Failure to Follow Bowel Management Protocol Leading to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to follow its standing bowel management orders for a cognitively intact resident, resulting in unmanaged constipation over an extended period. The facility’s standing orders and bowel protocol allowed nursing staff to administer multiple PRN bowel medications, including Bisacodyl suppositories, MiraLAX, Senna, Milk of Magnesia, and Fleet enemas, beginning after three days without a bowel movement and progressing from least to more invasive interventions. Record review showed the resident had a bowel movement on 1/9/26, then went seven days without a bowel movement before receiving Senna on 1/16/26, and ultimately went 15 days without a bowel movement before a Bisacodyl suppository was given on 1/24/26. The suppository was documented as ineffective, and nursing notes on 1/24/26 described hypoactive bowel sounds and a firm, tender abdomen, at which point an order was obtained to transfer the resident to the ER. The resident reported remembering going two weeks without a bowel movement and experiencing severe pain, stating they had informed multiple staff members of their pain and discomfort. Review of the medication and treatment administration records for the period 1/10/26 through 1/24/26 showed documented pain on multiple shifts, with two occurrences on day shift and six on evening shift under pain monitoring. Interviews with an LPN, a medication tech, the DON, and the administrator confirmed that the facility’s bowel protocol was to start after three days without a bowel movement and to escalate from prune juice to Senna, Milk of Magnesia, suppository, and then Fleet enema as needed. The DON and administrator acknowledged that the resident’s constipation was not appropriately managed according to this protocol, and the resident ultimately required transfer to the ER, where the constipation was resolved with an enema before the resident returned to the facility.
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