F0684

D

Failure to Follow Bowel Protocol and PICC Line Orders

Idaho Falls, Idaho Survey Completed on 04-02-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow physician orders and facility policies for bowel management and infusion therapy. For one resident with Parkinson's disease and chronic kidney disease, the facility had a standing bowel protocol with stepwise orders for Senna, Bisacodyl tablets, Bisacodyl suppository, and Fleet enema, including instructions to call the physician if no bowel movement occurred within specified time frames. The medication administration record showed this resident had a bowel movement on 3/17/26 and not again until 3/22/26, a gap of over 96 hours, without any bowel management medications documented as given between 3/20/26 and 3/22/26. There was no documentation in the nursing progress notes that the physician was contacted during this period despite the protocol requirements, and the Regional Clinical Specialist later stated that refusals had been recorded only on a separate bowel care worksheet and not on the MAR or in progress notes, where they should have been documented.

The deficiency also includes improper management and documentation of a PICC line for another resident with interstitial lung disease and heart failure. Observation revealed a PICC line in the resident’s right upper extremity with an undated dressing, loose edges, and unsecured tubing, contrary to the facility’s infusion therapy policy requiring adherence to aseptic technique and proper maintenance of infusion equipment and catheters. An LPN acknowledged the absence of a date on the dressing and was unsure if the line was still in use. Review of the medical record showed an order for IV Ertapenem for sepsis related to pneumonia that ended on 3/1/26, and an RN reported she could not locate current orders for the PICC line and stated that the line may have been discontinued, but in either case it should have been removed or had active orders.