Citation Number: 970003556
Citation Date: 10/2/2007
Violation Date: 5/1/2005
Class: AA
Penalty: $ 80000.00

Title 22 Section 72311 (a)(1)(A)(2) Nursing Service General Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

The facility's staff failed to identify care needs based on a continuous assessment and implement the plan of care to prevent constipation.

This citation is a result of a complaint investigation conducted on February 28, 2006.

Based on record review and interview, Patient 1, an 88-year old female, was admitted to the facility on February 24, 2005, with diagnoses that included dementia with psychosis, congestive heart failure, hypertension and depression. On April 30, 2005, according to the patient transfer document, the patient was discharged from the nursing facility to the acute hospital due to a distended abdomen and altered level of consciousness where she expired on May 1, 2005.

The admission Minimum Data Set (MDS) assessment dated March 8, 2005 indicated the patient had modified independence (some difficulty in new situations), short and long term memory problems, requiring one person assistance with hygiene, bathing and toileting. A review of Section (H) (a) revealed the patient had regular bowel movements (BM) every three days. There was also a notation on the Resident Assessment Protocol number 17 dated March 9, 2005, that revealed the patient was at risk for constipation and fecal impaction due to a physician's prescribed psychotropic drugs. According to the physician's order sheet dated February 24, 2005, the patient was receiving Lexapro 10 milligrams (mgs.) 1 tablet by mouth, Abilify 10 mg., 1 tablet by mouth for psychoses, and hydrochlorothiazide 12.5 mg., 1 tablet by mouth for hypertension. The adverse reactions (development of undesired side effects) for Abilify, Lexapro, and hydrochlorothiazide are constipation.

Patient 1's care plan dated April 19, 2005, identified the patient was at risk for constipation related to decreased mobility, congestive heart failure, depression, and dementia with psychosis. The goal was for the patient to have one BM at least every 3 days. The approaches included monitoring for the amount, consistency of the BM, and giving medications, as needed, per physician's order. However, there was no individualized approach to assess on a continuing basis, fluid intake and urinary output, to assist in preventing constipation. A review of the clinical record revealed no evidence of the resident's fluid intake and urinary output being recorded during the residents stay at the skilled nursing facility. However, according to the Resident Assessment Protocol, Dehydration/fluid Maintenance, page c-74, water is necessary for the elimination of waste. Without sufficient water, the body will not be able to rid itself of fecal waste, causing constipation.

A review of the CNA Flow Sheet (Certified Nurses Assistant's documentation of care and services provided) dated March 2005 revealed evidence that the patient's bowel pattern was irregular and infrequent, and was different from the regular pattern that was documented on the MDS assessment. For example, C N A Flow Sheets for the period of March 1, 2005 to March 31, 2005 revealed the following:

The patient had bowel movements varying in volume from small to large on March 10-12, 23, 27, 2005 and April 3, 5-9, 11, 14, 20-29, 2005

The patient had no bowel movements documented for March 1 to 9, 13 - 22, 24 - 26, 28 - April 2, April 4, 10, 12, 13, 15 - 19, 30, 2005. This pattern represented lack of bowel movements on an every 3-day pattern as ordered and as care planned.

A review of the Licensed Progress Notes dated April 19, 2005, at 2 p.m., documented by the Licensed Vocational Nurse (LVN 4) revealed the patient's abdomen was soft and not enlarged, with positive bowel sounds in 4 sections of the abdomen. According to the nurse's notes written on the same day, the patient had no BM for 3 days, and the attending physician was notified. At 2 p.m., according to the physician's order sheet, the physician called back with a new order, as follows: Milk of Magnesia (MOM) 30 cc. by mouth, at bedtime, as needed for constipation, and Dulcolax Suppository, 10 mg. 1 suppository per rectum, as needed, every 2 days, for constipation.

A review of the Licensed Progress Notes from April 21 to April 29, 2005 revealed there was no continued assessment of Patient 1's bowel status.

