Failure to Notify Physician of Resident’s Prolonged Loose Stools and Inappropriate Use of Stool Softeners
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a resident’s change in condition as required by its “Change of Condition Notification” policy. That policy states the facility will promptly inform the resident, consult with the attending physician, and notify the resident’s representative or family when there is a significant change in condition, including sudden and marked changes manifested by signs and symptoms different than usual. For one resident admitted with sepsis, pneumonia, and end stage renal disease, CNA documentation showed the resident had loose stools every day from 11/30/25 to 12/8/25. The Director of Staff Development confirmed CNAs are expected to report loose stools to the nurse and that nurses are expected to contact the physician after three days of loose stools. However, the physician was not notified until 12/8/25, after eight days of loose stools. Record review and interviews further showed that during this period the resident was given a stool softener on 12/4/25, 12/5/25, and 12/6/25 despite the ongoing loose stools documented since 11/30/25. The DON stated nurses are expected to review bowel elimination documentation and assess the resident before administering a stool softener and confirmed the physician should have been contacted after three days of loose stools. Licensed Nurse A reported typically not reviewing CNA bowel documentation and relying instead on verbal reports from CNAs or other nurses, and stated that after three days of loose stools she would notify the doctor. Licensed Nurse B stated that if a resident had loose stools for three days they would contact the doctor but acknowledged not always reviewing bowel elimination documentation before giving stool softeners. The resident reported that staff do not ask about bowel movements and described communication with staff about his condition as poor.
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