Failure to Act on Consultant Pharmacist's Recommendations for PRN Constipation Medications
Penalty
Summary
The facility failed to act upon recommendations from the Consultant Pharmacist regarding a resident's medication regimen for constipation. The resident, who had diagnoses including type 2 diabetes mellitus, major depressive disorder, and insomnia, was dependent on staff for several activities of daily living and had moderately impaired cognitive skills. The resident's physician orders included multiple PRN medications for constipation, such as bisacodyl suppository, lactulose, magnesium citrate, magnesium hydroxide, and polyethylene glycol, as well as a scheduled senna tablet. The Consultant Pharmacist's monthly medication regimen review specifically recommended that all PRN orders for constipation be reviewed and that the physician's orders specify the sequence in which these medications should be administered. Despite this recommendation, facility staff did not review the resident's PRN constipation medications or ensure that the physician's orders included the required sequencing. The Assistant Director of Nursing confirmed that the recommendation was received but not acted upon, acknowledging that licensed staff did not follow up as required by facility policy. The facility's policy states that staff must act upon all recommendations from the Consultant Pharmacist, but this procedure was not followed in this instance.