F0684

D

Failure to Complete Timely Admission Assessment and Initiate Bowel Protocols

Sault Ste. Marie, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely assessments and care according to orders and residents’ needs, including failure to complete an admission assessment and to initiate bowel protocols for constipation. One resident was admitted in the evening and reported that upon arrival staff briefly entered and left the room without explanation, and no vital signs, blood pressure, or head-to-toe assessment were performed at the time of admission. The resident, who was cognitively intact with a BIMS score of 15/15 and had a recent leg fracture limiting mobility, documented in a notebook that she lay in bed without understanding what was happening, needed pillows to elevate her legs, and did not receive dinner when told it was on the way. She also reported using the call light during the first night, which remained on for a long period without response, leading her to call the facility’s main phone number, which was answered first by one resident and then handed to another resident before staff eventually came to her room.

Record review for this resident showed she was admitted on one date and that the nursing assessment was not started until nearly six hours later and was not completed. Facility policy on admission orders required that a physician or other qualified practitioner provide orders for immediate care needs, including diet and other care-related orders, to allow staff to provide essential care. In interviews, an RN stated that on admission nurses are expected to settle the resident in the room, add a diet order, perform a head-to-toe assessment, obtain vital signs, complete a skin assessment, notify the physician, and write an admission note when the resident first arrives. The DON confirmed that nursing staff are expected to complete an assessment within the first hour of admission and obtain vital signs immediately, which did not occur for this resident.

The facility also failed to initiate bowel protocols in a timely manner for two residents with documented constipation and available PRN and scheduled bowel medications. One resident with diagnoses including diabetes, a Stage 2 sacral pressure ulcer, left hip fracture, mesenteric artery stenosis, and constipation reported not having a bowel movement for four days and expressed concern that no treatment had been provided, while a family member confirmed they had alerted nursing the previous day. The following day, the resident continued to report no bowel movement, nausea, and abdominal discomfort, and the family member stated a nurse had been informed and said she would call the physician. EMR review showed no bowel movement documented from admission through several days later, despite frequent administration of opioid pain medication. PRN Milk of Magnesia ordered for no bowel movement in three days was not given until day five without documented use of subsequent PRN Dulcolax suppository or Fleet enema, and scheduled daily laxative and stool softener orders were not started until more than five days after admission.

Another resident with demyelinating disease of the CNS, osteoporosis, arthritis, generalized weakness, and frequent falls, and with mild cognitive impairment (BIMS 13/15), was observed nauseated, declining breakfast and lunch, and unsure of the date of the last bowel movement. Bowel elimination documentation showed the last bowel movement occurred five days earlier, with repeated entries of no bowel movement through the date of review. There was no documented bowel assessment corresponding to the resident’s nausea or the prolonged absence of a bowel movement. Although multiple PRN bowel medications (Milk of Magnesia, Metamucil, Dulcolax suppository, Fleet enema) were ordered, none were documented as administered during the review period. The DON reported that night shift was supposed to pull bowel elimination reports and pass information to oncoming staff, but acknowledged the reports were not consistently provided and that a nurse did not receive a bowel protocol list due to staff being busy with multiple new admissions, and also stated there was no facility policy related to bowel protocol.