Failure to Follow Bowel Care Protocol for Multiple Residents
Penalty
Summary
The facility failed to follow its established bowel care standing orders for four residents whose records were reviewed for bowel and bladder care. According to the facility's protocol, specific interventions and medications were to be administered at 24, 48, 72, and subsequent hours without a bowel movement. However, documentation revealed that these steps were missed or delayed for multiple residents. For example, one resident with a history of stroke and hypertension did not receive the required interventions from day one through day five of no bowel movement. Another resident with polyosteoarthritis and respiratory failure had missed steps in the protocol during two separate periods of constipation. Additional residents with diagnoses such as epileptic seizures, hypertension, chronic kidney disease, and COPD also experienced missed or delayed administration of bowel protocol steps. The missed interventions included failure to provide prune juice, milk of magnesia, bisacodyl suppositories, or to notify the primary care provider as outlined in the protocol. The Director of Nursing confirmed that nursing staff had not followed the bowel protocol as required for these residents. The failure to administer medications and interventions according to physician orders and facility policy was identified through record review and staff interviews.