Failure to Follow Physician's Orders for PRN Medication Administration
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease and dependence on renal dialysis was admitted to the facility with a physician's order for Polyethylene Glycol 3350 (Miralax) to be administered as needed (PRN) for constipation, with instructions to hold for loose stools. Upon review, it was found that the order was incorrectly transcribed by an LPN as a daily medication rather than PRN, resulting in the resident receiving Miralax every morning from admission until the order was discontinued. The resident, who was cognitively intact, reported that they had never taken Miralax daily prior to admission and had not requested the medication to be changed to a daily order. Interviews with staff confirmed the transcription error, and there was no documentation to support that the physician's original PRN order had been changed to daily. The facility's leadership was unable to provide evidence that the medication was administered according to the physician's order during the specified period. The progress notes also did not indicate any provider-initiated change to the medication order upon admission.