Failure to Administer Bowel Protocol Medications
Penalty
Summary
The facility failed to provide the highest practicable care for a resident regarding the administration of bowel protocol medications. A clinical record review revealed that the resident had difficulty passing stool, as noted in a medical provider's progress note. Despite physician orders for a bowel protocol that included Milk of Magnesia, Bisacodyl Suppository, and Fleet's Enema to be administered sequentially if constipation persisted, there was no documentation indicating that these medications were administered or refused by the resident on several specified dates. The Director of Nursing confirmed the findings that the facility did not initiate the bowel protocol as ordered. The lack of documentation on the medication administration record (MAR) for the specified dates indicates a failure to adhere to the prescribed bowel protocol, which was intended to address the resident's constipation issues. This oversight in medication administration and documentation led to the deficiency noted in the report.
Plan Of Correction
F0684 1. The bowel protocol medication administration cannot be retroactively implemented for resident 48. 2. Audit will be completed for current residents' bowel elimination records from January 6, 2025 - January 13, 2025 to ensure that appropriate bowel protocol interventions are being administered. 3. Education will be provided to licensed staff on ensuring that the bowel protocol is being followed. 4. Random audits will be completed by the DON or designee weekly for 4 weeks, then monthly for 2 months to ensure appropriate bowel protocol interventions are being administered. Results of audits will be presented at the Quality Assurance Performance Improvement Committee meeting for review and recommendations.