HospitalInspections.org

Based on interview and record review, the hospital's registered nurse did not supervise and evaluate the nursing care for Management of Fecal Incontinence, citing 1 (Patient #3) of 3 patients that were discharged between 02/24/20 and 05/26/20.

Findings included:

Patient #3 was admitted on 12/12/19 for multiple diagnoses that included acute encephalopathy, acute renal failure pre-renal volume depletion, hypoxic respiratory failure, and congestive heart failure diastolic dysfunction. On 12/13/20, the wound care nurse noted Patient #3 had pressure injuries to the coccyx area that extended to the sacrum and gluteal. Patient #3 was a total assist and could not reposition herself. On 12/28/19 at 05:25, a rectal tube was inserted. This rectal tube was removed on 02/25/20 at 18:03 prior to discharge, a total of 66 days.

During an interview on 06/14/21 at 11:26 AM via email, Personnel #2 confirmed the rectal tube was inserted on the 12/28/19 and removed on 02/25/20. Personnel #2 confirmed there was no documentation why the rectal tube was not changed on the 29th day per protocol.

Policy and Procedure "Management of Fecal Incontinence with Fecal Monitoring System" last reviewed 07/16/2019 required "...4.6 The FMS (fecal monitoring system) will be completely changed at least every 29 days..."