Failure to Follow Bowel Protocol for Resident
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice by not following physician orders for a bowel protocol for Resident 59. The resident had physician orders for a specific bowel regimen, which included administering Milk of Magnesia, a bisacodyl suppository, and a mineral oil enema in a sequential manner if no bowel movement occurred over consecutive days. Despite these orders, the facility did not administer the prescribed treatments during a period in November 2024 when the resident did not have a bowel movement for five consecutive days. Additionally, there was no documented evidence that the staff notified the physician about the resident's lack of bowel movement during this period. The Director of Nursing was unable to provide evidence that the bowel protocol was followed or that the physician was notified in a timely manner. This deficiency was identified through observation, clinical record review, and interviews with the resident and staff.
Plan Of Correction
Resident documentation cannot be corrected. To identify residents with the potential to be affected, the DON/designee will complete an audit of bowel records for the previous 14 days to ensure all protocols have been followed. To keep from re-occurring, the DON/designee will educate all licensed staff to follow bowel protocol and notify MD of deviation. To monitor and maintain compliance, the DON/designee will audit 5 residents' bowel protocol and documentation weekly for 4 weeks, then monthly for 2 months. Any negative findings will be corrected immediately. All results will be brought to the QAPI committee.