Failure to Administer Ordered Constipation Treatment Leading to Fecal Impaction
Penalty
Summary
The facility failed to provide treatment and care according to physician orders when staff did not respond to a resident’s lack of bowel movements for four consecutive days. The resident was admitted with diagnoses including muscle weakness, and documentation showed the last recorded bowel movement occurred on 2/22/26, with no bowel movements recorded on 2/23, 2/24, 2/25, or 2/26. The resident had a standing order dated 11/10/25 for magnesium hydroxide to be administered if no bowel movement occurred for three days, but the Medication Administration Record showed the medication was not given on those four days. The facility’s progress notes contained no documentation between 2/22/26 and 2/26/26 regarding the resident’s bowel status or any offer or administration of magnesium hydroxide. On 2/27/26, a nurse’s note recorded that the resident had been admitted to a general acute care hospital with diagnoses including altered mental status, urinary tract infection, and fecal impaction. In a subsequent interview, the DON stated that nursing staff should have started magnesium hydroxide on 2/25/26 and acknowledged the facility did not have a policy on managing constipation.
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