© The Medical-Legal News 2007
By Margaret S. Wacker, RN, PhD, CLNC
Long-term care residents are especially vulnerable to constipation and fecal impaction. Impactions are preventable.
The occurrence of an impaction is considered a sentinel event by the Centers for Medicare & Medicaid Services (CMS). Once events are identified, a healthcare facility is subject to scrutiny by state surveyors. Oftentimes this scrutiny finds its way into the courtroom.
Constipation is a symptom that can be associated with life threatening disease. It is the most common bowel management problem in older adults. The prevalence of constipation in North American adults is estimated to be about 15 percent, accounting for more than 5.7 million physician visits in 2001. Whether an attorney has a defense or plaintiff issue, a nurse consultant can assist the attorney, and should be knowledgeable in identifying and detangling these types of common cases.
Case: A frail 56-year-old woman was admitted to a skilled nursing facility. She had diagnoses of anemia, multiple sclerosis, contractures of all extremities and Alzheimer’s disease. She was unable to move her upper and lower extremities. She required a urinary catheter and was subject to frequent fecal impactions. Prior to admission she had lived at home with her son while receiving home healthcare. After 23 days in the facility she was taken to an emergency room and admitted to the hospital. She presented with a urinary track infection, sepsis, dehydration, renal insufficiency and high fecal impaction. She developed acute abdominal pain due to a diverticular abscess necessitating a colostomy. She aspirated and died three days later. Her son filed a suit against the nursing facility for his mother’s wrongful death due to negligent care.
Review of the records indicated that she had two bowel movements during her 23-day stay, her fluid intake was less than half of the physician recommended amount and there was no dietary evaluation or documentation concerning her meal intake. Defense posited that there was no causal relationship between her death and the treatment she had received at the nursing facility. Plaintiff’s attorney proposed a direct link from the lack of monitoring, which led to the high fecal impaction. Following mediation both parties agreed to a $500,000 settlement in the plaintiff’s favor.
Case: A 76-year-old high-functioning gentleman sustained a fractured humerus and five fractured ribs in a slip and fall event. Following hospital care he was discharged to a skilled nursing facility for rehabilitation. About a month later he returned to the emergency room via ambulance following a vasovagal (heart-slowing) event, which occurred while he was straining to evacuate stool. He was catheterized for 2,400 ccs of urine (more than in a 2-liter soft drink bottle). The fecal impaction was large enough to press on the bladder, resulting in significant urinary retention and acute renal failure. He required a foley catheter and many weeks of discomfort and humiliation following bladder retraining.
His daughter filed a suit against the nursing facility for negligent care resulting in a lengthy hospitalization, prolonged rehabilitation and interruption in his quality of life. The case settled in the plaintiff’s favor for $35,000.
In these cases, identification of deviations from, and failure to follow, the standards of nursing care were pivotal. The professional nurse should have carefully monitored elimination, especially in light of the number of risk factors each patient presented on admission. Assessment was most frequently delegated to nursing assistants who did not have proper knowledge or training.
In reviewing medical records in cases like those above, a nurse consultant such as an LNC will carefully scrutinize the minimum data sets, input and output sheets, nutritional evaluations, physician orders, medication records and nursing care notations. The consultant may find that the care given was appropriate, or may find discrepancies and outright omissions that provide evidence of substandard care. •
Margaret S. Wacker, RN, PhD, CLNC is based in Florida, firstname.lastname@example.org
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