Failure to Follow Bowel Management Protocols
Penalty
Summary
The facility failed to adhere to physician's orders for bowel management protocols for three residents, leading to a deficiency in quality of care. Resident 1, who was severely cognitively impaired and had diagnoses including kidney failure, anemia, and dementia, did not receive the prescribed bowel management interventions despite not having a bowel movement from January 18 through 24, 2025. The medical administration records (MARs) for January 2025 showed that the staff did not initiate or follow the bowel protocol as ordered by the physician. Similarly, Resident 2, who was cognitively impaired with a diagnosis of dementia, did not have a documented bowel movement from November 1 through 6, 2024, and the MARs for November 2024 indicated that the bowel protocol was not followed. Resident 3, who was cognitively intact and occasionally incontinent of bowel, also did not receive the prescribed bowel management interventions during periods in January 2025 when there was no documented bowel movement. An interview with the Assistant Director of Nursing confirmed that the bowel protocol was not followed for these residents on the specified dates.
Plan Of Correction
1. Residents 1, 2, and 3 had no ill-effects from this deficient practice. 2. An audit was completed by Director of Nursing, or designee, on currently admitted residents who should have received bowel protocol in the past 7 days to ensure that the resident's bowel protocol orders were followed as per the physician's orders. 3. An education was completed with licensed nursing staff on following bowel protocol orders as per the physician's orders. 4. An audit will be conducted on 5 active residents who should have received bowel protocol to ensure that the resident's bowel protocol orders were followed as per the physician's orders weekly x 4 weeks, then monthly x 2 months. The results of these audits will be brought to the Quality Assurance Performance Improvement (QAPI) committee for review.