Incorrect Laxative Administered Instead of Ordered Senna Plus
Penalty
Summary
The deficiency involves the facility’s failure to administer medications as ordered for a resident. The resident, admitted with Parkinson’s disease, a right femur fracture, and hypertension, had an order starting 01/10/26 for two Senna Plus tablets, a combination laxative/stool softener. The admission MDS showed impaired cognition with a BIMS score of seven, independence with eating, supervision needed for bed mobility, moderate assistance for transfers, and maximum assistance for toileting hygiene. During a medication pass observed on 01/24/26 at 9:34 A.M., LPN #111 administered multiple medications including aspirin, Miralax, Ropinirole, carbidopa/levodopa, Vitamin D, Amlodipine, and two Senna 8.6 mg tablets. In a subsequent interview at 10:18 A.M. on 01/10/26, LPN #111 confirmed she had given Senna tablets instead of the prescribed Senna Plus tablets. Review of the facility’s “Administering Medications” policy dated 04/28/25 documented that medications must be administered in accordance with orders. This discrepancy between the ordered Senna Plus and the administered Senna tablets constituted the failure to ensure medications were given as ordered.
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