Health inspection·January 17, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to notify a resident's physician of weight gain as ordered. This affected one resident (#13) of three residents reviewed for change in condition. Findings Include: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hypertension, type II diabetes, chronic obstructive pulmonary disease, hyperlipidemia, and constipation. Additional diagnoses were added on 01/01/24 including encephalopathy and abdominal distention. Review of a quarterly minimum data set (MDS) assessment completed on 10/03/23 revealed Resident #13 had intact cognition, no behaviors, was always incontinent of bowel, and was dependent on staff for toileting assistance. In addition, Resident #13 had an order started on 05/01/22 to record daily weight and if there was a two-pound weight gain in one day or five-pound weight gain in one week notify the physician. Resident #13 gained four pounds on 12/04/23, gained two pounds on 12/05/23, gained nine pounds on 12/15/23, gained six pounds on 12/18/23, was not weighed on 12/19/23, gained four pounds on 12/23/23, and gained five pounds on 12/24/23. There was no documented evidence Resident #13's physician was notified of the resident's weight gain (2 pound gain in one day or five pound gain in one week). Interview on 01/16/24 at 3:00 P.M. with the Director of Nursing (DON) confirmed weight changes were not reported to the physician as ordered. This deficiency represents non-compliance investigated under Complaint Number OH00149782. Page 1 of 4 366367 366367 01/17/2024 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to administer as needed stool softeners to prevent a bowel obstruction. This affected one resident (#13) of three residents reviewed for constipation. The facility census was 66. Residents Affected - Few Actual harm occurred on 12/28/23 to Resident #13, who had a diagnosis of constipation, when facility staff failed to assess and monitor the resident and failed to provide ordered medical treatment when the resident did not have a bowel movement for six days resulting in the resident experiencing a bowel obstruction requiring hospitalization and treatment. Findings included: Record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, hypertension, type II diabetes, chronic obstructive pulmonary disease, hyperlipidemia, and constipation. Additional diagnoses were added on 01/01/24 including encephalopathy and abdominal distention. Review of a quarterly Minimum Data Set (MDS) assessment completed on 10/03/23 revealed Resident #13 had intact cognition, no behaviors, was always incontinent of bowel, and was dependent on staff for toileting assistance. Review of Resident #13's care plan revealed Resident #13 was incontinent of bowel and at risk for altered dignity, skin breakdown, diarrhea, and constipation with a goal of having a soft bowel movement at least every three days without any complications including constipation. Interventions included administer medications per physician orders, assess quarterly and as needed for changes in elimination pattern, observe and record bowel movements daily for amount and consistency, and observe and report any diarrhea, constipation, change in bowel movement, and abdominal distention or discomfort. Review of physician's orders revealed orders from 01/01/24 for Dulcolax suppository once a day, Milk of Magnesia (MOM) 400 milligrams (mg) per five milliliters (ml) give 15 ml at bedtime, Miralax 17 grams twice a day, and Sennosides-Docusate Sodium 8.6-50 mg one tablet twice a day. Review of a medication administration record (MAR) from December 2023 revealed Resident #13 had an order started on 11/21/23 for Miralax 17 grams twice a day which one dose was not administered on 12/01/23, 12/07/23, and 12/09/23 due to condition. There was no evidence or explanation of what due to condition meant. Resident #13 had an order for Senna 8.6 mg twice a day ordered on 11/21/23 which one dose was not administered on 12/01/23, 12/07/23, 12/09/23 or 12/10/23 due to condition. There was no evidence or explanation of what due to condition meant. Resident #13 also had an as needed order for Dulcolax suppository 10 mg once a day ordered on 11/21/23 which was not administered in December 2023, Lactulose solution 20 ml twice a day as needed ordered on 11/21/23 which was not administered in December 2023, and Sennosides-Docusate Sodium 8.6-50 mg once a day as needed ordered on 11/22/23 which was not administered in December 2023. Review of Bowel Movement Reports for December 2023 revealed Resident #13 did not have a bowel 366367 Page 2 of 4 366367 01/17/2024 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0684 Level of Harm - Actual harm movement on 12/17/23, 12/19/23, 12/20/23, 12/23/23, 12/24/23, 12/25/23 or 12/26/23. Resident #13 