An Iowa nursing home was cited for repeatedly failing to give residents their narcotic pain medications. According to a report from the Iowa Department of Inspections, Appeals and Licensing, the facility repeatedly failed to administer residents’ pain medications as ordered by a physician. This situation resulted in Immediate Jeopardy to residents’ health and safety.
The report said that based on observations, interviews, and record review, the facility failed to administer pain medication as ordered by a physician leaving 4 out of 4 residents reviewed without adequate pain control. The 4 residents reviewed were not administered their Controlled II pain medication as ordered for prolonged periods of time. The nurses and certified medical assistants (CMAs) stated the medication was not available to give, therefore they did not give it. One resident went 8 days without receiving his 3 times a day routine order of Percocet. The other 3 residents did not receive their fentanyl patches as ordered every 3 days. In a 22-day period, one of those residents went without their fentanyl for 11 days, another for 12 days, and the other for 7 days.
Nurses and CMAs reported that because the medications were often not available in the facility, the staff would initial the patient records and medication charts and then draw a circle around their initials to let other workers know that the medications were not actually being given.
A CMA told inspectors that the facility often did not have the prescribed medications in stock. The director of nursing (DON) told inspectors that she was looking into the shortage of fentanyl patches. A registered nurse (RN) said the fax machine had been down for a long time, and they had just gotten a new one that week. She said they’d been unable to fax the pharmacy to order medications. Two of the nurses told the inspectors they didn’t think there was any drug diversion occurring, but that the prescribed medications weren’t being given to the residents due to laziness and “sloppy nursing.”
One CMA, when asked by inspectors about doing the pain scales, told them that she sometimes didn’t ask the residents how they felt, and simply marked a 0 if they didn’t look like they were in pain. She said one resident rated his pain as 8, but she marked it as 2 since she didn’t see any facial grimacing.
As a result of the inspection, the facility was cited for 12 state and federal violations.
Compliance Perspective
Issue
According to F697, facilities must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. F755 states that facilities must provide pharmaceutical services (including procedures that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. Facilities must employ or obtain the services of a licensed pharmacist who provides consultation on all aspects of the provision of pharmacy services in the facility, establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation, and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.
Discussion Points
- Review policies and procedures regarding pain management and recognition, evaluation, treatment, and monitoring of pain. Also review policies on ordering and dispensing medications and accurate recordkeeping.
- Train staff regarding the required documentation of and accounting for controlled medications prescribed and administered to residents, and to report any suspected incident of diversion to a supervisor or through the Hotline. Also train staff to evaluate residents for pain on admission and during routine evaluations and to document accurately. Ensure that each nurse or CMA understands their responsibility to follow through to obtain pain medication for any resident whose physician or physician extender has ordered a controlled pharmaceutical for the person’s pain management. Teach them that if, for example, the fax machine is out of service, they should use alternate methods such as the telephone to contact the pharmacy to obtain needed prescriptions. Explain that they are accountable for follow-through and apply progressive discipline if they fail to perform these duties. Document that these trainings occurred and file the signed documents in each employee’s education file. Failure to provide ordered pain relief may be considered abuse and neglect, with potential impact on their professional licensure or certification, as well as resulting in citations from the Department of Health, fines, and potential lawsuits.
- Periodically audit to ensure that residents are receiving their physician-ordered medications at the proper time and in the correct amount. Compare controlled substance sign-out logs with Medication Administration Records and progress notes to determine that accurate recording has occurred. Interview residents to determine that their comfort level is in keeping with expectations based on physician orders for pain relieving medications. Thoroughly investigate and respond to any identified concerns. Your consultant pharmacist can be included in this effort.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
