Failure to Implement Bowel Regimen for High-Risk Tube-Fed Resident
Penalty
Summary
A resident in their 70s with traumatic subdural hemorrhage, facial fractures, aphasia, dysphagia, and a G-tube was assessed on admission as high risk for constipation and care planned on 1/10/26 with a goal of having satisfactory bowel movements every 1 to 3 days, including an intervention to administer medications per physician order. Despite this, the physician orders contained no routine bowel regimen (such as laxatives or stool softeners) other than a PRN MiraLax order obtained on 1/26/26 after the resident had already gone five days without a bowel movement. Bowel movement documentation showed a small, putty-like stool on 1/21/26 with no subsequent BMs recorded, and the resident had no bowel care medications in place during this period, contrary to the care plan focus on constipation risk. On 1/26/26, after recognizing that the resident had not had a BM for five days and had no bowel care orders, a nurse contacted the physician and obtained a PRN MiraLax order, which was administered on 1/26/26 and 1/27/26. The nurse acknowledged that going five days without a BM was significant and could lead to serious complications. The resident, who had been readmitted from the hospital on 1/21/26, was transferred back to the hospital on 1/27/26 when he became unresponsive. Hospital records from 1/30/26 documented no BM since 1/21/26, black/feculent G-tube output, a distended and tense abdomen, and imaging showing a large amount of gas and fecal material in the colon suggesting an ileus, with notes indicating bowel obstruction versus ileus. The DON stated her expectation that nurses monitor last BMs using the eMR alert, initiate bowel care if more than three days pass without a BM, and obtain routine bowel care orders when a constipation care plan is developed, and facility policy required assessment and documentation of lower GI symptoms including fecal impaction and abdominal assessment.
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