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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: September 8, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY 094), the facility did not have an effective system to monitor resident's bowel movements adequately. This issue was identified for one resident (Resident #1) out of the five residents reviewed. Specifically, Resident #1 was assessed to have constipation according to the Minimum Data Set (MDS). The Certified Nursing Assistant (CNA) records documented Resident #1 had no Bowel Movements (BM) or the bowel movement section was left blank on 15 days in August 2023. There was no documented evidence that Resident #1's Physician or Nurse Practitioner were notified or that the facility implemented their bowel protocol. On [DATE], Resident #1 was diagnosed with [REDACTED]. Subsequently, on [DATE], Resident #1 was transferred to the hospital and expired on [DATE] due to septic shock related to stercoral [MEDICAL CONDITION] with perforation (which occurs when chronic constipation leads to fecal impaction causing holes in the colon wall). This resulted in immediate jeopardy and actual harm to Resident # 1. The findings are: The facility policy and procedure titled Bowel Protocol, dated ,[DATE], documented the facility's policy to ensure that each resident has regular bowel movements (BM). The CNA is responsible for documenting bowel movements on the CNA accountability record, including the size. If a resident has not had a bowel movement for six shifts (2 consecutive days), Milk of Magnesia (MOM) (treatment for constipation) is to be administered per the Medical Doctor's (MD) order. If there is still no BM after the next shift, [MEDICATION NAME] (medication used to treat constipation) should be administered. If there is no BM by the end of the day, the steps must be repeated. Resident #1 was admitted with several diagnoses, including multiple fractures of right ribs, pneumothorax (collapsed lung), and [MEDICAL CONDITION] reflux disease (a common condition in which the stomach contents move up into the esophagus). The Minimum Data Set ((MDS) dated [DATE] documented that the resident was cognitively intact and had constant bowel incontinence. The Activities of Daily Living (ADL) documentation stated that Resident #1 requires extensive assistance from two people for toileting and transferring. The MDS also documented the presence of constipation. The admitting medication orders included various medications, including Senna 8. 6 milligrams (mg) (a medication for constipation). The comprehensive care plan documented that the resident had bowel incontinence related to immobility. The goal was for the resident to be continent during the daytime. Interventions included checking every 2 hours, providing a bedpan, peri care, monitoring and documenting any changes in mental status and bowel movement pattern each day. The (MONTH) CNA accountability records identified 81 opportunities to document bowel movements from [DATE]-[DATE], and they were documented as follows: ,[DATE] documents showed no bowel movement. ,[DATE] were not documented (left blank). ,[DATE] documented a bowel movement with its size. ,[DATE] documented code 97 indicating not applicable. 9 episodes had six shifts without evidence of a bowel movement. The Certified Nursing Assistant (CNA) accountability record documented the resident had no Bowel Movements (BM) or the section for the bowel movement was left blank on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE] ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE]/ 2023. The facility presented a High Alert Bowel monitoring form dated [DATE]-[DATE], where each shift was indicated as 0, S, M, or L, but this form was not consistent with the CNA accountability records. The form did not include initials or titles of staff who entered the information or a key defining the entries. LPN#1, who reportedly completed the form, works the day shift, and was noted to be off 15 days during this period. A nurse's progress note dated [DATE] documented the Nurse Practitioner (NP)#1 ordered a KUB (Kidney Ureter Bladder) x-ray and labs for abdominal pain. Radiology results dated [DATE] of the abdomen documented: There is a suggestion of a large rectal fecal impaction in rectum. A nursing progress note dated [DATE] at 3:47 PM documented Resident #1 received an enema as ordered by NP# 1. There was no documented evidence of the effectiveness of the enema. There was no documented evidence by the Primary Physician #1 (PP#1) or the Nurse Practitioner #1(NP #1) [DATE] regarding Resident #1's condition or whether they had an assessment. There was no documented evidence as to why the x-ray and labs were ordered. A nursing progress note dated [DATE] at 2:17 PM documented Resident #1 was lethargic. NP#1 was notified and ordered a chest x-ray, labs, and two different intravenous antibiotics. A nursing progress note dated [DATE] at 3:38 PM documented the intravenous line was infiltrated (not working). NP #1 was notified, and they provided orders for Resident #1 to increase their oral fluids. The [DATE] at 2:13 PM NP #2 note documented Resident #1's chest x-ray showed no acute cardio-pulmonary disease. The NP #2 general exam documented no acute distress but noted lethargy (a state of sleepiness or deep unresponsiveness). The note further documented Resident #1 was recently diagnosed with [REDACTED]. The note further documented Resident #1 was noted with increased weakness and lethargy. The [DATE] at 08:14 AM NP #1 note documented Resident #1 was diagnosed with [REDACTED].#1 is currently complaining of abdominal discomfort. A repeat abdominal x-ray and blood work ordered. A Nursing Change of Condition Note dated [DATE] at 1:38 PM Resident #1 was transported to Hospital via ambulance for increased lethargy. The hospital physician progress notes [REDACTED].