Failure to Perform GI Assessment and Monitoring After Rectal Bleeding
Penalty
Summary
A deficiency occurred when nursing staff failed to conduct a comprehensive gastrointestinal (GI) and abdominal assessment and provide continued monitoring for a resident following an incident of rectal bleeding. The resident, who had a history of constipation, impaired mobility, opiate use, and a prior ileus, was identified as being at risk for constipation and was dependent on staff for toileting. Despite these risk factors and a care plan that included monitoring for constipation and following a bowel protocol, the nurse's note documented only a visual assessment after the resident was found with bright red rectal bleeding. No abdominal assessment or evaluation of bowel sounds was performed at that time. Further review of the clinical record and nurse's notes revealed that, over the following days, there was a lack of documentation indicating that a GI or abdominal assessment was performed, even as the resident continued to experience rectal bleeding and discomfort. The hydrocortisone suppository ordered for suspected internal hemorrhoids was inconsistently administered due to unavailability, and there was no evidence of ongoing monitoring or reassessment of the resident's condition. The situation escalated when the resident exhibited worsening symptoms, including dark red rectal bleeding, nausea, and abdominal discomfort, eventually leading to the expulsion of a large blood clot and transfer to the emergency department for evaluation and urgent intervention. Interviews with facility staff confirmed that the nurse responsible did not review the resident's clinical record prior to the initial assessment and was unaware of the resident's history of constipation and current bowel regimen. Both the APRN and DON acknowledged that a full GI assessment should have been performed and that a more thorough review of the resident's history was necessary to ensure appropriate care and communication with the provider. Facility policy required monitoring and assessment for changes in condition, but these steps were not followed in this case.