F0658

E

Failure to Follow Physician’s Order and Improper Medication Storage for Linzess

Lumberton, North Carolina Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow a physician’s order for administration of Linzess for a resident with chronic idiopathic constipation, gastroparesis, paraplegia, and bilateral upper and lower extremity contractures. The resident had been assessed and determined not to be able to self-administer medications, and her care plan noted a history of refusing medications and care at times based on her personal routine. Despite this, nursing staff and medication aides routinely deviated from the written order for Linzess 290 mcg by mouth daily and instead accommodated the resident’s preferred regimen of taking three capsules twice weekly. The resident reported that staff left three Linzess capsules in a medication cup at her bedside on specific days for her to take later, and she demonstrated how she self-administered them using her mouth due to her hand contractures.

Surveyor observations confirmed that a medication cup with three capsules was left on the resident’s bed while she sat in her wheelchair, and that she had significant bilateral hand and wrist contractures. The resident explained that staff placed her daily Linzess capsules into an empty medication bottle labeled for Simethicone kept on her bedside table, and on certain days staff removed three capsules from that bottle, placed them in a medication cup, and left them for her to take at a specific time. The DON later opened the bedside bottle labeled Simethicone and found a Linzess capsule inside. Review of the medical record showed no order from the resident’s gastroenterologist authorizing three Linzess capsules twice weekly, and the current physician’s orders specified a single 290 mcg capsule daily, including Saturdays, as well as Magnesium Citrate twice weekly and Simethicone as needed.

Multiple staff interviews revealed that several nurses and medication aides had long been placing the Linzess capsules into the Simethicone bottle at the bedside and allowing the resident to take three capsules on designated days, rather than administering one capsule daily as ordered and observing ingestion. Nurse #1 admitted she had been placing the daily Linzess capsule into the bedside bottle for some time and acknowledged she should not have done so, especially given the resident did not have an order to self-administer medications. Medication Aides #1 and #2 stated they had been trained or told by other nurses to store the Linzess in the bedside bottle and to set out three capsules on the resident’s preferred days, and they acknowledged they did not question the discrepancy with the physician’s order. Another nurse confirmed that the resident had been taking three capsules on two days per week “for as long as she could remember” and that she knew this practice did not follow the written order. In contrast, one night-shift nurse reported she always stayed with the resident until she took the ordered Linzess and refused to leave capsules in the bedside bottle. The Nurse Practitioner and Consulting Pharmacist later confirmed that the dose the resident was actually taking exceeded the recommended maximum daily dose and that the medication should have been administered as prescribed, but there was no documentation in the record authorizing the altered regimen.

The facility’s own documentation showed that the Medication Administration Record was being signed to indicate that Linzess was administered daily as ordered, even though staff interviews and resident statements showed that the medication was being stored in a mislabeled bottle at the bedside and taken in a different dose and schedule than prescribed. The resident’s self-administer medication assessment, updated shortly before the survey, continued to show she was not approved to self-administer medications, yet staff left medications in her room and did not consistently remain present to verify ingestion. The DON stated she had no knowledge that staff were leaving Linzess capsules in the Simethicone bottle or that the resident was taking three capsules twice weekly instead of one capsule daily, and she stated she expected staff to follow the five rights of medication administration and the physician’s orders as written.