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Liability Landscape

April 1, 2005
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Handling Constipation and Fecal Impaction by Linda Williams, RN
LIABILITY landscape
BY LINDA WILLIAMS, RN

Handling constipation and fecal impaction As staff at most nursing facilities are aware, the occurrence of a resident having a fecal impaction is considered a sentinel event by the Centers for Medicare & Medicaid Services. It causes hardship for the resident and also for the staff, when their interventions are scrutinized by state surveyors to determine whether the event could have been avoided. Sometimes this same scrutiny and analysis find their way into a courtroom. Please take the time to review the circumstances surrounding the following situation, and make changes as appropriate at your facility.

The Situation
A 56-year-old woman was admitted to a skilled nursing facility with the following diagnoses: anemia, gastroesophageal reflux disease, Alzheimer's disease, severe multiple sclerosis, anxiety, contractures of all extremities, and reddened areas on her knees and one heel. For three years, the woman had been unable to move her upper and lower extremities voluntarily, so she had a urinary catheter and was subject to frequent fecal impactions. Before moving to the nursing facility, she had lived with her son while receiving home healthcare.

Because of the woman's frail condition, her physician wrote orders for the staff to encourage her to drink 3,000 cc of fluid each day. An enema also was to be given, up to three times per week, as needed. These and other constipation-prevention measures were incorporated into the woman's plan of care.

While at the facility, the woman's condition began to deteriorate. On her 23rd day of residence, the woman's urinary catheter began to leak, so she was transferred to the emergency room at her son's request.

The woman was admitted to the hospital with the following diagnoses: urinary tract infection with sepsis, dehydration, renal insufficiency, and high fecal impaction.

Three weeks after admission, the woman suffered acute abdominal pain, which proved to be a diverticular abscess, requiring a colostomy for relief. Three days after surgery, she seemed to be improving when she suddenly aspirated and died. Two months later, the woman's son sought legal counsel and filed a suit against the facility for his mother's wrongful death because of negligent care. His demand to settle was $3 million.

Upon examination of the woman's medical records at the nursing facility, both the plaintiff and defense attorneys discovered that the woman only had two bowel movements during her 23-day stay: One occurred two weeks after admission and the other was the day before being discharged to the hospital. In addition, the records revealed that during her last 48 hours at the facility, she consumed only 600 cc of fluids yet had a urine output of 2,000 cc. Other chart entries did not look much better, as her fluid intake during each of the previous days was less than half of the recommended 3,000 cc, and there was no dietary evaluation or notes concerning her meal intake.

Both attorneys hired expert witnesses to review the case and offer their medical opinions. The defense hired a geriatric specialist who felt that the woman's death was not causally related to the treatment she received at the nursing facility. However, the plaintiff's medical expert held an opposing view and felt there was indeed a direct link, especially related to the lack of monitoring, which led to the high fecal impaction. The parties went to mediation and agreed on a settlement of $500,000.

What Went Wrong
Undeniably, the defense's weakest point was that the staff did not pay close enough attention to the woman's bowel regularity patterns and did not intervene sooner (as directed by her plan of care) before the fecal impaction crisis struck. Medically speaking, individuals are considered to be constipated if bowel movement frequency is fewer than three times per week and/or if straining is experienced with more than 25% of bowel movements. Residents who are at risk for constipation include those with:
  • limited physical activity;
  • recent abdominal or perianal surgery or general anesthesia;
  • inadequate diet (e.g., less than 15 grams of dietary fiber per day);
  • inadequate fluid intake (e.g., less than 1,000 cc per day);
  • use of drugs known to be associated with constipation (e.g., anticholinergics, tricyclic antidepressants, antiemetics, antihistamines, anti-Parkinson agents, antipsychotics/phenothiazines, antacids containing aluminum, analgesics/nonsteroidal antiinflammatory drugs [NSAIDs], barium, bismuth, diuretics, histamine-2 blockers, hypotensives, iron supplements, opioids/narcotics, and phenytoin);
  • chronic constipation history;
  • laxative abuse history; and/or
  • comorbidities known to be associated with constipation (e.g., renal failure, electrolyte imbalances, spinal cord injury, arthritis, heart disease, diverticular disease, inflammatory bowel syndrome, colon cancer, painful lesions in the rectal or anal region, obstructing neoplasms, Parkinson's disease, amyotrophic lateral sclerosis, multiple sclerosis, myotonic dystrophy, stroke, insulin-dependent diabetes mellitus, untreated hypothyroidism, hyperparathyroidism, hypercalcemia, and symptoms of depression, dementia, psychosis, and acute confusion).
The woman in this case study had many of these risk factors, just as a significant percentage of residents that reside in nursing facilities today do. For this reason, it is important for staff to take the following precautions, as recommended by the University of Iowa in Evidence-Based Protocol: Management of Constipation, to minimize the occurrence of a similar crisis in their facility:

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