HospitalInspections.org

Based on clinical record review and staff interview the Facility Nursing staff failed to implement physician ordered plan of care, six (6) enemas prescribed for fecal impaction were not administered. Tap water enemas were not administered as ordered on 09/07/15, 9/23/15, 09/24/15 and 10/05/15. Soap suds enema was not administered as ordered on 09/23/15. This affected 1 of 1 Patient (#1) who had been assessed to have fecal impaction in total sample of 10 patients.

The findings included:

Clinical record revealed the Patient #1 was admitted via the Emergency Department (ED) on 09/06/15 with chief complaint of Shortness Of Breath and abdominal pain. An admitting history and physical on 9/7/15 revealed the patient was noted to have left lower quadrant abdominal pain that has been intermittent over the past 3 days.

A Surgical consultation conducted on 9/7/15 revealed the patient had a CT scan of the abdomen, which showed only small fatty umbilical hernia and otherwise negative. A lot of stool was noted in the colon with mild distention of the small intestine. The surgeon documented the patient may have fecal impaction. The treatment plan, to cleanse the bowel with a tap water enema.
On 9/7/15 at 4:04 PM a physician ordered a tap water enema to be administered. The clinical record did not document tap water enema was given to the patient on 09/07/15 as ordered.

Interview with a Registered Nurse/Medical Surgical Director on 11/06/15 at 2:30 PM, she stated the nursing documenting did not indicate tap water enema was administered on 09/07/15.

An interdisciplinary care plans related to "bowel function altered related to constipation" revealed the care plan was initiated on 9/26/15, nineteen days after admission.

The patient assessment specific to abdominal pain revealed the following information:
Gastroenterology assessment on 09/08/15, there is marked tenderness in the left lower quadrant (LLQ). Even caressing the skin in the left lower quadrant causes distress.
On 09/09/15, complained of LLG abdominal pain, severe, constant associated with vomiting. Patient states that the pain is getting worse.
On 9/10/15. patient is still complaining of mild tenderness in abdomen.
On 09/12/15, abdominal pain is improving.
On 09/14/2015, gynecological assessment, patient has a definitive focal tenderness to light touching on the left upper and lower quadrant. Light touching elicits pain, very specifically on the left upper and lower quadrant of the abdomen.
An X-ray of the small bowel with serial films performed on 09/21/15, reported the findings are consistent with a small bowel obstruction. Small bowel obstruction probably within the distal jejunal loops.
A Surgeon documented in an Operative Report on 09/22/15, the patient was admitted approximately 2 weeks ago, developed abdominal distention and pain. The surgeon evaluated the patient at that time, the patient was thought to have fecal impaction and suggested tap water enema to be given until clear. Surprising, the surgeon was called again to see the patient. The acute abdominal distention did not resolved, some rebound tenderness and some leukocytosis (increased white blood cell count). Due to the generalized tenderness of the abdomen and small bowel obstruction, the patient was advised to have emergency laparotomy and has agreed for the procedure to be done.
Operative findings revealed the whole small bowel was noted to be distended. The whole large bowel was noted to be collapsed in block with hard fecal material from the cecum to the rectum. No obstruction was found.

On 09/23/15 at 8:00 AM a physician ordered tap water enema to be given twice a day starting in AM on 09/24/15.
Subsequent orders at 2:09 PM on 09/23/15 noted tap water enema times 3 to be administered.
An additional order was noted on 09/23/15 at 8:18 PM for soap suds enema to be given now.

The clinical record revealed tap water enemas were given at 12:00 Noon and 1:00 PM on 9/23/15. The nurse did not document the reason why the enemas were not given as ordered on 09/23/15 and 9/24/15.
A Registered Nurse documented on 09/23/15 at 9:00 PM " No equipment to perform soap suds enema was available. Certified Nursing Assistant (CNA) was asked to get it from central supply ". On 9/23/15 at 10:00 PM, "No equipment for to perform soap suds enema was available at central supply, changed nurse verified ". On 9/23/15 at 11:09 PM, " Nurse supervisor was informed that no equipment to perform soap suds enema was available on floor or central supply". The nurse did not document in the clinical record that the physician had been notified that the enemas were not administered as ordered.

A colonoscopy procedure performed on 09/24/15 revealed large amount of stool in the left colon. During the coloscopy a large volume water flushing was performed to moved the fecal impaction.

An interview was conducted with a Registered Nurse Director of Medical Surgical Services on 11/09/15 at 11:10 A AM. The clinical record was again reviewed and no additional information was provided. The findings were discussed with the Administrative Director in Nursing and Clinical Services on 11/09/15 at 12:30 PM, no addition information was provided.

In an interview with the Director of Central supplies on 11/09/15 at 2:30 PM, the Director stated the nursing supervisor had access to central supply during off hours to get enema supply for patient needs. The Director denied lacking soap suds enema equipment in September 2015.

