Other·September 10, 2021

T22 DIV5 CH3 ART3- 72311(a)(2) Nursing Services -- General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. T22 DIV5 CH3 ART3- 72313(a) (2) Nursing Services -- Administration of Medication (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. §Health & Safety Code 1424 (d) (d) Class "A" violations are violations which the state department determines present either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom. From March 16, 2017 through April 3,2017, the Facility failed to comply with the requirements for nursing service when: a. The Facility staff failed to implement Resident 1's bowel care plan; and b. The Facility staff failed to implement Resident 1's medication orders for bowel regimen prescribed by Resident 1's physician. The resulting failures by Facility staff resulted in Resident 1 requiring transfer to an Acute Care Hospital's emergency room on 4/3/17 at 10:30 p.m. with signs and symptoms of low blood pressure (50/32 mm hg), a slow pulse of 44 beats per minute, a hard-distended abdomen, and Resident 1's complaints of severe abdominal pain that radiated to the back. On 4/4/17 Resident 1 was admitted to the Acute Care Hospital for an exploratory abdominal surgery and resection of Resident 1's bowel. On 6/8/17 at 10:00 a.m., an unannounced visit was conducted at the facility to investigate a complaint of nursing care related to bowel care that resulted in a bowel obstruction. Resident 1's physical and medical history, dated 4/3/13, indicated Resident 1 was an 81-year-old female who had a recent left hip fracture. Diagnoses included: cerebrovascular disease with hemiplegia (paralysis of one side of the body), osteoporosis (weakening of the bones), and Dementia (a condition involving loss of memory, language, problem-solving skills that are severe enough to interfere with daily life) and a past history of chronic constipation and small bowel obstruction. Resident 1 was readmitted to the Facility in 4/14/13 for long-term care. Resident 1's quarterly MDS (Minimum Data Set, an assessment tool), dated 2/5/17, indicated Resident 1's cognitive skills for daily decision making were severely impaired and she never/rarely made decisions. Additionally, Resident 1 needed extensive assistance with her activities of daily living. The MDS indicated Resident 1 was incontinent of bowel and bladder. Review of Resident1's care plan for constipation, rewritten on 7/26/16, indicated Resident 1 was at risk for constipation related to decrease in mobility, decrease in gastro-intestinal mobility, and medication (the Facility noted Plavix, a blood thinner, as a possible medication that may cause constipation and abdominal distention). The bowel care plan indicated Facility staff were to monitor for manifestations of abdominal distention, nausea/vomiting, and impaction (firmly packed stool). The goal of the care plan indicated Resident 1 would have a bowel movement at least every 2-3 days and Resident 1 would be free of nausea, vomiting and abdominal distention. The approach to the bowel care plan indicated Facility staff were to provide medication and treatment as ordered, monitor the effectiveness of medication and treatment, and monitor bowel movements for consistency and frequency. Review of Resident 1's prescribed physician's bowel medication orders on the March and April 2017 Medication Administration Records indicated Resident 1 was to have Senna 8.6 mg and Colace 200 mg by mouth twice a day. Staff were to administer the following bowel prn meds (medications given as needed: a. Milk of Magnesia (a laxative) 30 milliliter to be given by mouth as needed for no bowel movement in two days. b. Bisacodyl 10 mg rectal suppository, to be given by rectum, as needed, for no bowel movement in three days, c. To be followed by a Fleet mineral oil enema to be given by rectum if there was no bowel movement four hours after the Bisacodyl rectal suppository. A review of the Facility's Resident 1's Bowel Movement List recorded the following Resident 1's bowel movements between the dates of 3/13/17 through 4/3/17: a. On dates between 3/14/17 and 3/17/17 no bowel movements were recorded. A small bowel movement was recorded on "AM" shift of 3/18/17. A review of the March 2017 PRN Medication Administration Record indicated the facility staff did not administer the Milk of Magnesia, the Bisacodyl or a Fleet mineral oil enema per the March Medication Administration record. b. On the date of 3/19/17, no bowel movement was recorded. c. On the date of 3/20/17, one large loose bowel movement was recorded. D. On the date 3/21/17, one small bowel movement on "PM" shift. e. On dates between 3/21/17 and 3/24/17 no bowel movements were recorded. A review of the March 2017 PRN Medication Administration Record indicated the facility staff did not administer the Milk of Magnesia, the Bisacodyl or a Fleet mineral oil enema per the March Medication Administration record. f. On dates between 3/25 and 3/27, large bowel movements recorded g. On 3/28/17 a small "PM" bowel movement was recorded. h. On the date 3/29/17 no bowel movement was recorded i. On the date 3/30/17 one large bowel movement was recorded on "PM". j. On the dates 3/31/17, and 4/1/17 no bowel movements were recorded. A Review of the April MAR 2017 indicated the Facility staff failed to administer the Milk of Magnesia. k. On 4/2/17 one small bowel movement was recorded on "PM" shift. l. On 4/3/17 one small bowel movement was recorded on "AM" shift. Licensed Nurses Weekly Summaries provided for March 2017, indicated Resident 1, for the week ending 3/3/17, was incontinent, with a normal bowel pattern of every other day. For the week ending 3/10/17, the Licensed Nurses Weekly Summary indicated the resident was incontinent with no bleeding noted. The Facility did not provide the Weekly Summaries for the weeks ending in 3/11/17 and 3/17/17. The Weekly Summary ending 3/31/17 revealed the resident was incontinent every other day. The available weekly summaries failed to indicate any specific bowel assessment as described in Resident 1's care plan for constipation (e.g. monitoring for manifestations of abdominal distention, nausea/vomiting, impaction and consistency of bowel movements). On 6/8/17 at 10 