F0658

D

Failure to Document Digital Fecal Impaction Removal and Notify Physician of Bleeding and Delayed Labs

Kahoka, Missouri Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure services met professional standards of quality by not documenting a significant procedure, not promptly notifying the physician of changes in condition, and not communicating inability to obtain ordered labs for one resident with constipation and hemorrhoids. The resident had a history of constipation, hemorrhoids, and iron deficiency anemia, and was receiving multiple laxatives, hemorrhoid treatments, low-dose aspirin, an iron supplement, and an opioid (tramadol). A Significant Change MDS from the prior month documented moderately impaired cognition, maximum assistance for toileting and transfers, and no constipation. Facility policy required prompt physician notification and documentation in the medical record when there were changes in a resident’s condition or a need to significantly alter treatment.

On 1/11/26, the resident experienced severe difficulty having a bowel movement and reported feeling fecal material stuck in the rectum, causing pain. A CNA reported this to an RN, who assessed the resident twice that day. The RN found the rectum dilated with a firm, softball-sized fecal mass and, after initial lubrication and reassessment, digitally removed the fecal impaction in several passes, after which the resident passed additional loose stool. The RN later acknowledged not documenting the impaction, the digital removal procedure, or the resident’s complaints in the nurse’s notes, and did not notify the physician of the impaction or the intervention, stating he/she did not believe it was necessary because the resident was not bleeding and was able to have a bowel movement afterward. Nurse’s notes for that date contained no record of the impaction, the resident’s pain, or the digital removal.

On 1/13/26, nurse’s notes documented rectal bleeding that continued even without bearing down, and administration of a hemorrhoidal suppository. On 1/14/26, the nurse documented speaking with the physician about bleeding hemorrhoids and blood loss, and a CBC was ordered; however, staff were unable to obtain the blood sample and there was no documentation that the physician was notified of this inability. On 1/16/26, notes showed the resident passed a bright red rectal clot larger than a quarter and then a large amount of dark blood, with the DON notified and a hemorrhoidal suppository given. The DON attempted multiple blood draws without success, and later that evening the resident was documented as very pale, tired, and weak, but there was still no documentation that the physician was notified of these changes or of the continued inability to obtain the ordered lab. The CBC was finally obtained on 1/17/26, and the lab reported a critically low hemoglobin of 5.5 g/dL and critically high white blood cell count to the charge nurse, after which the physician was notified and the resident was sent to the hospital. In interviews, the DON confirmed she did not notify the physician about the failed lab draws until 1/17/26, and the physician stated his expectation that he be notified when manual fecal removal is performed and when staff are unable to obtain ordered labs.