Failure to Administer Medications per Physician Orders for Bowel Management
Penalty
Summary
The facility failed to administer medications according to physician orders for one resident who experienced multiple episodes of loose stools. The resident was prescribed Docusate Sodium for constipation with specific instructions to hold the medication if loose stools occurred. Despite this, the medication was not held on several occasions when the resident had documented episodes of loose stools, as confirmed by both the Activities of Daily Living flowsheet and the Medication Administration Record. The Director of Nursing acknowledged that the medication should have been withheld during these episodes, in accordance with the physician's orders. Additionally, the resident had physician orders for Imodium and Loperamide to be administered as needed for diarrhea. However, during at least two documented episodes of loose stools, neither medication was administered as ordered. The facility's policy and procedure required medications to be administered in accordance with prescriber orders, but this was not followed in the resident's case. The failures were confirmed through interviews and record reviews with the Director of Nursing.