Failure to Notify Physician and Document Change of Condition for Resident with No Bowel Movement
Penalty
Summary
The facility failed to ensure that a change in condition was identified and that the physician was notified for a resident who had not had a bowel movement for four days. The resident, who had diagnoses including enterocolitis due to clostridium difficile and irritable bowel syndrome, was dependent on staff for toileting and mobility. Documentation showed no bowel movement for several consecutive days, and the resident reported severe abdominal pain rated at 10/10. Despite a clinical alert for no bowel movement being generated, there was no evidence in the records that a change of condition was documented or that the physician was notified during this period. Interviews with nursing staff revealed gaps in communication and follow-through regarding the resident's condition. The Assistant Director of Nursing acknowledged that the absence of a bowel movement for more than three days should have triggered a change of condition and physician notification, as per facility policy. However, neither the required assessment nor the notification occurred. Licensed nursing staff indicated reliance on hand-off communication and did not receive or act upon alerts or reports from certified nursing assistants regarding the resident's status.