review found the pharmacy was not sending the amount of oxycodone requested for refills, though the pharmacy could not explain why.
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