Health inspection·April 6, 2022

F 760 §483.45(f)(2) The facility must ensure that its- Residents are free of any significant medication errors. § 72311. Nursing Service - 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. § 72313. Nursing Service -Administration of Medications and Treatments. (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. The facility failed to follow the aforementioned regulations by not monitoring Resident 1's bowel movements and providing prescribed medication when Resident 1 had no bowel movement for five days. This failure contributed to Resident 1's development of a fecal impaction (a hard, dry mass of stool which cannot be moved or excreted from the intestines with a normal bowel movement, also known as bowel impaction) which caused compression of internal organs, prevented normal urination, and required critical care treatment to prevent life-threatening urinary obstruction and severe constipation. A review of Resident 1's Hospital After Visit Summary (a summary of Resident 1's hospitalization history immediately prior to admission to the skilled nursing facility), dated 8/28/2020-9/15/2020, showed Resident 1 had included diagnoses of chronic constipation, fecal impaction, and chronic abdominal pain. A review of Resident 1's Face Sheet, undated, indicated Resident 1 was admitted to the facility on 9/15/2020 with a diagnosis of non-Alzheimer's dementia (a brain disorder that affects the ability to remember, think clearly, communicate, and perform daily activities and that may cause changes in mood and personality). A review of Resident 1's Minimum Data Set (MDS, an assessment tool used to guide care), dated 9/22/20, indicated Resident 1 was able to understand others and sometimes was able to be understood. The MDS indicated Resident 1 was always incontinent of bowel and bladder and was totally dependent on assistance from one person for toilet use. A review of Resident 1's Physician Order Report dated 9/1/20-10/31/20, indicated the following bowel regimen orders (a collection of orders designed to prevent constipation and fecal impaction) with a start date of 9/15//20, to be given once daily: docusate sodium (a stool softener), Linzess (promotes regular and more complete bowel movements), and Miralax (a laxative, used to promote bowel movements). The Physician Order Report also indicated two PRN medication orders for the bowel regimen: Senna (a laxative) to be given orally once daily if Resident had no bowel movement for two consecutive days; and a Dulcolax rectal suppository (a solid form of medication inserted into the rectum) to be given once, if the Senna was ineffective and Resident 1 had no bowel movement 24 hours after Senna was administered. A review of Resident 1's care plan titled, "Risk of Constipation," dated 9/16/20, indicated the goal of, "will have a bowel movement at least every three days." Resident 1's updated care plan intervention dated 10/2/20, indicated, "Dulcolax suppository rectally daily x1 as needed if Senna is ineffective and no bowel movement in 24 hours after Senna was administered ...Review medication regimen with the physician to help minimize risk of constipation." A review of Resident 1's care plan titled, "Incontinence," dated 10/2/20, indicated the goal of, "regain/maintain bowel and bladder function and to decrease risk of developing complications from incontinence..." Resident 1's care plan indicated the intervention of, "Inform Medical Doctor (MD) and responsible party for any abnormal changes..." A review of Resident 1's "Vitals Results, Intake and Output," dated 9/15/20-10/31/20, indicated Resident 1 had no bowel movements during night shift (11 p.m. to 7 a.m. the following morning), day shift (7 a.m. to 3 p.m.), or evening shift (3 p.m. to 11 p.m.) on 10/6/20, 10/7/20, 10/8/20, 10/9/20, or 10/10/20. During a concurrent record review and telephone interview with the Director of Nursing (DON), on 1/5/22, at 1:35 p.m., Resident 1's MAR, care plans, physician orders, and Vitals Results, Intake and Output dated 10/6/20-10/10/20, were reviewed. The DON was unable to provide documentation Resident 1 had received any of the PRN bowel regimen meds (Senna and Dulcolax suppository). The DON confirmed the Vitals Reports showed Resident 1 had no bowel movement for five consecutive days from 10/6/20 through 10/10/20. The DON stated the computer charting system-generated alerts for such items as no bowel movement for three days, and the charge nurses were supposed to check the alert messages every shift. The DON stated nursing must have failed to check the system-generated alerts, and therefore nursing staff had not notified the physician about Resident 1's lack of bowel movement for five days. During a telephone interview on 2/8/22, at 12:05 p.m., with Resident 1's facility attending Physician 1 (Physician 1), Physician 1 stated Resident 1 was admitted with a bowel regimen and if the resident had not had a bowel movement for more than three days, the nurses should have given PRN laxative medications as ordered and informed the physician of the lack of bowel movement. During a telephone interview on 2/24/22, at 12:45 p.m., with Resident 1's facility assigned attending Physician 2 (Physician 2), Physician 2 stated he shared responsibility with Physician 1 for residents at the facility. Physician 2 stated he was familiar with Resident 1's medical history and was aware of her previous fecal impaction; he had written her facility admission orders for the bowel regimen, including the PRN laxatives. Physician stated he had no recollection of receiving a call about Resident 1's lack of bowel movement for five days. Physician 2 stated it was important for Resident 1 to not go for more than two to three days without a bowel movement due to her history of constipation and fecal impaction. A review of Resident 1's Hospital Emergency Department (ED) Notes, dated 10/29/20, indicated Resident 1 was transferred from the facility and admitted to the acute care hospital on 10/29/20, with, "...a massive fecal impaction distending the rectum and sigmoid colon. (The large intestine's lowest parts are the sigmoid colon, which turns sharply down at the rectosigmoid junction, the area where the sigmoid colon becomes the rectum, into the rectum, which terminates at the anus.) The distended rectum compressed the uterus and urinary bladder where there was abundant stool in the remainder of the large bowel...A rectosigmoid fecal ball (also called a fecal impaction) measures approximately 24.4 x (by) 13.6 centimeters (cm). This occupies the majority of the pelvis. The uterus and the urinary bladder are compressed anteriorly (toward the front of the body) ...Abundant stool in the remainder of the large bowel to a lesser extent. Mild bilateral hydronephrosis (bilateral hydronephrosis is the swelling of both kidneys due to a back-up of urine that is unable to drain properly through the ureters, the tubes that lead from the kidney to the bladder) secondary to compression of the ureters by the distended rectum...." The ED Notes further indicated, "Critical care was necessary to treat or prevent life-threatening deterioration of the following conditions including dehydration, acute urinary obstruction, and severe constipation..." Therefore, the facility failed to monitor Resident 1's bowel movements and provide prescribed medication when Resident 1 had no bowel movement for five days. This failure contributed to Resident 1's development of a fecal impaction (a hard, dry mass of stool which cannot be moved or excreted from the intestines with a normal bowel movement, also known as bowel impaction) which caused compression of internal organs, prevented normal urination, and required critical care treatment to prevent life-threatening urinary obstruction and severe constipation.