Failure to Administer Constipation Medications as Ordered
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain bowel function for a resident, identified as Resident R36. The resident, who had diagnoses including high blood pressure, muscle wasting, and PTSD, was admitted to the facility and had physician orders for constipation management. These orders included administering Milk of Magnesia, Dulcolax suppository, and Miralax as needed for constipation. However, the facility did not follow these orders as the Dulcolax suppository and Miralax were not administered when required. The resident experienced a period of four days without a bowel movement, during which the facility failed to administer the prescribed medications in a timely manner. The facility's care plan for Resident R36 did not include goals and interventions related to constipation management, which contributed to the oversight. The Director of Nursing confirmed that the facility lacked a bowel protocol and acknowledged the failure to follow physician orders. This deficiency was identified through a review of the facility's policy, clinical records, and staff interviews, highlighting a lapse in ensuring that residents received appropriate care to maintain bowel function.
Plan Of Correction
R36 suffered no ill effects from not receiving constipation management from 12/6/24 to 12/10/24. Care plan reviewed and updated as needed. Cited care plan reviewed and updated as needed. An audit was completed on like residents to ensure there were no additional issues. Education will be provided to the RNAC, Nurses, and nursing management on constipation management on or before 2/11/2025. Audits will be completed on following bowel protocol by the DON or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.