Failure to Ensure Resident's Drug Regimen Was Free from Unnecessary Drugs
Penalty
Summary
A resident with a history of alcoholic liver disease and portal hypertension was admitted to the facility and prescribed lactulose. The physician's order indicated lactulose was to be administered for constipation, with instructions to hold the medication if the resident had more than three bowel movements daily. However, the resident stated that the medication was for his liver, and the hospital discharge summary confirmed that lactulose was intended for alcoholic cirrhosis with portal hypertension, not constipation. The facility staff, including the MDS Coordinator, acknowledged that the medication was being given for the wrong indication. Further review and interviews revealed that the facility did not monitor the effectiveness or adverse outcomes of lactulose as it was prescribed for the incorrect indication. The Consultant Pharmacist also noted that the dosage was higher than typically used for constipation and was more appropriate for hepatic encephalopathy. The facility's policy required clarification of medication orders that seemed excessive or unrelated to the resident's diagnosis, but this was not followed, resulting in the resident receiving unnecessary medication without proper monitoring.