Failure to Follow Bowel and Edema Management Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents, resulting in deficiencies related to bowel management and edema management. For one resident with moderate cognitive impairment, the facility did not follow its bowel care protocol or the resident's medication orders when the resident experienced six consecutive days without a bowel movement. Although the facility's protocol required specific interventions and provider notification after three days without a bowel movement, documentation showed that bowel medications were not administered until the sixth day, and there was no record of the resident refusing medications or being monitored for refusal. In a separate incident, another resident with acute heart failure and lymphedema did not receive timely or appropriate compression stockings as ordered. Despite nurses documenting that the resident wore compression stockings on certain days, multiple observations confirmed that the resident was not wearing them, and the correct size could not be verified. The compression stockings were found in the resident's room, unlabelled and unused, and staff were unable to confirm the appropriate size. The DON acknowledged that documentation and adherence to provider orders for compression stockings did not meet expectations.