One resident endured 117 hours without a bowel movement. Another went 96 hours. In both cases, nursing staff had clear protocols to follow but didn't.
The facility's standing orders, dated August 28, 2024, specify exactly what to do when residents haven't had bowel movements for three days: administer Miralax, Senna, Dulcolax, or Magnesium Citrate as needed for constipation.
Nobody followed those orders.
Resident #7, who has chronic obstructive pulmonary disease and survived a stroke, had his last bowel movement on July 27 at 1:55 PM. The next one didn't come until July 31 at 1:59 PM — four full days later.
His medication administration record shows no bowel management protocol was initiated during those 96 hours of constipation.
Resident #10 faced worse. This resident with diabetes and chronic respiratory failure experienced two separate episodes where staff ignored the facility's own rules.
The first time, he went from July 25 at 9:05 PM until July 29 at 9:50 AM without a bowel movement — 84 hours. No constipation medication was given.
The second episode lasted even longer. From August 9 at 3:31 PM until August 14 at 10:31 AM, nearly five full days passed without a bowel movement. Again, no medication was administered despite facility protocols.
That's 117 hours of potential discomfort that could have been prevented.
The Director of Nursing confirmed on August 19 that staff should start bowel management protocols when residents go 72 hours or more without bowel movements. She acknowledged they hadn't done so.
Federal inspectors reviewed eight residents' bowel and bladder care records during their August 21 investigation. Two of those eight — a 25 percent failure rate — showed clear violations of the facility's standing orders.
The facility's bowel management arsenal includes multiple options. Miralax can be mixed with eight ounces of fluid daily. Senna tablets, one or two daily as needed. Dulcolax, one tablet daily. Magnesium Citrate, one bottle daily for severe cases.
All of these medications were available. None were used when residents needed them most.
Resident #7 has been through the facility's admission process twice, most recently readmitted after an earlier stay. His medical conditions — stroke and progressive lung disease — already compromise his quality of life. Extended constipation adds unnecessary suffering.
Resident #10's situation is particularly concerning given his diabetes and chronic respiratory failure with hypoxia, a condition where his lungs can't adequately oxygenate his blood. Managing basic bodily functions becomes more critical when other systems are already compromised.
The inspection found this failure created "potential for residents to experience discomfort when medications were not administered according to the physician's order."
But this wasn't about physician orders. This was about the facility's own internal protocols, developed specifically to prevent exactly what happened to these two residents.
Standing orders exist to give nursing staff clear authority to act quickly when residents need help. When someone hasn't had a bowel movement for three days, waiting for a doctor's specific order could mean another day or two of discomfort.
The facility recognized this reality when it created its standing orders in August 2024. Staff just didn't follow them.
The medication administration records tell the story clearly. Documented bowel movements with precise timestamps. Empty spaces where constipation medications should have been recorded. A paper trail of inaction.
Resident #10's August episode — 117 hours — stretched from a Friday afternoon until the following Wednesday morning. That's an entire weekend and the start of a new week where staff documented the absence of bowel movements but took no action.
The Director of Nursing's acknowledgment that staff "had not" followed the 72-hour protocol suggests this wasn't confusion about policy. It was failure to implement known procedures.
Federal inspectors classified this as "minimal harm or potential for actual harm." But for residents experiencing extended constipation, the discomfort is immediate and real.
Both residents continue living at Parke View Rehabilitation & Care Center, where staff now know federal inspectors are watching how closely they follow their own bowel management protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Parke View Rehabilitation & Care Center from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
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