Failure to Follow Physician-Ordered Bowel Protocol
Penalty
Summary
A review of clinical records and staff interviews revealed that the facility failed to follow physician-ordered bowel protocols for a cognitively intact resident who was frequently incontinent of bowel movements. The physician's orders specified a stepwise administration of Milk of Magnesia, dulcolax suppository, and Fleets enema based on the number of days without a bowel movement. Documentation showed multiple periods in August and September 2025 where the resident did not have a bowel movement for several consecutive days, yet there was no evidence that the prescribed bowel protocol was initiated or followed. Medication administration records confirmed that staff did not administer the ordered interventions during these periods of constipation. The Nursing Home Administrator confirmed that the physician's orders for bowel medications were not followed for this resident.