Failure to Provide Skin and Bowel Care per Orders and Facility Protocol
Penalty
Summary
The facility failed to provide appropriate skin care and bowel management for several residents, as required by their own policies and physician orders. For one resident with a history of cancer and fractures, a skin impairment on the right elbow was observed and reported by the resident, but this impairment was not documented in the weekly skin assessment, nor was it identified by CNAs or addressed by nursing staff during routine care. The skin issue was only acknowledged after direct observation and inquiry, despite the facility's policy requiring comprehensive and weekly skin assessments with prompt reporting of changes. In addition, two residents with gastrointestinal diagnoses and specific physician orders for bowel management did not receive care according to the facility's bowel protocol. One resident, who was always incontinent of bowel and dependent on staff for toileting, went over seven days without a documented bowel movement. Although the resident received an initial dose of Milk of Magnesia (MOM), subsequent interventions such as a suppository or enema were not administered as ordered, and there was no documentation of the resident refusing care during this period. Another resident, who required moderate assistance with toileting and had no memory impairment, also experienced a seven-day period without a bowel movement. Despite clear physician orders for a stepwise bowel protocol, including MOM, suppository, and enema as needed, staff did not administer these interventions. Staff interviews confirmed that the bowel protocol was not followed, and the required medications were not given as ordered.