F0684

G

Failure to Assess, Monitor, and Notify Physician for Resident With Constipation, Abdominal Pain, and ADL Decline

Jackson, California Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide assessment, monitoring, and physician notification consistent with professional standards for a resident with constipation, abdominal pain, and progressive decline. The resident had multiple diagnoses including constipation, muscle weakness, and chronic kidney disease. Bowel movement (BM) records showed repeated periods with no documented BM for 2–6 days over December and January, as well as frequent documentation of foul‑odor stools. CNAs reported that the resident frequently complained of abdominal pain, pointed to her mid‑abdomen, had foul‑smelling stools, and experienced intermittent diarrhea, nausea, and decreased oral intake, and that these concerns were reported to nurses. The DON confirmed that there was no documentation that nurses assessed the resident, notified the physician, or implemented a bowel regimen when the resident went multiple days without a BM or when foul‑odor BMs were recorded, despite facility expectations and standing bowel regimen orders.

The resident also experienced a progressive decline in ADLs and mobility that was not appropriately escalated. On one date, an SBAR documented that the resident reported feeling too weak to shower independently, had lower back and abdominal pain, decreased mobility, and abdominal tenderness, with a blood pressure of 116/48. Nursing progress notes over the next two days documented that the resident went from needing help with showers only to needing assistance with dressing and then transfers, indicating increasing weakness. The nurse categorized this as a non‑emergent change, placed a written note in a communication binder instead of directly calling the physician, and did not obtain a fresh set of vital signs at the time of the change in condition. The physician’s late‑entry progress note for a visit the next day did not address the ADL decline or abdominal tenderness, and there was no documentation that the physician had been directly informed of these changes. The DON stated that such ADL decline and abdominal tenderness should have been reported to the physician right away and that the SBAR did not reflect the full extent of the resident’s progressive decline.

On another date, the Infection Preventionist completed an SBAR for the resident’s diarrhea but did not perform a comprehensive assessment or fully communicate the resident’s condition. The SBAR documented that the resident had diarrhea twice a day and was lying in a fetal position holding her stomach, but the IP reported that he only informed the physician about the diarrhea and request for medication, not the fetal position or abdominal holding. He did not obtain new vital signs, did not palpate the abdomen, did not auscultate bowel sounds, and did not assess pain, and he entered earlier vital signs into the SBAR instead. The IP obtained an order for PRN Imodium but did not administer the first dose, stating he believed he endorsed it to the oncoming nurse; the medication was first given the next morning. Meal intake records showed the resident repeatedly refused or minimally consumed meals over several days, but there was no nursing documentation of assessment related to decreased intake. The DON stated that repeated meal refusals or decreased intake over multiple days should be reported to the nurse and then to the physician.

Additionally, required weekly summary assessments and RN involvement in change‑of‑condition assessments were not completed as expected. The DON verified that weekly summary assessments were missing for multiple weeks in December and January and all of February, even though they were expected every Wednesday. These weekly summaries were described as comprehensive assessments of weight, skin, mental status, bowels, eating, ADLs, medications, and fluids, and as a means of monitoring for changes that would trigger a change‑of‑condition evaluation and physician notification. The DON also confirmed that SBARs for the resident’s changes in condition on two key dates were completed by an LVN, with no documentation that an RN assessed the resident or signed off, despite the facility’s stated practice that an RN should assess residents after a change in condition. Hospital records later documented that the resident presented with several weeks of abdominal pain, diarrhea, and increasing weakness, was found to have colitis with possible microperforation and significant constipation, and ultimately had a perforated sigmoid colon with fecal contamination, septic complications, and death.