Failure to Notify Provider of Resident’s Long-Term Deviation From Ordered Linzess Regimen
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician when nursing staff were not following a physician’s order for the administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, and rectal paralysis. The resident was cognitively intact and had a physician’s order for Linzess 290 mcg, one capsule by mouth daily. Review of the Medication Administration Record showed the medication was documented as given daily between 7:00 AM and 11:00 AM. However, during an observation of the resident’s room, three capsules were seen in a medication cup on the bed, and the resident reported these were her Linzess capsules, which she took to help move her bowels. Further interviews revealed that the resident did not take Linzess daily as ordered. Instead, nursing staff and medication aides placed the daily capsule into an empty medication bottle kept at the bedside. On specific days of the week, staff removed accumulated capsules from the bottle and placed three capsules into a medication cup for the resident to take together, in accordance with the resident’s request to take three capsules twice weekly rather than one capsule daily. Multiple staff members, including nurses and medication aides, acknowledged they had been following this practice for an extended period, knew it did not match the written physician order, and did not question or clarify the order. Staff interviews also showed that nurses and medication aides did not notify the physician, nurse practitioner, or DON that the resident was refusing the ordered daily dose and instead taking three capsules twice weekly. Nurses stated they understood they should have notified the provider about the resident’s refusal to take the medication as ordered but instead honored the resident’s request. Medication aides stated they believed it was the nurses’ responsibility to notify the provider and did not escalate the issue, despite recognizing that the administration method did not match the order. The DON and nurse practitioner both reported they had no prior knowledge of this altered dosing regimen and that they first became aware only after the DON was informed during the survey.
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