Failure to Implement and Document Bowel Management Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement and follow a complete care plan to address a resident's medical need for bowel management. The resident, who had a history of stroke with left-sided paralysis, chronic pain, dementia, traumatic brain injury, epilepsy, anemia, and constipation, was dependent on staff for all activities of daily living and had severe cognitive impairment. The care plan identified the resident as being at risk for constipation due to lack of exercise and medications, with interventions including medication administration, monitoring effectiveness, and documentation of bowel movements (BMs). However, the Certified Nursing Assistant (CNA) did not document the resident's BMs for two days, and the BM flow sheet showed no recorded BMs for five days. During this period, the resident's family member noticed changes in the resident's condition, including unusual abdominal movements and altered appearance, and reported these to the nurse. The resident was on multiple medications known to increase the risk of constipation, including opioids, iron supplements, and antipsychotics, with several prescribed interventions for constipation. The lack of documentation was attributed to a computer system outage, during which the CNA failed to ensure alternative documentation or communication per facility protocol. This resulted in the care plan not being fully implemented or followed as required.