F0684

G

Failure to Follow Bowel Protocols, UTI Assessment, and Post-Fall Procedures

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice and person-centered care plans for multiple residents, particularly in bowel management, infection assessment, and post-fall evaluation. One resident with chronic idiopathic and slow-transit constipation, a history of large bowel obstruction, and recent hospitalizations for severe constipation returned from the ED with instructions from a nurse practitioner to continue bowel regimen, closely monitor bowel movements, abdominal distention, nausea, vomiting, and overall comfort, and to update the plan of care. Despite this, the resident’s constipation care plan was not revised after mid-October, and there was no documented evidence that the nurse practitioner’s instructions were incorporated into the care plan or physician orders. Review of bowel movement records, MARs, and nursing notes for December and January showed no routine abdominal assessments when bowel movements were absent, no administration of PRN bowel medications per orders and facility policy, and no timely provider notification when the resident went more than 24 hours without a bowel movement, even on multiple multi-day stretches without documented bowel movements. The resident ultimately required repeated hospitalizations, including treatment for severe sepsis and proctocolitis and later fecal impaction requiring disimpaction under general anesthesia.

The facility also failed to ensure timely assessment and intervention for suspected urinary tract infection in another resident with severe dementia, diabetes, and chronic kidney disease. A nurse practitioner note documented that the family was concerned about a possible UTI and that a urinalysis would be considered, and a subsequent note documented decreased oral intake with a plan to provide extra fluids and obtain a urine sample for urinalysis. However, there was no documented evidence of an order for a urinalysis on the date specified, and progress notes lacked documentation of the resident’s condition around the time of the planned testing. The resident was later diagnosed with septic shock secondary to UTI, indicating that the infection progressed without documented timely diagnostic follow-up as initially planned.

Additional deficiencies involved failure to assess and document a reported fall and failure to administer PRN bowel medications or notify providers for other residents. One newly admitted resident reported a fall on an evening shift, but there was no nursing assessment documented at the time of the fall, no incident report initiated, and no documentation of family notification by the nurse on that shift. The resident later complained to a family member about the fall and was sent back to the hospital within 24 hours of admission. For two other residents with bowel management needs, the facility did not ensure administration of ordered PRN bowel medications during specified months and did not notify the provider when these medications were not given. Interviews with CNAs, LPNs, an RN, the nurse practitioner, the medical director, the DON, and the administrator revealed inconsistent understanding and implementation of the bowel protocol (including differing beliefs about when bowel alerts should trigger interventions and provider notification), lack of awareness of specific monitoring expectations, and acknowledged issues with documentation and processes for adverse event reporting and follow-through.