Unauthorized Administration of Stool Softener Without Physician Order
Penalty
Summary
The deficiency involves the failure to provide treatment and care in accordance with professional standards and physician orders when a nurse administered a stool softener without a valid order and failed to document it. Facility policy on administering oral medications, dated 12/2024, required verification of a physician’s medication order prior to administration. Resident #1, admitted with diagnoses including constipation, chronic pain syndrome, and a history of falling, had a care plan addressing bowel incontinence with interventions such as checking the resident every two hours, assisting with toileting, observing incontinence patterns, and initiating a toileting schedule if indicated. The Minimum Data Set dated 11/22/2025 documented moderately impaired cognition for Resident #1. Review of physician orders from 12/01/2025 to 12/29/2025 showed no active order for any stool softener. On 12/19/2025 at 11:11 AM, a nursing progress note by Licensed Practical Nurse (LPN) #1 documented that Resident #1 requested a stool softener and that the medication was given and tolerated well. Resident #1 later reported they informed LPN #2 of constipation and received medication for it, but continued to have pain and subsequently called 911. LPN #2 confirmed in interview that, at the resident’s request, they administered two tablets for constipation despite there being no physician’s order for the medication. The administration was not documented as a medication entry in the record. The Emergency Department note for that same date recorded that Resident #1 presented with constipation, intermittent cramping, and abdominal pain, reported no bowel movement for three days, had received medication at the facility and had a bowel movement just before arrival, and then had a large bowel movement in the ED with resolution of pain and no bowel obstruction found. The attending physician (Medical Doctor #1) stated that after an initial 30‑day bowel regimen at admission, there were no further constipation complaints and no call requesting a stool softener order on the date in question. The Administrator acknowledged that LPN #2 administered a stool softener without a physician’s order.
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