Failure to Initiate and Document Bowel Protocol for Resident with Constipation
Penalty
Summary
A resident with moderate cognitive impairment and a history of constipation was admitted to the facility with diagnoses including constipation and sepsis. The resident was frequently incontinent of bowel and bladder, and a care plan was in place to monitor and manage bowel movements, including initiating a bowel protocol if no bowel movement occurred in two days. Despite this, the resident was repeatedly flagged on the facility's bowel list report in June, July, and August for not having bowel movements, but the facility's bowel protocol was not initiated as required by facility guidelines. The resident's medication orders for constipation were inconsistently managed. Senna was ordered and then discontinued after the resident declined it, and Colace was started later. There was no documentation that the bowel protocol was initiated during multiple periods when the resident had no bowel movements, as indicated by clinical alerts. When the resident finally received a dose of Milk of Magnesia, there was no documented evidence of its effectiveness. The lack of follow-up and documentation persisted despite the resident being seen by nurse practitioners and other staff, and despite ongoing alerts indicating the absence of bowel movements. After discharge, the resident was admitted to the hospital with severe sepsis and was found to have large amounts of stool in the rectum and rectal mural thickening on imaging, consistent with severe constipation. Interviews with staff revealed inconsistent practices regarding monitoring, documentation, and initiation of the bowel protocol. Staff acknowledged that alerts were available and discussed, but there was no evidence that appropriate interventions were consistently implemented or documented for this resident.