Failure to Implement Bowel Protocol and PRN Constipation Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide timely constipation interventions according to physician orders, the bowel protocol, and resident preferences for two residents who went three or more days without a bowel movement (BM). One resident with intact cognition, continent bowel status, and diagnoses including gastro-esophageal reflux disease, functional dyspepsia, and constipation reported going three or more days without a BM and not receiving any medication despite requesting help. The resident had PRN orders for Milk of Magnesia, Miralax, and a bisacodyl suppository as part of a bowel management regimen, but the care plan did not address a bowel problem area. Record review showed multiple periods of three or more days without a documented BM, with only one administration of Milk of Magnesia during one such episode and no documented PRN constipation medications during later episodes, despite the facility’s bowel protocol requiring escalating interventions on days three, four, and five without a BM. A second resident with severe cognitive impairment, bowel incontinence, and dependence for all ADLs had a care plan problem for chronic constipation directing staff to follow the bowel protocol and had PRN orders for bisacodyl tablets, bisacodyl suppositories, and enemas. Documentation showed several days without recorded BMs, followed by a BM after an enema, with no evidence of earlier, stepwise interventions per the protocol. In another episode, the resident again went multiple days without a documented BM and there was no documentation of PRN constipation medications being administered. Staff interviews confirmed the existence of a bowel protocol requiring oral laxatives on day three without a BM, suppositories on day four, and enemas on day five with physician notification, and that night shift tracked BMs and day shift was responsible for administering protocol medications. The DON was unable to explain why the required interventions were not provided for either resident.
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