A review of the Medication Administration Record (MAR) revealed a new physician's order dated April 19, 2005, for Milk of Magnesia, 30 cc. by mouth, at bedtime, as needed for constipation, and Dulcolax suppository, 1 suppository, per rectum, as needed, for constipation.

Further review of the MAR documentation from April 19 - 30, 2005, revealed only one dose of MOM was given to the patient on April 24, 2005. There was no documented assessment to determine the effectiveness of the MOM by the medication nurse. In addition, there was no documentation in the MAR that the licensed staff administered any Dulcolax suppositories to the patient as ordered on April 19, 2005, or whether staff had assessed the patient for constipation.

Further review of the MAR, between April 25, 2005 and April 30, 2005, revealed no MOM, and no Dulcolax suppository was given to the patient to prevent severe constipation for over a period of six days.

A review of the MAR dated April 1, 2005 to April 30, 2005, disclosed the patient was receiving Lexapro (for depression), Abilify (for psychosis) and hydrochlorothiazide for hypertension. According to Nursing 2007 Drug Handbook, these medications have adverse reactions that include constipation. In addition, a footnote under Section H of the MDS noted that the patient was at risk for stool impaction (according to Taber's Cyclopedic Medical Dictionary, 15th edition, impaction is defined as overloading of an organ, as the feces in the bowels.)

Further review of the Licensed Progress Notes documented by the Registered Nurse (RN) dated April 30, 2005, at 9:15 a.m., indicated the patient was in bed, awake but slightly lethargic and noted with a rigid and distended abdomen. The patient's recorded vital signs prior to the physician being notified were: blood pressure=140/70, pulse=78, R=17 and temperature was 97.6. The attending physician's telephone exchange was notified. A review of the notes revealed there was no documentation of the attending physician returning the call. However, at 9:20 a.m., on the same day, another physician called back with an order to transfer the patient to an acute care hospital. The patient was picked up at 9:50 a.m. by ambulance and transferred to the hospital.

On March 8, 2006, at 2:40 p.m., during an interview, C N A 3 stated she saw the patient after breakfast crying and complaining of constipation, but was unable to remember the exact date. The C N A also said she had verbally reported the patient's complaint of being constipated to the charge nurse because she was instructed to report to the licensed nurses if the patient did not have a BM for 3 days. A review of the clinical records from the time period of February 24, 2005 to April 30, 2005, revealed there was no documentation that the licensed nursing staff had assessed the patient's complaint of constipation.

When requested, facility representatives were unable to produce a policy and procedure for dehydration and fluid management, or for management of constipation and stated that such policies did not exist.

Also, on March 8, 2006, at 3:15 p.m., during an interview, LVN 3 stated the patient complained of constipation during the medication pass, at 5 p.m., on April 24, 2005. The LVN stated he checked the MAR and noted the patient had physician's orders dated April 19, 2005, as follows: MOM, 30 cc. by mouth, at bedtime, if needed for constipation, and 1 Dulcolax suppository, 10 mg., by rectum, as needed, every 2 days for constipation. LVN 3 stated he gave MOM 30 cc. by mouth at 6 p.m. on April 24, 2005, because giving MOM 30 cc. by mouth is less invasive than giving Dulcolax suppository in the rectum. There was no documentation in the clinical record of LVN 3 giving a Dulcolax suppository by LVN 3 at that time. The LVN also stated that the patient had a small BM at 11 p.m., but he did not document the result of the MOM 30 cc. on the back of the MAR.

A review of the acute hospital's Emergency Physician's Record dated April 30, 2005, disclosed the patient told the ER physician, "I'm obstructed." The ER history also documented diagnoses that included congestive heart failure, and high blood pressure, with abdominal distention, and blood in the stool (+ guiac). (The autopsy report dated June 16, 2005, revealed the patient had hemorrhagic necrosis of the bowel mucosa.)

The acute hospital laboratory results dated April 30, 2005 recorded a BUN of 23. The hospital's laboratory reference range for a BUN is 7-18 mg/dl. According to A Manual of Laboratory & Diagnostic Tests, (c) 2000, the rate at which the BUN level rises is influenced by tissue necrosis, protein break down and the rate at which the kidneys excrete the Urea nitrogen.

