Failure to Implement Physician-Ordered Bowel Protocol and Notify Physician
Penalty
Summary
Nursing staff failed to implement a physician-ordered bowel management protocol for a resident who did not have a documented bowel movement over a five-day period. The resident's clinical record included active orders for a stepwise bowel regimen, including administration of Milk of Magnesia if no bowel movement occurred after three days, a bisacodyl suppository if there was no result on the fourth day, and a Fleet enema if there was still no result on the fifth day, with instructions to notify the physician if the interventions were ineffective. Review of the resident's bowel tracking records and Medication Administration Record revealed no evidence that any of the ordered interventions were administered during the five-day period without a bowel movement. Additionally, there was no documentation that the physician was notified as required by the protocol. The DON confirmed that the bowel protocol was not implemented and the physician was not notified during this time.