Failure to Monitor and Treat Constipation Resulting in Hospitalization
Penalty
Summary
The facility failed to appropriately monitor and treat constipation for two residents, resulting in significant negative outcomes, including hospitalization for one resident. For one resident with multiple complex medical conditions, including chronic respiratory failure, COPD, tracheostomy, and diabetes, the medical record showed no bowel movement for several consecutive days. Despite the facility's protocol to notify a physician after three days without a bowel movement, there was no evidence that medication was administered until the sixth day, and the Assistant Director of Nursing (ADON) could not explain the delay in intervention. Another resident, who was non-verbal and had severe cognitive impairment, experienced prolonged periods without documented bowel movements, with gaps of up to ten days. The only intervention noted was the administration of a suppository, which was ineffective. The resident was later found unresponsive with signs of vomiting and respiratory distress, requiring emergency intervention and hospitalization. Hospital records indicated the resident suffered an aspiration event, aspiration pneumonia, and abdominal distension related to constipation, with enteral nutrition being altered due to the event. Interviews with facility staff revealed a lack of clear responsibility and follow-through regarding bowel monitoring and intervention. The ADON and Director of Nursing (DON) both indicated that alerts for missed bowel movements could be cleared by nurses without action, and there was no facility policy or procedure for bowel elimination or constipation management. Additionally, a grievance filed by the resident's family regarding constipation concerns was not addressed or documented with findings or actions, and staff interviews suggested that family involvement may have led to missed communication about bowel movements.