Failure to Follow Bowel Protocol and Physician Orders for Constipation Management
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care for constipation in accordance with physician orders, the facility’s bowel protocol policy, and professional standards of practice for two residents. The facility’s Bowel Tracking Protocol required bowel activity to be recorded each shift, issues such as constipation to be reported to a licensed nurse, and a daily audit by the DON to identify residents without a bowel movement (BM) in 48 hours, followed by a stepwise laxative/enema protocol. For one resident, the care plan identified risk for constipation with interventions to administer medications, enemas, and suppositories as ordered, document bowel movement frequency and character, and check for fecal impaction as needed. For this resident, a physician order directed administration of an Enemeez (docusate sodium) micro enema if there was no BM by the morning of day 4, with instructions to contact the provider if no BM occurred within one hour after administration. Bowel documentation showed no BM for four consecutive days, yet the March MAR showed the ordered PRN enema was not given on the fourth day, and there was no documentation that the physician was notified of the absence of a BM after four days. The resident subsequently had a large BM the following day and reported concerns related to constipation, stating that when constipated it caused bleeding. Staff interviews indicated that nurses were expected to review daily bowel lists, administer PRN medications for constipation, and notify supervisors and physicians if residents did not defecate by mid-shift, and that unit managers ran reports to identify residents without BMs and ensured bowel protocols were implemented. The second resident had documented diagnoses including constipation and an MDS confirming current conditions, with a care plan noting increased nutrition/hydration risk related to constipation; however, the facility did not implement specific constipation interventions in the care plan. Physician orders directed administration of Miralax if no BM by day 2 in the morning, Miralax twice daily PRN for constipation, and Senna twice daily PRN if no BM by day 2 in the morning. Bowel documentation showed no BM for three days, but the March MAR revealed that neither Miralax nor Senna was administered as ordered on the third day, and there was no evidence the physician was notified of the continued absence of a BM. The resident reported constipation-related discomfort, including severe soreness, inability to defecate, very hard stool, and significant abdominal pain. The ADON and the Nursing Home Administrator confirmed that the ordered bowel protocol was not implemented for these two residents.
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