Failure to Monitor and Document Bowel Function Resulting in Fecal Impaction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel function for a resident who was care planned as being at risk for constipation. The resident, admitted with diagnoses including cerebral infarction, dysphagia, depression, and mood disorder, had physician orders for PRN milk of magnesia and senna for constipation and a care plan intervention to record bowel movement patterns each day and monitor for complications of constipation. The MDS indicated the resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel records for December 2025 and January 2026 showed no documented bowel movements, and the DON verified there was no documentation of a bowel movement after 11/19/25, despite a facility policy requiring nursing staff to document bowel movements each shift. On the date of the change in condition, the resident was evaluated with documented signs of fever and shortness of breath, along with other vital signs, but there was no documentation of an abdominal assessment. An LPN reported that when she came on duty, the ADON told her the resident had not had a recent bowel movement and was having respiratory issues; however, the LPN focused on the respiratory concerns when sending the resident to the hospital and did not assess the abdomen. At the hospital, the resident was admitted with acute hypoxic respiratory failure with pneumonia, encephalopathy, hypernatremia, and hyperglycemia, and was found to have a fecal impaction with concern for stercoral colitis. Imaging showed a large ball of stool in the rectum, and the resident required manual removal of the impaction, an enema, and initiation of a bowel regimen. The NP later stated she was unsure if staff had alerted her to the absence of bowel movements and was unaware that bowel movements had not been documented for the resident for two months, despite her expectation that staff document the presence or absence of bowel movements every shift.
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