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Based on record review and interview, the hospital failed to ensure the nursing staff communicated a change in the clinical condition of 1 (P #1) of 10 (P#1 - 10) patients to the respective physician for possible intervention and revision of the nursing care plan. This failure resulted in the patient's discharge to a skilled nursing facility (SNF) while in severe pain related to constipation. The findings are:

A. Record review of P#1's hospital admission record dated 12/04/16 - 12/08/16 (first admission to hospital) for treatment of a tibial fracture injury indicated the patient was immobile and taking opiod medication for her pain.

B. On 12/19/16 at 4:41 pm during interview, the complainant stated that according to the SNF medical record, P#1 had a bowel obstruction. However, review of an x-ray of the abdomen and hip obtained on 12/15/16 (second admission to hospital) revealed significant stool in the large intestine. The impression from the x-ray indicated "significant constipation without evidence for high-grade small bowel obstruction [a complete obstruction of the small bowel which prevents normal transmission of its contents] or perforation on radiographic imaging." These findings were confirmed by Computed Tomography (a finer detailed x-ray) during the hospital readmission.

C. Record review of the abdominal x-ray dated 12/19/16 (second admission to the hospital) for P#1 indicated "prominent stool throughout the colon especially within the rectal vault, please correlate for constipation."

D. Record review of nursing documentation dated 12/05/16 - 12/08/16 (first admission to the hospital) for P#1 showed worsening constipation signs and symptoms, such as no bowel movement, abdominal rigidity, and patient guarding (protective gesture). No documentation of more aggressive intervention for constipation was noted. The patient was discharged to the SNF.

E. Record review of P#1's medical record indicated neither documentation nor communication to the physician from nursing staff regarding the worsening signs and symptoms of her condition (constipation).

F. Record review of the hospital's discharge policy indicated it does not address bowel function. However, the hospital provided the order set (used to standardize and expedite care orders for common clinical diagnoses) referred to as the "Bowel Program Power Plan" used by the hospital's physicians. The bowel program was initiated at the time of P#1's admission on 12/04/16.

G. Record review indicated that P#1 was administered stool softeners during her initial hospitalization 12/04/16 -12/08/16.

H. On 12/20/16 during interview, the Chief Nursing Officer (CNO) stated, "Maybe this [stool softeners] was not aggressive enough" in light of P#1's worsening signs and symptoms of constipation.

I. The CNO was asked about P#1's discharge from the hospital without a bowel movement and documented worsening signs and symptoms of constipation. She stated, "It should not happen."

J. Record review of the Gastrointestinal (GI) Assessment of P#1 in the nursing notes indicated:
1. 12/04/16 bowel sounds present and abdomen described as round, soft. Patient denies any GI signs and symptoms.
2. 12/05/16 constipation.
3. 12/07/16 - 12/08/16 increasing signs and symptoms showing patient guarding, constipation, abdomen as rounded and firm.

K. Review of nursing notes did not indicate contact by nursing staff with the physician regarding the patient's worsening GI signs and symptoms.