The hospital's History and Physical (H&P) dated May 1, 2005, written by the attending physician, revealed a chief complaint of abdominal pain, nausea and vomiting, and mild distention of the abdomen. The patient's diagnoses included history of congestive heart failure (CHF), chronic obstructive pulmonary disease, emphysema, hypertension, dementia, depression and psychosis.

The patient's medications included Digoxin and Hydrochlorothiazide (HCTZ). According to Nursing 2007 Drug Handbook, Lippincott Williams and Wilkins, Digoxin is given for CHF. HCTZ is given for high blood pressure and further limits body fluid by increasing urine output.

The H&P also revealed the patient had vomited 6 times and had a small bowel movement with no relief of abdominal pain while in the emergency room. A review of the x-ray report dated April 30, 2005, at 11:19 a.m., disclosed there was extensive stool seen throughout the colon consistent with constipation. The x-ray assessment was severe constipation.

A review of the Hospital Death Summary dated June 14, 2005,revealed the patient was admitted to the hospital on April 30, 2005, and expired on May 1, 2005. The hospital admission diagnosis included a new onset of chronic atrial fibrillation confirmed by an electrocardiogram dated April 30, 2005, at 2:10 p.m. According to the Death Summary the morning following the patient's admission to the hospital, on May 1, 2005, the patient was seen and examined by a gastro-intestinal (GI) consultant. The patient was disimpacted (defined by Taber's as stool manually removed from the rectum) and then the patient had a large bowel movement. After the bowel movement, the patient had an acute bradycardia (defined by Taber's as slow heart beat rate) with subsequent asystole (defined by Taber's as absence of heart beat).

The physician order sheet dated May 1, 2005, showed a GI consultant physician order noted by a Registered Nurse (RN) at 11:15 a.m. for a Harris Flush enema. The Registered Nurse's notes written at 11:30 a.m. showed the patient was in bed and awake. At 12:39 p.m. the note revealed the patient had bradycardia with a heart rate of 51 beats per minute. At 12:42 p.m. the patient was not breathing, no resuscitation was done per family request and the patient was pronounced dead at 1:15 p.m.

A review of the hospital's Autopsy Final report dated June 16, 2005, revealed the autopsy findings were significant for the presence of extremely dilated bowel segments starting from the descending colon and extending to the rectum with marked stool impaction (defined by Taber's as overloading of an organ, as feces in the bowels) and extensive ischemic and hemorrhagic necrosis of the bowel mucosa and extensive acute ischemic colitis (Taber's defines ischemia as deficiency of blood supply due to obstruction of the circulation to a part. Hemorrhagic necrosis according to Miller-Keane's Encyclopedia and Dictionary of Medicine, Nursing and Allied Health, 6th edition, hemorrhagic is defined as pertaining to or marked by hemorrhage. Necrosis is defined as the morphological (cell) changes indicative of cell death caused by enzymatic breakdown of the bowel mucous membrane. Colitis is defined as inflammation of the colon).

Other significant pertinent autopsy findings included bilateral acute tubular necrosis (consistent with medical diagnosis of acute renal failure) and bilateral pleural effusions. The summary indicated, "the cause of death is thought to be due to shock secondary to extensive acute ischemic colitis and toxic mega colon" (According to Taber's, ischemic colitis is defined as inflammation of the colon and a deficient blood supply due to blocking circulation of blood to a part of the colon. Toxic mega colon is defined as a marked enlargement of the colon, especially the transverse colon). According to the Physician/Coroner's Amendment Death Certificate the cause of death was Cardiopulmonary Arrest, Hypotension, Ischemic bowel, and Coronary Artery Disease: Atrial Fibrillation.

The facility's staff failed to:

1. Identify care needs based on a continuous assessment of Patient 1's bowel status, 2. Implement Patient 1's care plan to prevent constipation/fecal impaction

This violation presented an imminent danger that death or serious harm would result and was a direct proximate cause of the death of Patient 1.