Failure to Follow Physician Orders and Protocols for Constipation Management
Penalty
Summary
The facility failed to follow physician-ordered interventions for two residents who experienced extended periods without a bowel movement. For one resident with a diagnosis of constipation and always incontinent of bowel, electronic health records showed multiple episodes of three or more days without a bowel movement. Although there was a physician's order for milk of magnesia to be given as needed for constipation, medication administration records indicated it was not consistently administered according to the order, and there was a lack of documentation for administration during some periods. The resident's care plan required documentation of bowel movements every shift and adherence to facility protocol for stool softeners, laxatives, or enemas, but these interventions were not consistently followed or documented. For another resident with moderate cognitive impairment and multiple diagnoses, including malnutrition and a history of falls, records showed a gap of three days without a bowel movement. The resident had several as-needed orders for constipation management, including milk of magnesia, Miralax, and bisacodyl suppository, with instructions to escalate interventions if no bowel movement occurred for several days. However, medication administration records showed these interventions were only given on two occasions during the month, and progress notes indicated refusals without documentation of any assessment related to constipation. There was also a lack of abdominal assessments or documentation of change in condition in the resident's records. Interviews with nursing staff and administration revealed inconsistencies in following the bowel protocol and confusion regarding the use of bowel movement reports generated from the electronic health record system. Staff acknowledged that the bowel report was not functioning correctly, leading to missed identification of residents with prolonged periods without a bowel movement. Additionally, the facility lacked a formal bowel protocol policy, a policy for when assessments should be completed, and a medication administration policy, contributing to the failure to provide appropriate treatment and care as ordered.