Failure to Administer Bowel Care and Monitor Weights per Orders
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards and residents' person-centered care plans for several residents, specifically in the areas of bowel management and fluid volume monitoring. For four residents reviewed for bowel management, there were multiple instances where residents went several days without a bowel movement, and as-needed (PRN) bowel medications were not administered as per physician orders or the facility's bowel protocol. In some cases, PRN bowel medication orders were missing or not visible to nursing staff, particularly following a transition to a new electronic health record (EHR) system. Staff interviews confirmed that these medications should have been administered but were not, and that the EHR transition likely contributed to the oversight. Additionally, for two residents with orders for regular weight monitoring due to conditions such as heart failure and the use of diuretics, the facility failed to obtain and document weights as ordered. In one case, weights were not recorded for over a month, and in another, only a fraction of the required daily weights were documented over a 49-day period. Staff confirmed that these failures were due to issues with order input in the EHR, which prevented nurses from seeing the weight monitoring orders. These deficiencies resulted in residents not receiving care and monitoring as directed by their physicians and care plans.