Failure to Discontinue Laxative as Ordered After Bowel Movement
Penalty
Summary
Facility staff failed to provide treatment and care according to medical provider orders and professional standards of practice for one resident. The resident had multiple diagnoses including chronic kidney disease, mild vascular dementia with agitation, left femur fracture, and difficulty walking, and had a BIMS score of 12/15 indicating moderately impaired cognition. On 2/16/26, a medical provider progress note documented that the resident was flagged for constipation greater than three days and that polyethylene glycol (MiraLAX) 1 capful every evening had been added until the resident had a bowel movement. A corresponding MD Communication Form dated 2/16/26 specified the order as polyethylene glycol 1 capful “until BM.” The facility’s policy on non-controlled medication orders required that medication orders specify the quantity or duration of therapy. Review of the resident’s bowel elimination record for February 2026 showed the resident had a bowel movement on 2/17/26. Despite this, the February 2026 MAR showed that staff continued to administer polyethylene glycol at bedtime from 2/16/26 through 2/24/26, rather than discontinuing it after the bowel movement as ordered. The comprehensive person-centered care plan identified the resident as at risk for constipation related to reduced physical mobility and included an intervention to administer medications as ordered. During the survey, the DON acknowledged that the MiraLAX should have been discontinued after the resident’s bowel movement on 2/17/26, confirming that staff did not follow the provider’s order regarding the duration of the medication.
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