Failure to Assess and Notify Physician for Ongoing Diarrhea
Penalty
Summary
Facility staff failed to provide care and treatment in accordance with a resident's assessed needs and professional standards of practice for bowel care. The resident, who had complex medical conditions including kidney and heart disease, unstable blood sugar, bone infection, and a recent toe amputation, began experiencing multiple episodes of loose bowel movements over a period of several days. Despite documentation of ongoing diarrhea and the resident expressing distress, fatigue, and lack of energy to therapy staff, there was no evidence that nursing staff assessed the resident's condition, addressed the symptoms, or notified the physician as required by the care plan. The care plan specifically indicated that timely communication with the physician or nurse practitioner was necessary for any change in the resident's condition. However, medical records and staff interviews confirmed that no assessment, intervention, or physician notification occurred regarding the resident's ongoing diarrhea. The Director of Nursing acknowledged the lack of documentation and stated that staff did not follow expected procedures. Additionally, the facility did not have a policy in place for managing residents with diarrhea.