Failure to Follow Physician's Orders for Bowel Protocols and Medication Administration
Penalty
Summary
The facility failed to adhere to physician's orders regarding bowel protocols for two residents and medication administration for another resident. For one resident, the facility did not administer the prescribed Dulcolax suppository and Fleets enema after Milk of Magnesia proved ineffective, resulting in the resident not having a bowel movement for seven days. Similarly, another resident did not receive the prescribed Milk of Magnesia and Dulcolax suppository on the third and fourth day without a bowel movement, as ordered by the physician, leading to extended periods without bowel movements. Additionally, the facility did not follow physician's orders for a third resident regarding the administration of a Salonpas patch. The patch was applied multiple times without documented evidence of its removal within the prescribed 12-hour period. These failures were confirmed through interviews with the Nursing Home Administrator, highlighting a lack of adherence to established protocols and physician's orders for these residents.
Plan Of Correction
(Bowel) An Immediate Remedy could not occur for Resident 4 and 41 in this situation as the events occurred in the past. A audit/review of all other current residents in the facility shows that all residents have had appropriate administration of all bowel protocols where necessary. The Bowel Protocol Policy was reviewed and updated by Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the Bowel Protocol Policy three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Patch) An Immediate Remedy could not occur for Resident 27 as this situation as the events occurred in the past. An audit/review of orders was completed with no other resident prescribed as needed topical patches. The Transdermal Patch Policy was reviewed and updated by the Nursing Administration and Medical Director. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff are to be educated on the bowel protocol policy. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with the documentation of removal of as needed transdermal patches three times a week for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.