Failure to Ensure Timely Reordering and Availability of Controlled Antidiarrheal Medication
Penalty
Summary
The facility failed to implement an effective system to ensure that an antidiarrheal medication, diphenoxylate-atropine (Lomotil), was reordered and available for administration, resulting in 12 missed doses for a resident with incontinence, end stage renal disease, and end stage renal dialysis. The resident was cognitively intact and had a physician's order for Lomotil to be administered four times daily for diarrhea. According to the Medication Administration Record, the medication was administered as ordered until it was put on hold due to being out of stock, and the resident missed doses over several days. Multiple staff members, including medication aides and nurses, became aware that the medication was out of stock, but there was confusion and miscommunication regarding the process for reordering a controlled medication. Some staff believed the medication had been reordered through the electronic Medication Administration Record (eMAR), but as a controlled substance, a new provider order was required, which was not immediately obtained. The pharmacy confirmed that a refill request was received but could not be processed without a new script, and there was no record of follow-up calls from the facility to the pharmacy. The Director of Nursing and other staff acknowledged that the process for reordering controlled medications was not clearly understood or followed. During the period when the medication was unavailable, the resident did not report significant changes in his condition and was not experiencing diarrhea according to staff and the resident himself. The Medical Director and Nurse Practitioner were eventually notified and placed the medication on hold until a new order could be obtained. The deficiency was attributed to a lack of an effective system for ensuring timely reordering and availability of controlled medications, as well as inadequate communication among staff regarding the specific requirements for ordering such medications.