Failure to Provide Timely Assessment and Physician Notification for Constipation Leading to Harm
Penalty
Summary
A resident with a history of Parkinson's Disease, dementia, and chronic constipation experienced a significant decline in bowel function, going six days without a bowel movement. Despite facility policies requiring monitoring and intervention for constipation, there was no documented evidence that the resident was properly assessed by a registered nurse or that a medical provider was notified in a timely manner. The resident exhibited symptoms including abdominal distention, pain, and discomfort, which were reported by staff and family members, but these concerns were not adequately addressed or escalated according to protocol. The facility's bowel management protocol required that residents with no bowel movement for three days receive specific interventions and that abnormal findings be reported to a physician. However, the resident was administered bowel medications, including Milk of Magnesia, without a physician's order or proper documentation in the medication administration record. Multiple staff members, including LPNs and CNAs, noted the resident's symptoms and attempted to communicate concerns, but there was a lack of follow-through in notifying supervisors or ensuring a registered nurse assessment was completed. The medical provider was not made aware of the resident's condition until after a significant delay, and the facility's documentation was inconsistent regarding bowel movements and interventions provided. Ultimately, the resident's condition deteriorated, leading to hospitalization for a bowel obstruction that required emergency surgery. Interviews with facility staff and medical providers confirmed that the expected protocols for assessment, notification, and documentation were not followed. The failure to provide timely and appropriate care according to professional standards and the resident's care plan resulted in actual harm to the resident.