§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
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Observations:
Based on a review of clinical records and staff interview it was determined that the facility failed to follow physician orders for bowel protocol to promote bowel activity for four resident out of four sampled (Residents 56, CR1, CR2, and CR3).
Findings include:
Review of facility's physician ordered bowel protocol, provided at the time of the survey ending June 29, 2022, indicated that the resident has no bowel movement (BM) in 5-7 shifts, give 4 oz of prune juice on the 3 PM to 11 PM shift; if no BM/small in 8-10 shifts, give 30 cubic centimeters (cc) of milk of magnesia ( MOM, a laxative) on the 7 AM to 3 PM shift; if no BM/small in 8-10 shifts, give Dulcolax suppository rectally on the 3 PM to 11 PM shift; if no BM in 11-13 shifts, give fleets enema; and if no BM after fleets enema, contact the physician and obtain further orders.
According to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week.
A review of the clinical record revealed that Resident 56 had diagnoses that included constipation and hypertension. Review of Resident 56's clinical record indicated that she had physicians orders for the bowel protocol starting on July 21, 2016.
Review of the Documentation Survey Report for Bowel Elimination from June 1, 2022, to June 28, 2022, indicated that from June 7, 2022, 2nd shift to June 10, 2022 1st shift, 9 shifts of nursing duty, Resident 56 did not have a bowel movement. From June 14, 2022, 2nd shift to June 16, 2022, 3rd shift, 8 shifts, Resident 56 did not have a bowel movement.
Review of Resident 56's MAR (Medication Administration Record) for June 2022 revealed no no documented evidence that the physician ordered bowel protocol was implemented from June 7, 2022, 2nd shift to June 10, 2022, 1st shift, and from June 14, 2022 2nd shift to June 16, 2022, 3rd shift to promote bowel activity.
Clinical record review revealed that Resident CR1 had diagnoses that included constipation and hypertension. Review of Resident CR1's clinical record indicated that she had Physicians orders for bowel protocol starting on January 20, 2022.
Review of the Documentation Survey Report for Bowel Elimination from January 20, 2022, to February 12, 2022, indicated that from January 26, 2022, to January 30, 2022, for 15 shifts Resident CR1 did not have a bowel movement.
Review of Resident CR1's January 2022 MAR revealed no documented evidence that the physician ordered bowel protocol was followed in response to the resident's lack of bowel activity.
Clinical record review revealed that Resident CR2 had diagnoses that included constipation and hypertension.
Review of Resident CR2's clinical record indicated that she had physician orders for the bowel protocol starting on February 17, 2022.
Review of the Documentation Survey Report for Bowel Elimination from February 17, 2022, to March 10, 2022, indicated that from February 17, 2022, to February 21, 2022, for 15 shifts Resident CR2 did not have a bowel movement. From February 21, 2022, 2nd shift to February 25, 2022, 2nd shift, 10 shifts Resident CR2 did not have a bowel movement.
Review of Resident CR2's February 2022 MAR revealed no documented evidence that the physician ordered bowel protocol was followed, with the exception of February 21, 2022, at 12:36 p.m. after 15 shifts of no BM, milk of magnesia was given. However, this medication should have been given after 8-10 shifts without a bowel movement.
Clinical record review revealed that Resident CR3 had diagnoses that included brain cancer and hypertension. Review of Resident CR3's clinical record indicated that she had a physician orders for the bowel protocol starting on February 5, 2022.
Review of the Documentation Survey Report for Bowel Elimination from February 5, 2022, to February 14, 2022, indicated that from February 9, 2022, to February 11, 2022, for 7 shifts Resident CR3 did not have a bowel movement.
Review of Resident CR3's February 2022 MAR there was no documentation that physician ordered bowel protocol was carried out from February 9, 2022 to February 11, 2022 to promote bowel activity.
Interview with the Administrator on June 29, 2021 at 1:30 p.m. confirmed that the facility was unable to demonstrate that the physician ordered bowel protocol was accurately and consistently implemented to promote bowel activity for these residents.
28 Pa. Code 211.12 (a)(c)(d)(1)(3)(5) Nursing services
28 Pa. Code 211.5(f)(g)(h) Clinical records.
28 Pa. Code 211.10 (c)(d) Resident care policies
| | Plan of Correction - To be completed: 07/26/2022
1. Residents CR1, CR2, and CR3 no longer reside at the facility. Resident 56 had no ill effects from bowel protocol not being followed.
2. To prevent this from recurring a facility audit was completed from the last two weeks for residents who were on bowel protocol to ensure bowel protocol was being followed.
3. DON/ Designee to educate licensed nursing staff on facility bowel protocol.
4. DON/Designee will audit 5 residents on bowel protocol daily x 5, weekly x3 and monthly x 2 to ensure bowel protocol is being followed. Findings will be brought to the monthly QAPI meeting.
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