Based on clinical record review and staff interview the Facility Nursing staff failed to implement physician ordered plan of care, six (6) enemas prescribed for fecal impaction were not administered. Tap water enemas were not administered as ordered on 09/07/15, 9/23/15, 09/24/15 and 10/05/15. Soap suds enema was not administered as ordered on 09/23/15. This affected 1 of 1 Patient (#1) who had been assessed to have fecal impaction in total sample of 10 patients.

The findings included:

Clinical record revealed the Patient #1 was admitted via the Emergency Department (ED) on 09/06/15 with chief complaint of Shortness Of Breath and abdominal pain. An admitting history and physical on 9/7/15 revealed the patient was noted to have left lower quadrant abdominal pain that has been intermittent over the past 3 days.

A Surgical consultation conducted on 9/7/15 revealed the patient had a CT scan of the abdomen, which showed only small fatty umbilical hernia and otherwise negative. A lot of stool was noted in the colon with mild distention of the small intestine. The surgeon documented the patient may have fecal impaction. The treatment plan, to cleanse the bowel with a tap water enema.
On 9/7/15 at 4:04 PM a physician ordered a tap water enema to be administered. The clinical record did not document tap water enema was given to the patient on 09/07/15 as ordered.

Interview with a Registered Nurse/Medical Surgical Director on 11/06/15 at 2:30 PM, she stated the nursing documenting did not indicate tap water enema was administered on 09/07/15.

An interdisciplinary care plans related to "bowel function altered related to constipation" revealed the care plan was initiated on 9/26/15, nineteen days after admission.

The patient assessment specific to abdominal pain revealed the following information:
Gastroenterology assessment on 09/08/15, there is marked tenderness in the left lower quadrant (LLQ). Even caressing the skin in the left lower quadrant causes distress.
On 09/09/15, complained of LLG abdominal pain, severe, constant associated with vomiting. Patient states that the pain is getting worse.
On 9/10/15. patient is still complaining of mild tenderness in abdomen.
On 09/12/15, abdominal pain is improving.
On 09/14/2015, gynecological assessment, patient has a definitive focal tenderness to light touching on the left upper and lower quadrant. Light touching elicits pain, very specifically on the left upper and lower quadrant of the abdomen.
An X-ray of the small bowel with serial films performed on 09/21/15, reported the findings are consistent with a small bowel obstruction. Small bowel obstruction probably within the distal jejunal loops.
A Surgeon documented in an Operative Report on 09/22/15, the patient was admitted approximately 2 weeks ago, developed abdominal distention and pain. The surgeon evaluated the patient at that time, the patient was thought to have fecal impaction and suggested tap water enema to be given until clear. Surprising, the surgeon was called again to see the patient. The acute abdominal distention did not resolved, some rebound tenderness and some leukocytosis (increased white blood cell count). Due to the generalized tenderness of the abdomen and small bowel obstruction, the patient was advised to have emergency laparotomy and has agreed for the procedure to be done.
Operative findings revealed the whole small bowel was noted to be distended. The whole large bowel was noted to be collapsed in block with hard fecal material from the cecum to the rectum. No obstruction was found.

On 09/23/15 at 8:00 AM a physician ordered tap water enema to be given twice a day starting in AM on 09/24/15.
Subsequent orders at 2:09 PM on 09/23/15 noted tap water enema times 3 to be administered.
An additional order was noted on 09/23/15 at 8:18 PM for soap suds enema to be given now.

The clinical record revealed tap water enemas were given at 12:00 Noon and 1:00 PM on 9/23/15. The nurse did not document the reason why the enemas were not given as ordered on 09/23/15 and 9/24/15.
A Registered Nurse documented on 09/23/15 at 9:00 PM " No equipment to perform soap suds enema was available. Certified Nursing Assistant (CNA) was asked to get it from central supply ". On 9/23/15 at 10:00 PM, "No equipment for to perform soap suds enema was available at central supply, changed nurse verified ". On 9/23/15 at 11:09 PM, " Nurse supervisor was informed that no equipment to perform soap suds enema was available on floor or central supply". The nurse did not document in the clinical record that the physician had been notified that the enemas were not administered as ordered.

A colonoscopy procedure performed on 09/24/15 revealed large amount of stool in the left colon. During the coloscopy a large volume water flushing was performed to moved the fecal impaction.

An interview was conducted with a Registered Nurse Director of Medical Surgical Services on 11/09/15 at 11:10 A AM. The clinical record was again reviewed and no additional information was provided. The findings were discussed with the Administrative Director in Nursing and Clinical Services on 11/09/15 at 12:30 PM, no addition information was provided.

In an interview with the Director of Central supplies on 11/09/15 at 2:30 PM, the Director stated the nursing supervisor had access to central supply during off hours to get enema supply for patient needs. The Director denied lacking soap suds enema equipment in September 2015.