F0658

D

Failure to Timely Notify Physician and Administer Ordered Antidiarrheal Medication

Bakersfield, California Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The facility failed to ensure timely physician notification and appropriate medication administration for a resident experiencing ongoing diarrhea, resulting in a delay in care. The resident had a BIMS score of 8, indicating moderately impaired cognition. Point of Care documentation showed the resident had multiple episodes of loose stools beginning on 2/9/26, with at least three episodes within a 24-hour period by 2/10/26 and continued frequent loose stools on subsequent days. The DON stated that three episodes of loose stools within 24 hours constituted a change of condition and acknowledged that the physician should have been notified on 2/10/26. However, the physician was not notified of the resident’s change in condition until 2/21/26, 11 days after the change of condition occurred, contrary to the facility’s Change of Condition Notification policy requiring timely notification when there is a need to alter treatment due to a change in condition.

On 2/21/26 at 8:10 a.m., a CNA informed the charge nurse that the resident had three bowel movements with diarrhea, and the primary clinician recommended loperamide 2 mg every eight hours as needed. The Order Summary Report reflected a physician order for loperamide on 2/21/26. Despite this order and continued documentation of loose stools on 2/21/26 and 2/22/26, the Medication Administration Record showed no loperamide was administered on those dates. The DON confirmed that the loperamide should have been given because the resident continued to have loose stools. On 2/22/26, an alert note documented that the resident requested transfer to an acute hospital due to diarrhea and abdominal pain, and the nurse practitioner ordered the resident to be sent out. The DON stated there was a delay in treatment due to poor communication between the nursing staff.