The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ESSENTIA HEALTH ST MARY'S MEDICAL CENTER 407 EAST THIRD STREET DULUTH, MN 55805 Dec. 6, 2012
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review the hospital failed to ensure that an accurate nursing care plan was developed for 6 of 10 reviewed patients/(P) P1, P4, P5, P7, P8, and P9, who were using pain medications but who were not were not assessed for bowel status/constipation on admission; therefore did not have accurate data upon which to base the care plan.

Findings include:

Medical record review on 12/3/2012 revealed that P1 was admitted on [DATE] with a fractured humerus. There was no documentation of an initial bowel assessment. Physician orders dated 8/10/12 were reviewed and revealed P1 was being treated for pain with Tylenol, Dilaudid and Lortab. Physician orders on admission revealed that P1 received Senna and Colace for constipation. There was evidence of a nursing care plan for constipation, however, there was no initial bowel assessment and although there were no bowel movements documented during P1's 6 day hospital stay, there was no change of bowel intervention and staff simply documented the patient ' s bowel status as "WDL" (within desired limits) repeatedly. A review of the hospital discharge instructions for P1 dated 8/16/12 revealed under "Last Bowel Movement Information:" the form was left blank, giving no information to the receiving nursing home.

P1's family member (F)-A was interviewed on 12/6/12 at 8:45 a.m. and stated that P1 always had difficulty with constipation and had been home after the fracture on a Fentanyl patch which increased her constipation in the days prior to her admission to the hospital. F-A stated that P1 had not had a bowel movement in the two days prior to her hospitalization . F-A stated that when P1 was admitted to the hospital, staff members did not note the previous constipation nor monitor P1 ' s constipation while hospitalized , but gave her pain medicine. F-A stated that after P1 was discharged from the hospital, she was in pain and the nursing home she was sent to had to administer enemas to resolve the constipation.

The hospital floor manager, Registered Nurse/RN(B) was interviewed on 12/3/2012 at 4:20 p.m. RN(B) stated that she became aware of the constipation concern for P1 when the skilled nursing facility P1 was sent to called and informed them of the concern. RN(B) stated she reviewed P1's chart and confirmed that P1 did not have an adequate bowel intervention program in place while P1 was hospitalized . RN(B) stated she used P1 as a case study to provide training to staff regarding consistently monitoring charts. RN(B) stated that she received feedback from staff that the initial bowel assessments were not consistently being completed.

Medical record review revealed P4 was admitted on [DATE] with diagnoses that included left total hip replacement. A review of her medical record on 12/3/2012 revealed that although there was a bowel care plan, no initial bowel assessment had been completed on which to base the care plan and she had not had a BM since admission. P4 was receiving Vicodin and Oxycodone for pain and had been receiving Senna since admission with no results. There was no evidence that P4's bowel intervention had been changed since admission.

P4 was interviewed on 12/3/2012 at 1:05 p.m. and stated that she had not had a bowel movement since admission, a period of three days, and had been receiving Senna since admission with no results.

Medical record review revealed P5 was admitted on [DATE] with diagnoses that included right total knee replacement. A review of his medical record on 12/3/2012 revealed that although there was a bowel care plan, no initial bowel assessment had been completed which to base that care plan. P5 was receiving Lortab for pain and had been receiving Senna since admission.

Medical record review revealed P7 was admitted on [DATE] with diagnoses that included right total knee replacement. A review of her medical record on 12/3/2012 revealed that although there was a bowel care plan, no initial bowel assessment had been completed on which to base that care plan. P7 was receiving Lortab for pain and had been receiving Senna since admission.

Medical record review revealed P8 was admitted on [DATE] with diagnoses that included right total knee replacement. A review of his medical record on 12/3/2012 revealed that although there was a bowel care plan, no initial bowel assessment had been completed on which to base that care plan. P8 was receiving Oxycodone for pain and had been receiving Senna since admission.

Medical record review revealed P9 was admitted on [DATE] with diagnoses that included right total knee replacement. A review of her medical record on 12/3/2012 revealed that although there was a bowel care plan, no initial bowel assessment had been completed on which to base that care plan. P9 was receiving Dilaudid for pain and had been receiving Senna since admission.

During the interview on 12/3/2012 RN(B) stated that she was surprised that the initial bowel assessments were not complete for the patients reviewed. RN(B) indicated that hospital practice would be to obtain an initial bowel assessment on admission. RN(B) stated she was surprised a patient assessment could be marked as complete in the electronic record when the initial assessment of bowel status was not entered.

A review of the hospital policy titled Management of Opiod-induced Adverse Effects, undated, and provided by the hospital as the hospital practice/reference manual for nursing staff revealed under constipation:

"1. Begin all patients receiving ATC opiods with a combined stool softener and mild peristaltic stimulant... Docusate Sodium + Senna...1 to 4 tabs 3 times a day...

2. If no BM in any 48 hour period, add one to two of the following to above: Senna to 4 tabs three times a day, Bisacodyl..to 15 mg three times a day, milk of magnesia, lactulose, Mirilax,...

3. If no BM by 72 hours, perform rectal exam to rule out impaction...

4. If not impacted, try one of the following: Dulcolax suppository, Magnesium Citrate, Senna extract liquid, Mineral oil, Milk of Magnesia, Fleet enema....

5. If impacted Administer rescue analgesic if indicated before disimpaction. Manually disimpact if stool is soft enough, if not soften with glycerin suppository, then disimpact manually. Followup with tap water enema until clear, Increase daily bowel regimen and monitor laxation patterns closely..."