Failure to Implement Gastroenterology Consultation Recommendations for Chronic Constipation
Penalty
Summary
A deficiency occurred when a resident with a history of chronic constipation and multiple comorbidities, including dementia and schizoaffective disorder, did not receive care in accordance with professional standards following a gastroenterology consultation. The resident was recommended to start Linzess, a medication for chronic constipation, after a consult, but there was no documented evidence that this medication was ever ordered or administered. The facility's policy required that consultation recommendations be reviewed by the nurse manager or supervisor within 24 to 72 hours and that the attending physician or nurse practitioner be notified within 24 hours for review and potential orders. Upon the resident's return from the gastroenterology appointment, the LPN who received the resident documented that there were no recommendations from the consult. The LPN stated during interviews that they did not recall seeing any new orders on the consultation document and would have acted if there were any. The LPN also indicated that if there were no new orders, the consultation sheet would be filed in the resident's chart. However, the consult documentation recommending Linzess was not found in the resident's chart, and the medication was never ordered. Interviews with the DON, nurse practitioner, and assistant director of nursing revealed that the consultation documentation was either not received, misfiled, or not reviewed as required. The nurse practitioner stated that if they had seen the consult documentation, the order for Linzess would have been entered. The DON confirmed that the process involves reviewing the consult and informing medical staff of recommendations, but in this case, the consult form could not be located, and the recommended medication was not initiated.