F0580

D

Failure to Notify Provider of Ongoing Refusal of Bowel Regimen

Omaha, Nebraska Survey Completed on 01-29-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to the facility’s failure to notify the medical practitioner of ongoing refusals of prescribed bowel medications for one resident. The facility’s policy, last reviewed on 08/27/2018, required notification of the physician or designee and the resident’s legal representative when there was a need to significantly alter treatment, including discontinuation of existing treatment due to ineffectiveness or adverse consequences, or initiation of new treatment. The policy specified use of an SBAR tool for non-emergent notifications, with documentation to be filed in the physician’s order section of the chart. Despite this policy, the facility did not notify the provider when the resident repeatedly refused bowel regimen medications over a series of days.

The resident involved had a history of cerebral infarction with right-sided hemiplegia/hemiparesis, difficulty walking, moderate cognitive impairment (BIMS score of 7), and constipation. The comprehensive care plan included monitoring for constipation, monitoring bowel and bladder patterns every shift, and ongoing education about bowel management, noting that the resident often stated it was normal to go a lengthy time between bowel movements and that the resident sometimes refused bowel protocol due to past work circumstances. Physician orders included multiple bowel regimen medications (prune products PRN, milk of magnesia PRN, senna, bisacodyl suppository PRN, Motegrity, Miralax, and an order to document bowel sounds and abdominal characteristics daily).

Medication Administration Records showed that over a 10-day period the resident refused docusate sodium 15 of 20 scheduled doses, refused Motegrity and Miralax 8 of 10 scheduled doses, and refused senna on 2 occasions. Progress notes documented repeated refusals despite RN education on the importance of bowel medications and more frequent bowel movements, and noted the resident had gone 7 and then 8 days without a bowel movement while continuing to refuse bowel protocol, though bowel sounds were active in all quadrants at those times and the resident denied pain or discomfort. Additional notes documented vomiting episodes and changes in bowel sounds on one day. A physician dictation later acknowledged the resident had not been taking the bowel regimen because of dislike of the medications. However, review of progress notes, scanned documents, and the physical chart revealed no evidence that the medical practitioner had been notified of the repeated refusals, and there were no documented parameters for notification of medication refusals in the physician’s orders or care plan. The RN Team Lead and DON confirmed there was no evidence of SBAR communication or provider notification for these refusals during the period reviewed.