F0684

J

Failure to Implement Bowel Monitoring Policy Resulting in Fecal Impaction and Bowel Perforation

Harrison, Ohio Survey Completed on 01-14-2026

Penalty

Fine: $28,190

Summary

The deficiency involves the facility’s failure to monitor and respond to a resident’s bowel status in accordance with the facility’s bowel monitoring policy and the resident’s care plan. The resident had diagnoses including Parkinson’s disease, anemia, constipation, depression, and edema, and the care plan identified a potential for constipation related to decreased mobility and medication side effects. Interventions in the care plan included monitoring and recording the frequency of bowel movements and administering laxatives per physician orders. The physician had ordered daily polyethylene glycol (Miralax) for constipation.

Review of the bowel tracking report showed that the resident had a small bowel movement on one documented date, followed by no recorded bowel movements for five consecutive days. The facility’s bowel monitoring policy required the charge nurse to review the electronic medical record for residents without a bowel movement for three consecutive days and to administer PRN laxatives or other interventions such as prune juice and/or notify a clinician. The DON confirmed that the electronic medical record dashboard was designed to alert nurses when a resident had not had a bowel movement for three days, and that there was no documentation that the bowel monitoring policy was implemented after the resident went multiple days without a bowel movement. The DON also verified that the charting reflected no bowel movement for the five-day period.

During this period without documented bowel movements, the resident’s condition changed. On one evening, the resident reported a pain score of five on a zero to ten scale. Later that night, a nursing note documented complaints of abdominal pain with pain upon palpation, coughing up mucus, and labored breathing. The on-call MD was notified and ordered that the resident be sent to the emergency department for evaluation and treatment, with the note indicating concern about possible delay of treatment due to a holiday. An SBAR form and progress note documented that the resident’s last bowel movement had been five days earlier. At the hospital, imaging (CTA) showed a large amount of stool in the rectum and sigmoid colon with wall thickening, mesenteric induration, and a moderate amount of pneumoperitoneum consistent with bowel perforation, likely related to fecal impaction and stercoral colitis. The resident was admitted to the hospital and subsequently died; the death certificate listed cardiac respiratory arrest as the cause of death. The MD and NP later stated they had not been notified when the resident had gone three days without a bowel movement, despite the expectation that they would be called at that point so new orders could be given.

The surveyors determined that this failure to monitor and act on the resident’s bowel status according to the facility’s bowel monitoring policy and the resident’s care plan resulted in a fecal impaction with a perforated bowel requiring hospitalization and contributed to Immediate Jeopardy. The Immediate Jeopardy was cited for one resident reviewed for change of condition out of a facility census of 123 residents. The deficiency was investigated under a specific complaint number and was supported by medical record review, hospital records, staff and provider interviews, policy review, and reference to clinical information from the National Library of Medicine regarding stercoral colitis and constipation.

Removal Plan

• DON reviewed all current residents with any new progress notes to identify possible changes of condition; no concerns identified.
• Held a QA meeting with Administrator, Medical Director, DON, ADON, Corporate Nurse Educator, Regional Director of Operations, and VP of Nursing to review findings and develop, review, and approve the plan of action.
• Provided in-service education to DON and ADON by the Corporate Nurse Educator on the Change in Condition Policy and conducting assessments.
• Initiated and completed an audit of each resident with no bowel movement for three days; residents were assessed, providers contacted as appropriate, and interventions implemented as needed; bowel monitoring policy implemented for identified residents.
• Conducted in-service education for all current licensed nurses on timely assessment for potential change in condition, reviewing the EMR clinical dashboard, and related expectations; off-site nurses educated by telephone; nurses not yet educated were restricted from working until education completed.
• QA Nurse initiated an audit to ensure appropriate care plan interventions are in place and being implemented as needed; audit completed.
• Implemented review of current residents’ progress notes by DON, ADON, and unit managers to identify possible changes of condition, including residents at risk for constipation.
• Implemented ongoing review by DON, ADON, and unit managers of residents with no bowel movement noted for three days to ensure assessment, intervention, and physician notification as appropriate.
• Implemented a Performance Improvement audit worksheet for residents to ensure assessment for potential change in condition related to no bowel movement in three days, with a monitoring schedule and reporting of results to the QA committee for determination of further monitoring needs.
• Held a follow-up QA meeting with Administrator, Medical Director, DON, ADON, Regional QA Nurse, Regional Director of Operations, and VP of Nursing to review education, audit findings, and the ongoing audit schedule; QA committee to monitor.