Failure to Implement and Document Bowel Management Protocol
Penalty
Summary
The facility failed to implement and document its bowel management protocol for two residents who were at risk for constipation and unnecessary medication use. For one resident, there was a six-day period with no documented bowel movements, and no bowel medications were administered during that time, despite physician orders and facility policy requiring intervention. Staff interviews confirmed that there was no documentation of bowel medications being given or of staff verifying the resident's self-reported bowel movement, even though the resident was dependent on staff for care. For another resident, there were three separate periods ranging from four to five days without a documented bowel movement, and again, no bowel medications were administered or documented as required by the facility's protocol. The resident's care plan specified the goal of a normal bowel movement at least every third day and directed staff to follow the facility's bowel management protocol, which was not done. Staff confirmed that the necessary interventions were either not started or not documented during these periods.