Failure to Follow Bowel Management Protocol Resulting in Fecal Impaction
Penalty
Summary
The facility failed to provide appropriate care and services for a resident at risk for constipation, as required by its bowel management protocol and standing house orders. The resident, who had a history of constipation and impaired mobility, did not have a bowel movement for over four days. Despite the facility's policy requiring specific interventions such as offering prune juice, administering Senna, and escalating to a bisacodyl suppository and provider notification if no bowel movement occurred, the medical record showed that these steps were not implemented. On the third day without a bowel movement, the resident requested prune juice, but there was no documentation that further protocol interventions were carried out after this request. Subsequently, the resident experienced an unresponsive episode, was found to be pale and hypotensive, and was transferred to the hospital, where they were diagnosed with a urinary tract infection and fecal impaction. The resident's bowel movement log confirmed no bowel movement occurred between the last recorded event and the hospitalization. An administrative nurse confirmed that the medical record lacked evidence of the required bowel management interventions being implemented prior to the resident's hospitalization.