Failure to Withhold Contraindicated Medications During Diarrhea Episodes
Penalty
Summary
A resident with a history of iliac artery aneurysm and left-sided hemiplegia was admitted to the facility and prescribed multiple medications, including Sennosides-Docusate for constipation and Loperamide for diarrhea. The resident was also receiving morphine for pain management. Despite the presence of ongoing diarrhea, both Sennosides-Docusate and Loperamide were administered concurrently over an extended period, as documented in the Medication Administration Record and confirmed by staff interviews. This practice is contraindicated, as the medications have opposing effects and should not be given together. Nursing notes and interviews revealed that the resident experienced frequent, loose, and watery stools for at least two weeks, with multiple episodes of diarrhea documented. The resident reported feeling unclean, having a persistent foul odor, and being left in soiled briefs for extended periods due to staff unavailability. The resident also expressed a preference for showers over bed baths, which was not accommodated. Certified Nurse Aides and LPNs confirmed the resident's ongoing diarrhea and the continued administration of both medications, with some staff acknowledging that the medications should not have been given together. The facility's Nurse Practitioner and Director of Nursing both stated that standard practice would be to hold or discontinue Sennosides-Docusate if a resident developed diarrhea and to administer Loperamide as needed. However, the review of records and staff interviews confirmed that this protocol was not followed, resulting in the resident receiving both medications simultaneously and experiencing ongoing diarrhea and discomfort.