Failure to Provide and Document Bowel Care Interventions
Penalty
Summary
The facility failed to provide appropriate bowel care services for three residents, as evidenced by a lack of interventions and documentation when residents did not have bowel movements for several days. For one resident with hemiplegia, diabetes, dementia, and a history of stroke, there was no documented bowel movement for seven consecutive days, and no interventions or assessments were recorded in the medical record during this period. The Medication Administration Record also showed no administration of as-needed cathartic medication, and the Assistant Director of Nursing (ADON) confirmed the absence of both interventions and documentation. Another resident, diagnosed with hydrocephalus, diabetes, and dementia, experienced multiple periods without documented bowel movements, including three days in April and four days in May. During these times, there was no evidence in the progress notes or MAR of any interventions or assessments to address the lack of bowel movements. The ADON confirmed that the medical record lacked documentation of both interventions to promote bowel movements and bowel assessments for this resident as well. A third resident, admitted with diabetes, a foot ulcer, and on palliative care, reported not having a bowel movement in two weeks and was aware of their own elimination patterns. The review of the resident's records showed the last documented bowel movement was over two weeks prior, and although there were physician orders for as-needed laxatives, there was no documentation of these being administered. The care plan included monitoring and recording bowel movements daily and following physician orders for laxatives if no bowel movement occurred for three or more days, but there was no evidence these interventions were implemented. Interviews with facility staff confirmed the absence of required documentation and interventions for all three residents.