Resident 51 was prescribed gabapentin 800 milligrams four times daily for nerve pain. The facility didn't have the medication available and she missed 21 doses between May 8 and May 13, according to federal inspection records from July.
Her pain reached a 10 on a 10-point scale. She complained of constant pain, numbness in her legs, and muscle spasms.
At 3 a.m. on May 12, she asked to go to the emergency department. Hospital staff treated her acute pain with gabapentin and sent her back to Premier Living the same day.
The facility still didn't have her medication. She missed three more doses on May 12.
That evening, she requested another trip to the emergency room as her muscle spasms worsened. Again, hospital staff treated her acute pain with gabapentin and returned her to the nursing home.
She missed four more doses before Premier Living finally obtained the medication.
A second resident experienced a similar medication shortage. Resident 46 was prescribed gabapentin 800 mg twice daily for nerve pain. The facility ran out on May 10 and she missed 14 doses over the next eight days through May 17.
Her pain sustained at an 8-9 level. She couldn't sleep, developed anxiety and irritability, felt nauseous, and couldn't complete her normal daily routine due to leg pain.
Federal inspectors found Premier Living failed to provide effective pain management for both women during a July complaint investigation. The facility also failed to manage symptoms of withdrawal that can occur when gabapentin is stopped suddenly.
Gabapentin is commonly prescribed for nerve pain and seizures. Stopping the medication abruptly can cause withdrawal symptoms including anxiety, insomnia, nausea, pain, and sweating.
The inspection reviewed 10 residents' pain management. Two experienced medication shortages that left them in severe, untreated pain.
For Resident 51, the ordeal lasted nearly a week. Her prescribed four-times-daily regimen meant she needed the medication every six hours around the clock. Missing 21 doses over six days represents more than a full day without any pain relief.
The emergency room visits highlight the severity of her condition. Hospital staff had the medication available and treated her acute pain both times, providing temporary relief that the nursing home couldn't deliver.
Her middle-of-the-night trip on May 12 suggests the pain was unbearable. After receiving treatment and returning to Premier Living, the facility's continued inability to provide her prescribed medication forced another emergency visit the same day.
Resident 46's experience stretched over eight days. Missing 14 doses of twice-daily medication meant she went multiple days without any gabapentin. Her sustained 8-9 pain level and inability to complete normal activities demonstrate the medication shortage's impact on her daily life.
The anxiety and irritability she experienced are consistent with gabapentin withdrawal symptoms. Her sleep problems and nausea further suggest she was experiencing withdrawal effects on top of her underlying nerve pain.
Both cases reveal systemic problems with medication management at Premier Living. Running out of a commonly prescribed pain medication suggests issues with inventory management, pharmacy coordination, or both.
The facility's inability to quickly resolve the shortage prolonged both residents' suffering. Even after Resident 51's first emergency room visit clearly demonstrated the medication's necessity, Premier Living still couldn't provide it, leading to her second trip.
Federal inspectors interviewed staff, residents, the consultant pharmacist, and physicians as part of their investigation. The findings represent a significant failure in basic nursing home care - ensuring residents receive their prescribed medications.
The complaint investigation suggests someone reported the medication shortages to state regulators, prompting the July inspection. The facility's failure to manage pain and withdrawal symptoms violated federal requirements for pharmaceutical services in nursing homes.
Both residents relied on Premier Living to manage their chronic pain conditions. The facility's medication shortages forced them to seek emergency care for problems that should have been prevented with proper pharmacy management.
Resident 51's two emergency room visits in 24 hours represent a cascade of preventable medical crises. Her 10-out-of-10 pain level and requests for emergency transport underscore the human cost of the facility's pharmaceutical failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Premier Living and Rehab Center from 2024-07-02 including all violations, facility responses, and corrective action plans.
Additional Resources
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