Failure to Hold Laxatives and Stool Softeners for Resident with Diarrhea
Penalty
Summary
A facility failed to ensure that a resident did not receive docusate sodium and senna while experiencing loose, watery stools, contrary to physician orders that specified these medications should be held in such circumstances. The resident, who was cognitively intact and had diagnoses including end-stage renal disease requiring dialysis, generalized anxiety disorder, depression, and a tracheostomy, was at risk for pressure injuries and moisture-associated skin damage. Despite clear orders to hold the medications for loose stools, medication administration records showed that both docusate sodium and senna were administered on multiple days when the resident was documented as having diarrhea. Certified nursing assistants (CNAs) and family members reported that the resident was experiencing ongoing diarrhea, with associated skin irritation and discomfort. Documentation confirmed multiple episodes of loose stools, and interviews revealed that CNAs informed charge nurses about the resident's condition. However, at least one LVN stated they were not made aware of the loose stools and continued to administer the medications as ordered, without holding them as required by the physician's instructions. The Director of Nursing confirmed upon review that the medications should have been held on days when the resident had loose stools, in accordance with the physician's order and facility policy. The facility's policy on medication administration required medications to be given as prescribed and for staff to contact the prescriber if a dosage was believed to be inappropriate. The failure to hold the medications as ordered constituted a significant medication error, as the medications were administered despite clear documentation and communication regarding the resident's loose stools.