F0690

D

Failure to Follow Bowel Management Protocol for Constipated Resident

Dublin, Ohio Survey Completed on 01-26-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency related to failure to follow the facility’s Bowel Management Protocol for a resident with bowel incontinence. The resident was admitted with diagnoses including necrotizing fasciitis, acute and chronic respiratory failure, type 2 diabetes, and obstructive and reflux uropathy. The admission MDS documented that the resident was cognitively intact, had an indwelling catheter, and was always incontinent of bowel. The care plan dated 11/13/25 indicated the resident had bowel incontinence, with interventions to check and change the resident and encourage use of the call light for toileting assistance. A separate care plan dated 11/13/25 documented an ADL self-care performance deficit, stating the resident was totally dependent on one staff member for toileting.

Review of bowel movement documentation showed that the resident did not have a bowel movement for four consecutive days on 12/23/25, 12/24/25, 12/25/25, and 12/26/25. During an interview on 01/14/26 at 2:31 P.M., the DON confirmed that the resident had no bowel movement for four days and that no bowel interventions were implemented during that period. The DON verified that the facility’s Bowel Management Protocol should have been followed. The protocol, dated 02/15/15, stated that residents were to be kept free from complications secondary to constipation through adequate assessment, tracking, and treatment, with normal bowel patterns defined as once every day up to once every three days. It further required nurses to provide or obtain ordered bowel medications for residents on the bowel care list, document medications on the MAR and bowel care list, and follow up for results. These steps were not carried out for this resident during the four-day period without a bowel movement.