Failure to Assess and Document Bowel Status for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, nursing staff did not conduct or document comprehensive bowel elimination assessments for a resident with a recent history of fecal impaction and multiple risk factors for constipation, including opioid and sedative medication use, advanced dementia, and bowel incontinence. The care plan required assessment and documentation of the resident's usual bowel movement history, including pattern, frequency, and characteristics, and the facility had physician orders to monitor for constipation every shift due to medication side effects. On multiple shifts over two consecutive days, both licensed nurses (LVNs and RNs) and CNAs failed to assess and/or document the resident's bowel status in the electronic health record. Interviews with staff revealed that some nurses relied on computer alerts, which only function if bowel movement data is entered, and did not perform physical assessments unless prompted by symptoms or alerts. CNAs cited technical issues with computers and did not always inform nurses when documentation was incomplete. The lack of documentation and assessment occurred despite the resident's recent hospital discharge for fecal impaction, ongoing risk factors, and explicit care plan interventions and physician orders. Facility leadership, including the DON, unit manager, and administrator, confirmed that staff were responsible for assessing, monitoring, documenting, and reporting changes in bowel patterns, and that these actions were not carried out as required. The facility's policy required bowel and bladder assessments upon admission, readmission, and as needed, with ongoing documentation and care plan updates. The failure to assess and document the resident's bowel status as required by policy and care plan interventions led to the deficiency cited by surveyors.