Failure to Ensure Timely Refill and Continuous Administration of Opioid Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely refills and uninterrupted administration of an opioid pain medication for one resident. The resident was an adult female with chronic pain syndrome and angina pectoris, cognitively intact with a BIMS score of 15, and care planned for pain management with a noted potential for uncontrolled pain. Her care plan directed staff to anticipate her need for pain relief and respond immediately to any complaint of pain. The facility’s own policy required that Schedule II controlled substances be reordered when a 3–5-day supply remained. Medication Administration Records (MARs) showed multiple missed doses of the resident’s scheduled oxycodone-acetaminophen 5-325 mg. In November, she missed 10 doses over three days, with several entries marked as “unavailable” or “see nursing notes.” During this lapse, a new order for acetaminophen-codeine 300-60 mg every 4 hours as needed for pain was obtained, and the resident received that medication several times until the order ended. In January, the MAR again showed 11 missed doses of oxycodone-acetaminophen over several days, many marked as “unavailable,” “not given,” or “see nursing notes.” During this second lapse, a new order for tramadol 50 mg four times daily was written to be used until the oxycodone arrived, and the resident received tramadol as documented on the MAR. Interviews revealed that the resident and her family member were aware of and reported multiple lapses in her pain medication refills, with the resident stating that staff and the physician’s office blamed each other and the pharmacy. The MD acknowledged that the oxycodone refill process was lengthy and required the facility to request refills when two days of medication remained, but stated there was no reason the medication should have lapsed. The ADONs and DON stated they relied on nursing staff to request refills when 1–5 days of medication remained and suggested nurses may not have accounted for the four-times-daily dosing when estimating remaining supply. Nursing staff interviewed recognized that lapses in regularly scheduled opioid medications could negatively affect residents and stated that alternative orders should be obtained until refills were received. Despite these understandings and existing policies, the resident experienced repeated lapses in her scheduled opioid pain medication.
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