Failure to Monitor and Timely Treat Constipation and Infection
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor a resident's condition, specifically regarding bowel and bladder elimination, which resulted in a delay in identifying and treating infection and constipation. The resident had multiple risk factors, including diabetes, impaired cognition and mobility, cystitis, a history of sepsis, and was at high risk for both constipation and infection. The care plan included interventions for constipation and infection, but did not comprehensively address all infection risks related to the resident's diagnoses. After returning from a hospital stay for sepsis, there was no evidence of comprehensive infection monitoring as outlined in the care plan. The resident had physician orders and a bowel protocol in place, which required administration of specific medications if no bowel movement occurred after three days, escalating to physician notification if interventions were unsuccessful. Despite documentation showing no bowel movement for four consecutive days, the required interventions were not administered in a timely manner according to the protocol. Staff interviews confirmed that the bowel protocol was not followed as ordered, and there was a lack of timely physician notification and assessment when the resident's condition changed. On the day of the incident, the resident exhibited progressive symptoms including stomach upset, diaphoresis, vomiting fecal matter, a firm and distended abdomen, hypoxemia, change in mental status, elevated heart rate, and pallor. Although some interventions were eventually initiated, there was a delay in both the administration of bowel protocol steps and in notifying the physician. The resident was ultimately transferred to the hospital with diagnoses of aspiration pneumonia and possible small bowel obstruction, and subsequently passed away with sepsis listed as the cause of death.