Failure to Hold Stool Softener and Notify Physician for Ongoing Loose Stools
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order to hold a stool softener when a resident experienced loose stools, and failure to assess bowel documentation and notify the physician after three days of loose stools. Resident 1 was admitted with diagnoses including sepsis, pneumonia, and end stage renal disease. A physician’s order dated 11/17/25 directed that Bisacodyl, a laxative, be given once daily with instructions to hold the medication for loose stools. Review of the electronic MAR for 12/2025 showed that Bisacodyl was held from 12/1/25 to 12/3/25 due to loose stools, but then administered from 12/3/25 to 12/6/25, and refused by the resident on 12/7/25. The order was not changed to an as-needed basis until 12/8/25 after the physician was notified. Interviews and record reviews with the DSD, DON, and IP confirmed that CNAs documented loose stools for Resident 1 daily from 11/30/25 through 12/8/25. The DSD stated that CNAs are expected to report loose stools to the nurse and that nurses should contact the physician after three days of loose stools. The DON confirmed that Bisacodyl was administered on 12/4/25, 12/5/25, and 12/6/25 despite documentation of ongoing loose stools since 11/30/25, and that the physician was not contacted until 12/8/25, after eight days of loose stools. The IP stated that medications causing loose stools should not be given when a resident is having loose stools and that the physician should be contacted after three days of loose stools. The facility’s Medication - Administration policy indicated that all medications must be administered by licensed nursing staff according to physician orders, which was not followed in this case.
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