#1 was found to be in septic shock related to stercoral [MEDICAL CONDITION] with perforation and multi organ failure with altered mental status requiring mechanical ventilation. Resident #1 expired. A telephone interview was conducted on [DATE] at 1:00 PM with CNA #1 who stated they do not remember Resident#1 having a bowel movement on their shift, only wet brief. CNA #1 documented only on the computer and does not remember anyone asking about the resident's bowel movement. A telephone interview was conducted on [DATE] at 1:15 PM with CNA #2 and stated they would report bowel abnormalities to the nurse. CNA #2 does not remember anyone asking about Resident #1's bowel movements. CNA #2 stated they are responsible for documenting what happens only on the assigned shift on the computer. An interview was conducted with LPN # 1 on [DATE] at 3:00 PM stated they work regular day shift on the same floor. LPN#1 stated they do not document resident BM. LPN #1 stated that the CNA's are responsible to document when residents have a BM. LPN#1 further stated resident was lethargic, pale and the blood pressure was low. LPN #1 stated it was reported that resident was not at baseline, but does not remember reporting the bowel movements to the Nurse Practitioner. LPN #1 further stated they did not follow up on the x-ray but were given a verbal order by the NP #1 for an enema. LPN#1 stated the order was entered in the computer but LPN#1 did not administer the enema. An interview was conducted with the Unit Manager on [DATE] and [DATE] who stated they would interview different staff members and complete the high alert bowel form for all shifts on the days they worked. The Unit Manager could not identify who reported bowel movements on any day. The Unit Manager further stated they did not know who completed the form on weekends or when they were off. An interview was conducted on [DATE] at 1:05 PM and at 5:29 PM with Director of Nursing Services (DNS), who stated CNAs document bowel movements in the CNA accountability record in the electronic medical records. The Unit Manager is responsible to check the CNA accountability record, and the CNAs let the Unit Manager know if the resident does not have a bowel movement. The D | Plan of Correction: ApprovedOctober 18, 2023 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Resident #1 was discharged to the hospital on [DATE] and expired in the hospital on ,[DATE]/ 23. Primary Physician NP#1 was educated regarding documenting on Resident #1's condition or whether they had an assessment and documenting the evidence as to why the x-ray and labs were ordered. Residents #1 direct care nursing staff were educated regarding the Bowel Management policy, bowel movement documentation, signs and symptoms of constipation, monitoring clinical alerts on the electronic medical record (EMR), and monitoring CNA Point of Care to ensure any lack of bowel movements or missing documentation will be documented and to reported to the Residents Physicians and will be addressed accordingly. There were 15 CNAs identified that did not document bowel movements in the EMR for Resident # 1. 2 of these identified CNAs are no longer employed at the facility. The remaining 13 CNAs were provided with education on documenting bowel movements in the EMR and completed a competency on the same. 2. All residents at risk of constipation have the potential to be impacted. All resident at risk of constipation care plans were reviewed and revised as appropriate by an RN. An audit of all residents bowel movement documentation and clinical alerts was conducted to ensure any lack of bowel movements or missing documentation will be documented and reported to the Residents Physicians and will be addressed accordingly. All newly admitted residents will be reviewed for the potential risk for constipation upon admission by a Licensed Nursing Staff to ensure an appropriate plan of care and proper intervention are in place. All resident at risk of constipation care plans were reviewed by the RD and identified residents care plans were revised as necessary with nutritional interventions. All newly admitted residents will be assessed by the RD for potential nutritional interventions as it relates to their potential for constipation. 3. The Bowel Protocol for Constipation policy was reviewed and revised, to include that physician orders [REDACTED]. A Bowel Disorders Clinical Protocol policy was implemented that includes Assessment and Recognition of Bowel (Lower Gastrointestinal Tract) Disorders, Cause Identification, Treatment and Management, and Monitoring and Follow Up by staff and physician. The facility utilized the services of an outside consultant Registered Nurse to develop lesson plans and assist with education. The content of the new Bowel Disorders Clinical Protocol policy has been included in the lesson plans utilized to educate all licensed and unlicensed nursing staff, occupational therapy staff, and RD staff. The content of the policy includes the signs for constipation and presence of fecal impaction. Education of bowel movement documentation and signs and symptoms of constipation was provided to all CNA staff, occupational therapy staff, and RD staff. The content of the education includes the signs for constipation and presence of fecal impaction. Education on bowel movement documentation, signs and symptoms of constipation, presence of fecal impaction, monitoring clinical alerts on the EMR, and monitoring CNA Point of Care documentation was provided to all licensed nursing staff. Education will be provided to Unit Managers, Nursing Administration (DNS, ADNS, ICP Nurse, Wound Care Nurse), RN Supervisors, physicians, and physician extenders to include sentinel event notification in the High Acute Status MD group chat. The education on the High Acute Status MD Group Chat was provided by the Administrator. The Unit Manager/Designee will review all EMR Dashboard Clinical Alerts at the end of the shift/beginning of the next shift to ensure documentation is completed by CNAs daily. The Unit Manager/designee will identify CNA/s if there is missing bowel movement documentation. Any identified CNA/s will be provided with re-education and progressive disciplinary action as needed. An audit tool was created (Supervision Bowel Audit) to monitor residents who have alerted for no bowel movements in 48 hours. Residents who have no bowel movement recorded in the EMR triggers a clinical alert after 48 hours on the EMR Dashboard under Clinical Alerts. This audit will be conducted nightly by the RN Supervisor/Designee. The result of the audit will be reported to DNS/designee. The High Alert Bowel monitoring tool has been replaced with this audit tool. The RN will ensure an assessment was completed or conduct an assessment if necessary for those residents who have alerted on the EMR for no bowel movement in 48 hours to ensure appropriate bowel protocols are in place and notify the physician/physician extender. The RN will ensure the resident is placed on the 24-hour report to be discussed at the interdisciplinary Morning Report meeting. 4. DON/Designee will audit clinical alerts and residents BM documentation weekly X4 then monthly X3 to ensure conducted to ensure any lack of bowel movements or missing documentation will be documented and to reported to the Residents Physicians and will be addressed accordingly by physician assessment and interventions and to be followed up for effectiveness of interventions. The result of all audits will be reported to QAPI committee monthly for review and feedback. 5. Responsible Party: Director of Nursing |