Failure to Notify NP of Significant Change and Continued Laxative Use During C. diff Infection
Penalty
Summary
The facility failed to immediately notify a resident's nurse practitioner (NP) when the resident experienced a significant change in physical status, specifically after being diagnosed with Clostridioides difficile (C. diff) infection on two separate occasions in May 2025. Despite the resident's care plan indicating the need to notify the physician if persistent diarrhea occurred, and lab results confirming C. diff, the NP was not informed of the increased diarrhea or the continued administration of a laxative (Bisacodyl) prescribed for constipation. The medication was given daily as per the medication administration record, even as the resident experienced worsening diarrhea. Interviews with staff revealed that the certified nursing assistant (CNA) and medication aide (MA) were aware of the resident's excessive diarrhea, and the MA expressed concern about administering the laxative but deferred to the licensed vocational nurse (LVN). The LVN acknowledged awareness of the diarrhea and the ongoing laxative order but did not notify the NP, believing it was acceptable due to the C. diff diagnosis. The director of nursing (DON) stated that nurses were expected to notify the NP immediately in such cases. The facility's policy required prompt physician notification when treatment needed to be altered due to adverse consequences.