Failure to Implement Bowel Protocol and PRN Laxatives for Constipated Resident
Penalty
Summary
The deficiency involves the facility’s failure to timely implement and follow a bowel management protocol for a resident with multiple complex medical conditions and known constipation. The resident, admitted with diagnoses including cerebral infarction, stroke, malnutrition, hemiparesis, epilepsy, type II diabetes, schizoaffective disorder, bipolar disorder, and PTSD, was dependent on staff for toileting and was incontinent of bowel and bladder. The care plan identified constipation with interventions to record bowel movement patterns and administer medications as ordered. Physician orders included routine Docusate Sodium and Polyethylene Glycol for bowel management, as well as PRN Bisacodyl suppositories and Milk of Magnesia for constipation. Record review showed multiple periods where the resident had no documented bowel movements for several consecutive days, yet there was no documentation that PRN bowel medications were administered. Specifically, there were no documented bowel movements on several dates in December and January, and the MAR showed no administration of PRN Bisacodyl suppositories or Milk of Magnesia during those periods. Despite the facility’s bowel management policy stating that residents without a bowel movement for three consecutive days should have a specified bowel protocol initiated, the DON confirmed that the bowel protocol was not initiated on the dates when it should have been, based on the absence of bowel movements. During these episodes of unaddressed constipation, the resident experienced abdominal symptoms that led to multiple ER visits. An abdominal x-ray on one occasion showed a large, dilated bowel loop with a recommendation for a CT scan to rule out obstruction, and an ER summary documented significant constipation and stool burden treated with a suppository and oral laxatives. On another occasion, progress notes described the resident as inconsolable with abdominal pain, absent bowel sounds in lower abdominal quadrants, and pain on palpation, prompting transfer to the ER where the resident had a bowel movement. A later ER visit for possible bowel obstruction resulted in a CT scan, administration of a soap suds enema, and adjustments to the resident’s laxative regimen. These events occurred in the context of the facility not initiating the bowel protocol as required by its own policy and the resident’s orders.
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