Failure to Monitor and Document Bowel Movements Leads to Unaddressed Constipation
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of bowel movements for a resident with a diagnosis of constipation, hemiplegia, hemiparesis, unspecified muscle disorder, and difficulty walking. The resident had an active physician order for ferrous sulfate and was being monitored for bowel management. Review of the Bowel Movement Task Sheet over several days showed multiple entries of 'none' or 'not applicable,' with no bowel movements documented on several consecutive days. There were also no nursing progress notes indicating that a bowel assessment was completed on a day when the resident reported abdominal pain. The resident reported to a CNA that he was experiencing stomach pain and requested that the LPN be notified early in the morning, but the LPN did not enter the room until later. Interviews with the Medical Director and Regional Nurse Consultant confirmed that staff are expected to notify the physician if a resident has no bowel movement for three days and to assess residents who report symptoms of constipation. The facility's Bowel Management Program requires prompt documentation by CNAs and daily review by nursing staff, but these procedures were not followed, resulting in unaddressed constipation for the resident.