had a small bowel movement on 12/16/23, a medium bowel movement on 12/18/23, a small bowel movement on 12/21/23, a large bowel movement on 12/22/23, and a large bowel movement on 12/27/23. Review of Bowel Control Reports from December 2023 revealed Resident #13 was incontinent. Residents Affected - Few Review of a nursing note dated 12/23/23 at 10:29 A.M. by LPN #102 revealed a skin check was completed and no new skin areas or issues were noted for Resident #13. There was no documented evidence the condition of the resident's shingles was assessed. Review of a nursing note dated 12/28/23 at 10 A.M. by LPN #102 revealed Resident #13 had decreased strength in her right arm, a fixed stare, unable to follow directions, and responded to questions with mumbled and nonsensical speech. A new order was received to send Resident #13 to the emergency department. Review of a hospital note from 12/28/23 revealed Resident #13 presented to the emergency department for altered mental status. Resident #13 was admitted to the hospital with a diagnosis of encephalopathy and abdominal distention. A CT scan of Resident #13's abdomen and pelvis revealed Resident #13 had severe diffuse dilation of the colon and a large amount of stool associated with a chronic obstruction. The resident was admitted to the hospital for treatment. Review of a hospital discharge from 01/01/24 revealed it was undetermined if the encephalopathy was caused by herpes simplex virus or severe constipation. Due to the treatment of constipation, a lumbar puncture would expose the resident to iatrogenic infection. After discussion with the interdisciplinary team a 14 day course of Acyclovir, an anti-viral, was prescribed for treatment as well as Senna S twice daily and Milk of Magnesia. Review of a history and physical completed on 01/03/24 by Physician #300 revealed Resident #13 was treated for constipation with bowel regimen during admission to the hospital from [DATE] through 01/01/24. Results of an abdomen radiograph completed on 12/30/23 was reviewed and showed large stool burden predominantly within the distal large bowel, redemonstration of gaseous distention of large bowel, and development of dilated gas-filled small bowel loops which were likely secondary to upstream dilation from the large bowel findings. All findings were likely due to severe constipation of colonic ileus. Interview on 01/16/24 at 1:09 P.M. with Resident #13 revealed before she went to the hospital, Resident #13 went two weeks without having a bowel movement. Resident #13 reported she would let the aides know she had not had a bowel movement when they would come to change her, but no one ever gave her additional medications to help. Resident #13 stated she was still struggling with constipation, but the facility had started to administer stool softeners which has helped. Resident #13 revealed she was now having a bowel movement daily. Interview on 01/16/24 at 3:00 P.M. with the Director of Nursing (DON) revealed there was not a protocol that was followed for constipation specifically. The facility attempts to give the resident prune juice first, then moves on to contacting the physician for orders. The DON reported the resident was flagged after three days of having no bowel movement then administered softeners if it was not their normal bowel pattern. The DON reported water was passed at a minimum of once per shift and staff encourage fluids intakes and offer flavor packets if needed. The DON confirmed Resident #13 had several days without a bowel movement, but she did have one on 12/18/23, 12/21/23 and 12/27/23. The DON confirmed constipation was not addressed between 12/21/23 and 12/27/23 which was longer than 366367 Page 3 of 4 366367 01/17/2024 Altercare of Canal Winchester Post-Acute Rc 6725 Thrush Drive Canal Winchester, OH 43110

F 0684 Level of Harm - Actual harm Residents Affected - Few normal. The DON confirmed as needed stool softeners were not given and she was unsure of what not administered due to condition meant for Miralax and Senna. The DON confirmed there were no nursing notes explaining what due to condition meant. The DON stated she was unaware of Resident #13 having an impaction because the hospital and Resident #13's brother did not ever call to let them know. The DON stated she was unaware of the treatment Resident #13 received at the hospital. Review of an undated Bowel (Lower Gastrointestinal Tract) Disorders Protocol revealed assessment and recognition of bowel disorders should be assessed by change in mental status or level in consciousness, presence of fecal impaction, signs of dehydration, abdominal assessment, digital rectal exam, all current medications, active diagnoses, and labs. This deficiency represents non-compliance investigated under Complaint Number OH00149782. 366367 Page 4 of 4