Failure to Follow Bowel Management Protocol and Notify Provider Leads to Resident Harm
Penalty
Summary
The facility failed to adhere to its established bowel management protocol for a resident who experienced prolonged constipation. According to the facility's policy, if a resident has no bowel movement for 9 consecutive shifts, a specific bowel protocol must be initiated, starting with Milk of Magnesia (MOM), followed by a Bisacodyl suppository, and then a Fleet enema if needed, with results documented and the provider notified if the protocol is ineffective. Record review showed that the resident went 15 consecutive shifts without a bowel movement, and the bowel protocol was not initiated as required. When MOM was eventually offered and refused by the resident, there was no evidence that this refusal was reported to the provider for further instruction or adjustment of the care plan. Further review revealed that after the resident was sent to the hospital for stroke-like symptoms and returned with a new diagnosis of constipation, the provider was not notified of this new diagnosis to allow for appropriate care plan adjustments. Documentation also failed to show timely reassessment or updates to the care plan in response to the resident's ongoing constipation and new medical findings. Staff interviews confirmed lapses in communication and monitoring, including failure to generate and pass along the required bowel management lists between shifts and lack of provider notification regarding medication refusal and significant changes in the resident's condition. As a result of these failures, the resident developed severe fecal impaction, abdominal distention, and was ultimately hospitalized with a diagnosis of constipation and stercoral colitis. The resident's condition deteriorated further during the hospital stay, leading to hypotension, hypoxia, and death. The facility was unable to provide evidence that its bowel management protocol was followed or that appropriate notifications and interventions were made in accordance with its own policies.