a.m., CNA C stated she had given Resident 1 showers occasionally and had noted the resident's abdomen was distended. CNA C stated she reported the observation to the charge nurse. CNA C stated she did not know if the nurse took note of it. Licensed Staff A interview on 6/8/17 at 10:15 a.m., indicated she gave Milk of Magnesia to Resident 1 on 4/3/17 because the Resident 1 had had no bowel movement for four days. Licensed Staff A stated that the resident's abdomen was hard and distended. Licensed Staff A stated that after two days of no bowel movements, staff were to give Milk of Magnesia, and if not effective give the suppository and then an enema if no results from the suppository. On 6/8/17 at 11:35 a.m. the Director of Nursing (DON) stated that she was not told of an abdominal mass in Resident 1's abdomen and acknowledged knowing that the resident had an history of bowel obstruction. In a subsequent interview with the Director of Nursing on 6/12/17 at 10:15 a.m. the Director of Nursing verified Resident 1's bowel care orders as stated by Licensed Staff A. Interview with CNA B on 6/12/17, stated that if a bowel movement was documented as a small bowel movement, it was like no bowel movement at all. CNA B stated a small bowel movement was only a size of a quarter. Interview with Licensed Staff D on 11/9/2020 at 1:00 p.m., stated that staff should be recording the consistency of the stool on the Bowel Movement List and report any concerns to the charge nurse. Licensed Staff D stated that a small bowel movement was the "size of a golf ball" and a small bowel movement might be an indication of constipation. Per the Medication-Administration policy No-NP-76, dated 1/1/2012, provides that "medications and treatments will be administered as prescribed". The same policy, under PRN Medication Documentation read as follows: "When a PRN medication is given, it will be charted on the Medication Administration Record. The Nurse will document the reason given, reason for the drug, route of administration, date, and time." The Facility's in-service training material, labelled Relias Learning, and dated 2015, was submitted by the Facility as the bowel training/procedure used by the Facility. A review of the Relias Learning document under Section 2: The Facts About Constipation, under Documentation: Stool observation for all individuals should include: normal color, consistency, odor, frequency or infrequency of elimination, complaints of pain, and anything that may be unusual. According to this training procedure, changes related to the bowel movements should be "reported to the nurse along with changes and irregularities that may indicate problems with bowel elimination. The sooner these problems are identified, the sooner they can be treated." SBAR Communication Form, initially, dated 4/3/17, at 7:30 p.m. indicated Resident 1 was diaphoretic (sweating profusely) with a blood pressure of 88/55 mm Hg (normal reading would be any blood pressure below120/80 mm Hg and above 90/60 mm Hg millimeters of mercury). Licensed staff notified the physician who ordered increased fluids for Resident 1. Licensed Staff A documented Resident 1's abdomen was distended. Licensed Staff A documented that Resident had only a small bowel movement in the last two days and documented that she gave Milk of Magnesia at 8:15 p.m. to Resident 1. At 9:35 p.m. Licensed Nurse A documented Resident 1's color was pale and abdomen "very hard and distended". Resident 1 reported she was "hurting everywhere". Licensed Staff A recorded Resident 1's blood pressure as 50/32 with a pulse rate of 44 beats per minute at 10:30 p.m. At 10:55 p.m. on 4/3/17 the Facility transferred Resident 1 to an Acute Care Emergency Room for further evaluation. Resident 1's Emergency Department Acute Care Hospital record, dated 4/3/17, indicated Resident 1's chief complaint upon admission was abdominal pain; the resident presented with "acute distress", with an abdomen that was "distended, rigid". An x-ray indicated Resident 1 had severe obstipation (severe constipation with hard compacted stool). The CT scan indicated Resident 1 had obstipation without perforation (without tearing or piercing bowel tissue) after "post disimpaction" (manual removal of stool from the rectum). A naso-gastric tube was place (tube inserted through the nasal passages into the stomach) and manual disimpaction (using gloved fingers to remove stool from the rectum). Resident 1 was admitted to the Acute Care Hospital for treatment. Acute care hospital's operative report, dated 4/4/17, indicated that Resident 1 had a gigantic sigmoid colon [part of the large intestine that transport fecal material to the rectum to the anus]. "The sigmoid colon was approximately the size of an [sic] eight-month pregnant uterus." The operative report indicated the surgeon removed approximately 3 to 4 liters of stool "plus anything that spilled into the abdominal cavity". The surgeon made a left upper abdominal ostomy (an opening to skin) bringing the descending colon to the ostomy which produced "copious amounts of stool as well.". Resident 1 became hemodynamically unstable [unstable blood pressure] during surgery. After surgery was completed, Resident 1 was transferred into the Post Anesthesia Care Unit in critical condition. Discharge summary, dated 4/4/17, indicated Resident 1's family decided to withdraw care and Resident 1 died in the Post Anesthesia Care Unit on 4/4/17. The Certificate of Death, dated February 13, 2018, indicated the cause of death was cardiopulmonary arrest with Ogilvie Syndrome (disorder characterized by acute dilatation of the colon in the absence of an anatomic lesion that obstructs the flow of intestinal contents). The facility's failure to administer as needed bowel care medications as prescribed by a physician and the failure to implement Resident 1's bowel care plan for constipation resulted in Resident 1 requiring emergency transfer to an Acute Care Hospital and subsequent exploratory laparotomy with colonostomy immediately before death. These violations jointly, separately or in any combination presented either imminent danger that death or serious harm would result or a substantial probability that death or serious harm would result.