Failure to Monitor and Report Bowel Movements Resulting in Harm
Penalty
Summary
The facility failed to provide treatment and care according to physician orders, resident preferences, and professional standards for three out of five residents reviewed. Specifically, multiple residents experienced prolonged periods without bowel movements, ranging from six to eleven consecutive days, without documented evidence that the physician was notified or that staff were aware of the need for interventions. Facility policy required nurses to check bowel movement patterns every shift and notify the physician if a resident had no bowel movement in 48 hours, but this protocol was not followed. One resident, admitted with spinal stenosis, spondylosis, and constipation, had no bowel movements for eight and then nine consecutive days. There was no documentation that the physician was notified as required by the resident's orders. The resident was later hospitalized for bowel impaction, with a CT scan confirming fecal impaction and stercoral proctitis. Interviews with staff revealed that certified nursing aides and LPNs were either unaware of how to check bowel reports in the electronic medical record or did not run the reports as required. The primary care physician confirmed they were not notified of the resident's condition. Two additional residents with diagnoses including hemiplegia, dysarthria, multiple sclerosis, ulcerative colitis, and chronic obstructive pulmonary disease also experienced extended periods without bowel movements. Documentation showed no evidence of physician notification or staff awareness of the issue. Staff interviews further revealed a lack of knowledge or adherence to the bowel management protocol. The DON and Administrator were unaware that the bowel reports were not being run and that the issue had not been discussed in Quality Assurance and Performance Improvement meetings.