F0658

D

Delay in PRN Anti‑Nausea Medication and ED Transfer After Change in Condition

Owatonna, Minnesota Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely implement a physician’s order for an anti‑nausea medication and to timely act on an order to transfer a resident to the emergency department (ED) following a change in condition. The resident had diagnoses including a non‑traumatic perforation of the intestine and colostomy status, used a walker and wheelchair, required one‑person assistance with several ADLs, and had an ostomy. On the afternoon in question, a nursing assistant reported that after emptying the resident’s colostomy bag and taking him to dinner, the resident soon stated he did not feel well, had stomach pain, was not hungry, and wanted to lie down. Vital signs taken at 6:43 p.m. showed elevated blood pressure (171/95), oxygen saturation of 94%, pulse 90, temperature 96.7°F, respirations 18, and pain 3/10. A clinician note documented that the resident had developed nausea that afternoon, chose not to eat supper, had mild diffuse abdominal tenderness with bowel sounds present, and nausea over the past couple of hours without abdominal pain at that time. The note indicated Zofran was available and that nursing was to update the physician later that evening.

A signed physician order dated that day directed administration of ondansetron (Zofran) 4 mg by mouth every 6 hours as needed for nausea. The physician later clarified that this order was written between 6:00 p.m. and 7:00 p.m. and that she expected the Zofran to be administered at that time because the resident had acute issues requiring immediate attention. However, the medication administration record shows Zofran 4 mg was not given until 9:40 p.m., with a comment time of 9:15 p.m., and was documented as not effective. During interview, the RN on duty acknowledged that she did not administer the Zofran after the order was written and could not clearly articulate why, stating she associated the resident’s symptoms with indigestion and was occupied with other paperwork and documentation. Multiple nursing assistants reported that between approximately 9:00 p.m. and 10:00 p.m. the resident repeatedly requested to go to the ED, appeared gray, sweaty, anxious, and complained of epigastric or chest‑area pain, with abnormal vital signs reported to the RN.

Progress notes document that the resident refused supper, complained of stomachache, dry heaved, and later complained of epigastric pain while spitting clear phlegm. Zofran was given at about 9:15 p.m. with no relief. The note was later edited to add that the physician had been at the facility, ordered Zofran every 6 hours as needed, and was called again when the resident did not improve. A subsequent edit at 10:22 p.m. recorded that the physician ordered the resident sent to the ED for increased belly pain. The physician stated her expectation that an ambulance should be called right away after she gave the order to send the resident to the ED. Instead, the record shows ongoing documentation of severe epigastric pain rated 10/10, continued dry heaving, elevated blood pressure, low oxygen saturations requiring an increase in supplemental oxygen, and the resident remaining pale and diaphoretic. The resident continued to state he wanted to go to the ED. Non‑emergency dispatch was called for transport, and the resident ultimately left with paramedics after midnight. The DON later stated that, based on the vital signs and symptoms documented at 6:43 p.m. and again around 9:10 p.m., she would have expected focused assessment, timely physician notification, and that the ambulance should have been called when the order to send the resident to the ED was obtained. The facility also lacked a policy on administering newly ordered medications for a change of condition.