Failure to Coordinate Post-Surgical Care and Follow Bowel Protocol
Penalty
Summary
The facility failed to coordinate post-surgical care and follow established bowel protocol for two residents. For one resident with a recent colostomy and abdominal surgery, the facility did not ensure timely removal of surgical staples or schedule a required follow-up appointment with the surgeon, as directed in the hospital discharge instructions. Despite multiple staff being aware of the need for post-operative follow-up and staple removal, there was no documentation of communication with the surgeon’s office, and the staples remained in place for 28 days post-surgery. The resident was ultimately sent to the emergency department for staple removal after being seen by her primary care provider, who noted the lack of follow-up and the presence of redness and inflammation at the surgical site. For another resident with a history of anoxic brain damage and chronic constipation, the facility did not follow physician orders or its own bowel management protocol. The resident went seven days without a bowel movement, during which time there was no documentation of abdominal or bowel assessments, and prescribed interventions such as Milk of Magnesia, Dulcolax suppository, or Fleet enema were not administered as ordered. The facility’s policy required nursing staff to assess residents and administer interventions after three days without a bowel movement, but this was not done, and the resident was eventually transferred to the hospital for evaluation of possible bowel impaction. Interviews with facility staff confirmed that protocols for post-surgical care and bowel management were not followed. Staff members were either unaware of the need for certain interventions or failed to document and communicate necessary actions, resulting in lapses in care for both residents. The deficiencies were identified through record review, staff interviews, and review of facility policies.