Deficiencies in Medication Management and Bowel Care Protocols
Penalty
Summary
The facility failed to provide necessary treatment for opioid addiction for two residents, resulting in missed doses of Suboxone, a medication used to treat opioid dependence. Resident R56 experienced missed doses over the Thanksgiving period, leading to withdrawal symptoms such as stomach pains, aches, and sweating. The facility's documentation showed delays in obtaining a prescription refill from the physician, and there was no evidence of nursing staff checking on the resident's condition during this period. Similarly, Resident R61 also experienced missed doses due to delays in prescription refills, with no documented assessments or nursing notes during the time the medication was not administered. Additionally, the facility failed to follow a bowel care protocol for Resident R81, who had a history of constipation and was hospitalized for stomach distention. Despite physician orders for preventive measures, such as administering prune juice and milk of magnesia, the nursing staff did not follow these orders when the resident had no bowel movements for several days. This lack of adherence to the bowel protocol was confirmed by a registered nurse, and the resident was eventually sent to the hospital for further evaluation due to stomach ache and vomiting. The facility's Director of Nursing acknowledged the issues with medication administration, citing delays in receiving prescriptions from physicians and pharmacy deliveries as contributing factors. The report highlights deficiencies in medication management and adherence to care protocols, which resulted in residents experiencing discomfort and potential health risks.
Plan Of Correction
Resident R56 received their suboxone on 11/29/2024. Resident R61 received their suboxone on 5/28/2024. The facility completed a suboxone supply count immediately to verify appropriate supply before needing to request a refill. The facility has re-educated all licensed nurses on the facility's policy on Medication/Opioid Management and Reordering such as: when counting controlled drugs, the licensed nurses must be alert for medications needing refills or new script within 10 days of the last dose. The facility has re-educated all nursing staff on Bowel and Bladder policy and protocol including monitoring, assessing, documenting resident's bowel movements. The facility will complete a medication audit on all residents who are presently on suboxone to monitor consistency and appropriateness of pain management regimen and receiving their medication in a timely manner. The facility will complete a bowel and bladder audit on 10 residents to ensure a proper bowel and bladder protocol is in place. The facility will monitor and check for knowledge on licensed nurses' ability to verbalize understanding of facility's policy on Medication/Opioid Management and Reordering. The DNS will oversee and serve as the point of escalation in contacting the physician and/or pharmacy for refill and/or new script and specifically monitor Suboxone supply. The facility will monitor for effective bowel and bladder program and verify that nursing staff are appropriately documenting and following physician orders and recommendations. DNS / designee will audit 4 residents prescribed Opioids to monitor consistent, timely and appropriate medication administration and pain management regimen. Audits will be conducted daily x2 weeks, then weekly x4 weeks and then monthly x3 months. UM/ designee will audit 4 residents BM log to monitor for consistent and appropriate bowel hygiene and regimen. Audits will be completed weekly x4 weeks then monthly x2 months. Findings will be reported to the QAPI committee.