Failure to Monitor and Treat Constipation per Bowel Protocol and Physician Orders
Penalty
Summary
The facility failed to monitor and manage a cognitively intact resident’s bowel function in accordance with its bowel protocol and the physician’s PRN constipation orders. The facility’s bowel protocol required the 11–7 nursing supervisor to monitor bowel movements (BM) daily, identify residents without a BM for 2 days as at risk for constipation, and then implement a stepwise regimen including prune juice, Milk of Magnesia, Dulcolax suppository, and Fleet enema, with assessment and physician notification if there were no results or if pain or absent bowel sounds were present. The physician’s orders for the resident included PRN prune juice, magnesium hydroxide suspension, bisacodyl suppository, and Fleet enema for constipation. The resident’s admission MDS showed they were cognitively intact, required supervision with toilet transfers and partial/moderate assistance with toilet hygiene, and were coded as having an ostomy or no BM for seven days, while the admission assessment documented that the resident did not have an ostomy. Facility documentation showed that the resident had no documented BM for multiple extended periods: four consecutive days, then five days, and another five days without a BM. During these periods, there was no documented evidence that the bowel protocol steps were implemented, that the resident’s bowel status was assessed, or that the ordered PRN constipation medications were administered. Nursing progress notes on two of the days without a BM did not include an abdominal exam or bowel sounds assessment to determine constipation. A later nursing note documented the resident’s complaint of nausea and diarrhea, with vitals checked, but the nurse was unsure how many BMs the resident had, and there was no comprehensive assessment to determine whether the reported diarrhea represented fecal seepage related to constipation. The DON reported that the EMR generates alerts when a resident has no BM for two days and that supervisors are to communicate these alerts so staff can implement the bowel protocol, but confirmed there was no documentation that the protocol was followed for this resident.
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