Failure to Timely Evaluate and Act on Signs of GI Bleed
Penalty
Summary
A deficiency occurred when the facility failed to timely act upon or evaluate signs of a potential gastrointestinal (GI) bleed in a resident who was later hospitalized with GI complications. The resident, who had a history of colon cancer, chronic kidney disease, and a recent right hemicolectomy, was admitted to the facility following a fall and cervical fracture. Initial assessments and documentation did not indicate any active or monitored GI bleed, and bowel movements were recorded as formed and normal in consistency. However, on the day of the incident, a nursing assistant noticed a foul, unusual odor in the resident's room in the early morning, which was later identified as similar to the odor present when the resident had a large, bloody, black stool during transfer to the hospital. The nursing assistant did not report the abnormal odor to the nurse, assuming it had already been addressed based on information from a previous shift. Later that day, while preparing the resident for hospital transfer due to complaints of head and neck pain, staff observed a large amount of bloody, loose stool with a distinctive odor, which an EMT identified as indicative of a GI bleed. The nurse confirmed that if such an odor had been reported earlier, they would have initiated monitoring and notified the physician immediately. The medical record lacked evidence that the odor noticed by direct care staff was evaluated in a timely manner or that the resident was assessed for other symptoms of a GI bleed prior to the EMT's arrival. Interviews with the assistant director of nursing and director of nursing confirmed that no concerns about a potential GI bleed were reported by staff prior to the incident. The facility's change of condition policy required evaluation and physician notification for significant changes in status but did not specifically mention GI bleed symptoms such as abnormal stool odor or black stools. The failure to recognize and act upon early signs of a GI bleed resulted in a delay in care for the resident.