Failure to Ensure Continuous Availability and Administration of Ordered Medications for Bowel Management
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services to meet the needs of a resident with Ogilvie syndrome, hemiplegia, and hemiparesis following a cerebral infarction. The resident was cognitively intact per a recent MDS and had a care plan focus on altered gastrointestinal status related to Ogilvie syndrome, with interventions including administering medications as ordered and monitoring side effects and effectiveness. Physician orders included bisacodyl rectal suppository 10 mg daily, lactobacillus two tablets by mouth daily, and polyethylene glycol 17 grams by mouth twice daily. Record review of the MAR showed that the resident did not receive lactobacillus for several consecutive days, did not receive polyethylene glycol on two days, and did not receive the ordered bisacodyl suppository on another day. Nursing progress notes documented that lactobacillus and polyethylene glycol were not administered because they were "on order" and that the bisacodyl suppository was not administered because it was "on reorder." The resident reported he was not getting his constipation medications consistently, stated he had run out of medications, and specifically noted he did not receive his suppository the previous night because staff told him they had run out. The resident’s responsible party reported that running out of the resident’s medications had been an ongoing problem and that he had missed multiple doses of lactobacillus, polyethylene glycol, and bisacodyl suppositories. A medication aide stated that the resident’s polyethylene glycol and probiotic were OTC medications and explained that OTC orders had to be submitted to the DON on a specific day of the week, with delivery occurring later, and that missing the weekly order meant waiting until the next week. The DON stated that OTCs were ordered a week ahead, that the facility had a contract with a local pharmacy that could supply OTCs, and that residents should not run out of medications, while acknowledging that the resident’s suppositories were not on the current week’s delivery list. Facility policies required accurate documentation and management of medication ordering, reordering, dispensing, and receipt through the EHR, and required medications to be administered in a safe and timely manner as prescribed.
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