Failure to Document and Address Resident Constipation per Physician Orders
Penalty
Summary
The facility failed to ensure accurate documentation and appropriate follow-through regarding a resident's lack of bowel movements, which resulted in not administering physician-ordered PRN medications for constipation. The resident in question had multiple diagnoses, including unspecified dementia, COPD, a recent hip fracture, and a history of constipation. He was severely cognitively impaired, non-ambulatory, and dependent on staff for all activities of daily living. After returning from a hospital stay, he was prescribed routine stool softeners and had PRN orders for additional laxatives if no bowel movement occurred within three days. However, the electronic medical record (EMR) did not accurately reflect the absence of bowel movements, as staff selected 'Response Not Required' instead of 'No bowel movement,' and no alert was generated to notify staff of the issue. During the period in question, there was no documentation in the progress notes regarding the lack of stooling, nor was the physician or nurse practitioner notified of the resident's constipation. As a result, the PRN medications ordered for constipation were not administered. The DON confirmed that the facility did not have a specific bowel protocol policy and that the EMR system failed to alert staff to the resident's condition. The resident did not display symptoms of abdominal discomfort during this time, but the lack of accurate documentation and follow-up led to a failure to provide care as ordered.