BY LINDA WILLIAMS, RN
Handling constipation and fecal impaction
|As staff at most nursing facilities are aware, the occurrence of a resident having a fecal impaction is considered a sentinel event by the Centers for Medicare & Medicaid Services. It causes hardship for the resident and also for the staff, when their interventions are scrutinized by state surveyors to determine whether the event could have been avoided. Sometimes this same scrutiny and analysis find their way into a courtroom. Please take the time to review the circumstances surrounding the following situation, and make changes as appropriate at your facility.|
Because of the woman’s frail condition, her physician wrote orders for the staff to encourage her to drink 3,000 cc of fluid each day. An enema also was to be given, up to three times per week, as needed. These and other constipation-prevention measures were incorporated into the woman’s plan of care.
While at the facility, the woman’s condition began to deteriorate. On her 23rd day of residence, the woman’s urinary catheter began to leak, so she was transferred to the emergency room at her son’s request.
The woman was admitted to the hospital with the following diagnoses: urinary tract infection with sepsis, dehydration, renal insufficiency, and high fecal impaction.
Three weeks after admission, the woman suffered acute abdominal pain, which proved to be a diverticular abscess, requiring a colostomy for relief. Three days after surgery, she seemed to be improving when she suddenly aspirated and died. Two months later, the woman’s son sought legal counsel and filed a suit against the facility for his mother’s wrongful death because of negligent care. His demand to settle was $3 million.
Upon examination of the woman’s medical records at the nursing facility, both the plaintiff and defense attorneys discovered that the woman only had two bowel movements during her 23-day stay: One occurred two weeks after admission and the other was the day before being discharged to the hospital. In addition, the records revealed that during her last 48 hours at the facility, she consumed only 600 cc of fluids yet had a urine output of 2,000 cc. Other chart entries did not look much better, as her fluid intake during each of the previous days was less than half of the recommended 3,000 cc, and there was no dietary evaluation or notes concerning her meal intake.
Both attorneys hired expert witnesses to review the case and offer their medical opinions. The defense hired a geriatric specialist who felt that the woman’s death was not causally related to the treatment she received at the nursing facility. However, the plaintiff’s medical expert held an opposing view and felt there was indeed a direct link, especially related to the lack of monitoring, which led to the high fecal impaction. The parties went to mediation and agreed on a settlement of $500,000.
What Went Wrong
|The woman in this case study had many of these risk factors, just as a significant percentage of residents that reside in nursing facilities today do. For this reason, it is important for staff to take the following precautions, as recommended by the University of Iowa in Evidence-Based Protocol: Management of Constipation, to minimize the occurrence of a similar crisis in their facility:|
1. Identify residents at risk for constipation by using a standardized assessment tool to determine a resident’s constipation risk factors. This should be done upon admission, routinely, and whenever there is a change in cognition or functional ability. “The Management of Constipation Assessment Inventory” form developed by the University of Iowa is an excellent tool. It can be found in Evidence-Based Protocol: Management of Constipation (contact the university’s Nursing Research Department at  384-4429 for more information).
2. Implement a prevention program that includes all of the following, as indicated:
3. A daily bowel movement record should be kept for all dependent residents to track regularity and assess the need for interventions. All CNAs should document whether the residents they provided care for had a bowel movement. The charge nurse should look at the record each shift and initiate interventions as appropriate.
4. If the resident has not had a significant bowel movement for three days, laxative treatment is necessary, per physician order. A stepwise progression of laxative treatment is recommended. Once constipation is resolved, management should be moved to the top of the laxative pyramid. The following steps are recommended, from first to last:
Finally, the resident’s physician should be notified of any new patterns of constipation. This includes a previously regular resident who has a bowel movement less than three times per week and/or straining with more than 25% of bowel movements, or if a resident with chronic constipation is uncontrolled to the extent of fecal impaction removal.
By taking these necessary precautions, you have the ability to protect your residents and facility, now and into the future.
Linda Williams, RN, is a Long-Term Care Risk Manager for the GuideOne Center for Risk Management’s Senior Living Communities Division. She previously served as Director of Nursing in a CCRC and as a nurse consultant for two corporations with numerous long-term care facilities in Iowa. The GuideOne Center for Risk Management is dedicated to helping churches, senior living communities, and schools/colleges safeguard their communities by providing practical and timely training and resources on safety, security, and risk-management issues. For more information, contact Williams at (877) 448-4331, ext. 5175, or email@example.com, or visit www.guideonecenter.com. To send your comments to the author and editors, please e-mail firstname.lastname@example.org. To order reprints in quantities of 100 or more, call (866) 377-6454.
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