Failure to Implement Effective Bowel Management Protocol Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The resident, who had diagnoses including multiple sclerosis, depression, generalized weakness, hypothyroidism, and a history of constipation, did not have a documented bowel movement for an extended period. Despite having physician orders for as needed laxatives, there was no documented evidence that these medications were administered during the period of no bowel movements. The facility's electronic medical record system was programmed to generate alerts and reports for absent bowel movements, but there was no evidence that these alerts and reports were reviewed or acted upon by staff during the relevant timeframes. The resident was eventually hospitalized after developing fever and tachycardia, where imaging revealed a severe rectal stool burden and stercoral colitis, requiring manual disimpaction. Upon return from the hospital, the resident again had no documented bowel movement for several days, and as needed bowel medications were not administered until several days later. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of bowel management protocols, with some staff unaware of the resident's condition or the need to act on bowel movement alerts. The facility did not have a written bowel management protocol specifying monitoring timeframes or parameters for administering as needed medications, and staff relied on inconsistent practices for reviewing and acting on bowel movement reports. Documentation showed that the resident was repeatedly listed on bowel movement reports as having no bowel movement, but there was no evidence of follow-up or intervention. Staff interviews indicated confusion about the frequency and use of bowel movement reports and alerts, and some staff were not aware of the resident's prolonged constipation or the need to notify providers. The lack of a clear, written bowel management protocol and failure to act on documented alerts and reports resulted in actual harm to the resident, as well as a likelihood of serious harm for other residents.
Removal Plan
- The facility provided a copy of the defined Bowel Management Regimen policy and procedure.
- The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports.
- The facility provided supporting documentation for nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift.
- A list of all facility residents who did not have a documented bowel movement in three days was provided.
- Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns.