Failure to Monitor and Replace Rectal Tube for Resident With Stage IV Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to assess, monitor, and replace a fecal management system (rectal tube) and to include it in the care plan for a resident with a stage IV sacral/coccyx pressure ulcer. Facility policy for management of fecal incontinence with a flexible seal required effective diversion and containment of liquid and semi-liquid stool, frequent observation of the device for obstruction, and physician notification for specified adverse events. The resident was admitted with a stage IV coccyx pressure ulcer, tracheostomy status, gastrostomy status, critical illness myopathy, osteomyelitis of the vertebra and sacral region, bowel incontinence, and dependence on staff for all ADLs and mobility. The care plan addressed the pressure ulcer and skin breakdown prevention but did not include any plan of care for the rectal tube. Physician orders directed staff to monitor placement and empty the contents of the rectal tube every shift for wound care beginning in November, but the Treatment Administration Record from November through mid-January contained no documentation of rectal tube placement checks, assessments, or bowel content monitoring. A nursing progress note documented that the rectal tube fell out on January 1 and that the MD instructed staff to monitor and call the surgeon; the nurse was unable to locate the surgeon’s number and notified the DON, with no further documentation that the surgeon was ever contacted. Subsequent progress notes by the nurse practitioner indicated that the rectal tube had come out on two occasions, that there was no replacement tube at the bedside, and that previous attempts to reorder the product were unsuccessful because it was out of stock. The notes also documented that the resident initially declined reinsertion but later consented after discussion that the rectal tube could help keep the wound from contamination; however, the tube was never reinserted due to lack of availability. During this period, there was no documentation that the gastric surgeon was notified of the rectal tube removal or that the rectal tube was replaced. The resident’s family reported that the rectal tube was never replaced after it came out the second time and described observing stool-soaked wound dressings remaining in place for over four hours before being changed. The resident was later admitted to the hospital with fever, abdominal pain, diarrhea, nausea, vomiting, and an ill and toxic appearance, and was diagnosed with sepsis with contributing sources including a stage IV decubitus ulcer with concerns for osteomyelitis. The facility medical director, emergency room physician, nurse practitioner, DON, and wound nurse confirmed that the rectal tube had been intended to keep the sacral pressure ulcer clean, that it was not monitored or documented as ordered, that it was not replaced when unavailable from the supplier, that the surgeon was not notified, and that the rectal tube was not included in the resident’s care plan or daily assessments.
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