Health inspection·August 23, 2023

F684 FCR §483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents’ choices, including but not limited to the following: Resident Care Policies The facility in collaboration with the medical director must develop and implement resident care policies that are consistent with current professional standards of practice for not only pain management and symptom control, but for assessing residents’ physical, intellectual, emotional, social, and spiritual needs as appropriate. On 7/12/2023, at 10:15 am, an unannounced visit was made to the facility to investigate a complaint and Facility Reported Incident (FRI) regarding resident neglect. The facility failed to ensure Patient 1 who was assessed as having severely impaired cognition (thought process), and diagnoses of intestinal blockage (blockage of the intestine where food and stools [feces] may not be able to move freely), constipation (occurs when the bowel movements become less frequent and stools become difficult to pass), and bladder (an organ inside the body that stores urine) neck obstruction (blockage) received care and services to prevent and manage constipation by failing to: 1. Ensure Registered Nurse 2 (RN 2) assessed Resident 1’s abdominal bowel (intestine/gut) sounds (sounds made by the movement of the intestines as they push food through) when Resident 1 complained of abdominal pain (unrated) and when RN 2 observed Resident 1 with abdominal distention (swollen beyond its normal size) on 6/29/2023 as indicated in the facility’s Bowel Disorders policy and procedure. 2. Ensure Licensed Vocational Nurse 2 (LVN 2) and Medical Doctor 1 (MD 1) assessed Resident 1’s abdominal pain and abdominal distention from 6/29/2023 to 7/8/2023 as indicated in Resident 1’s untitled Care Plan, dated 5/20/2023. 3. Ensure Registered Nurse 2 (RN 2) assessed Patient 1’s pain level and administered pain relief medication as ordered by the Physician. As a result, Patient 1 had abdominal pain (unrated), abdominal and bladder (an organ inside the body that stores urine until it can be emptied) distention (enlarged/inflamed), tachycardia (fast heartbeat), hypotension (low blood pressure), decreased appetite (reduced desire to eat), and required a transfer to General Acute Care Hospital 2 (GACH 2). Resident 1 required an admission to GACH 2 for evaluation for tachycardia and was diagnosed with severe fecal impaction (the result of constant constipation when stools/feces were stuck inside of the rectum [anus]) causing the bladder outlet/neck obstruction (a blockage at the base of the bladder), urinary tract infection (UTI, an infection in any part of the urinary system), and sepsis (the body’s overwhelming and life-threatening response to an infection which can lead to tissue damage, and organ failure). A review of Patient 1’s GACH 1 record titled, “Computerized Tomography (CT scan, a medical imaging/pictures technique used to obtain detailed internal images of the body) of the abdomen (belly),” dated 5/13/2023, indicated Patient 1 had a very large stool burden (load) in the rectum (the final section of the large intestine), consistent with constipation, hydronephrosis (swelling of the kidney due to build up of urine), and a severely distended bladder (a condition in which the bladder becomes enlarged or inflamed). A review of Patient 1’s Admission Record indicated the facility a indicated the facility admitted a 38 year old, female on 5/20/2023 with diagnoses including intestinal obstruction, constipation, and bladder neck obstruction. A review of Patient 1’s untitled Care Plan, dated 5/20/2023, the care plan indicated Patient 1 was at risk for constipation, fecal impaction, and bowel obstruction. The nursing interventions included to document and report signs and symptoms of complications related to constipation such as abdominal distention, changes on bowel sounds, and the necessity of disimpaction (manual removal of feces from the rectum using a lubricated [a substance capable of reducing friction and allow smooth movement] gloved finger) as needed. During a review of Patient 1's untitled care plan dated 5/20/2023, the care plan indicated Patient 1 was at risk for pain and discomfort and the nursing interventions were to monitor and record pain characteristics and administer pain relief medication to Patient 1. A review of Patient 1’s Physician Order, dated 5/20/2023, indicated to administer Acetaminophen tablet (pain relief medication), 325 milligram (mg) give two tablets by mouth every six hours as needed for mild pain. A review of Patient 1’s History and Physical (H&P), dated 5/23/2023, the H&P indicated Patient 1 did not have the capacity to understand and make decisions. The H&P indicated Patient 1 had a recent hospitalization (unspecified date) due to obstipation (severe or complete constipation). A review of Patient 1’s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 6/2/2023, the MDS indicated Patient 1 was severely impaired with cognitive (ability to think and process information) skills for daily decision making. The MDS indicated Patient 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with one staff for toilet use and personal hygiene. The MDS indicated Patient 1 had bladder and bowel incontinence (inability to hold urine and stool). A review of Patient 1’s Progress Notes, dated 6/29/2023, timed 7:46 am, the Progress Notes indicated Patient 1 had a distended abdomen, and the abdomen was painful to touch (pain unrated). The Progress Notes indicated nursing staff (unidentified) notified MD 1, and MD 1 ordered to perform a straight catheter (thin tube used to insert into the bladder to pass urine from the body) every six hours as needed. A review of Patient 1’s Progress Notes, dated 6/29/2023, timed 10 am, the Progress Notes indicated Patient 1 had 800 milliliters (ml, unit of measurement) of dark urine. A review of Patient 1’s Subjective, Background, Assessment and Recommendation (SBAR, a communication tool between members of the health care team ) Communication Form, dated 6/29/2023, timed 11:29 am, the SBAR indicated Patient 1 “had little to no pee,” had decreased urine output, urinary retention (a condition when the bladder does not empty all the way during urination [act of passing urine]), distended abdomen, and the abdomen was tender and painful to touch (pain unrated). A review of Patient 1’s Physician’s Progress Record dated 7/1/2023, the Progress Notes indicated Patient 1’s abdomen was soft, and Patient 1 was stable for discharge. A review of Patient 1’s Physician’s Progress Record dated and 7/5/2023, the Progress Notes indicated Patient 1 had urinary retention. The record indicated Patient 1 was ready to discharge and planning for placement. A review of Patient 1’s SBAR Communication Form, dated 7/7/2023, timed 2:21 pm, the SBAR indicated Patient 1 had tachycardia. Patient 1 had a heartbeat of 105 beats per minute (normal heartbeat 60 to 100 per minute), and decreased appetite. The SBAR indicated MD 1 ordered to give Patient 1 ice cream and fruits. A review of Patient 1’s Nursing Progress Notes, dated 7/7/2023 timed 3:11 pm, the notes indicated Patient 1 had tachycardia (heart rate undocumented) and decreased in appetite. The notes indicated MD 1 ordered a bladder scan. A review of Patient 1’s bladder scan/ultrasound result (imaging test that used sound waves to make pictures of organs), dated 7/8/2023, timed 9:30 am, the bladder scan indicated debris (scattered pieces of waste or remains) were identified. The bladder scan/ultrasound result indicated Patient 1 was uncooperative. A review of Patient 1’s Nursing Progress Notes, dated 7/8/2023, timed 6:41 pm, the notes indicated Patient 1 complained of abdominal pain (pain unrated), and Patient 1 had abdominal distention. The notes indicated Patient 1 became hypotensive (low blood pressure) and had tachycardia (heart rate unrated). The notes indicated Licensed Vocational Nurse 2 (LVN 2) notified MD 1 regarding Patient 1’s condition (abdominal pain, abdominal distention, hypotensive, tachycardia) and MD 1 ordered to transfer Patient 1 to GACH 2. A review of Patient 1’s SBAR Communication Form, dated 7/8/2023 timed 6:45 pm, indicated Patient 1 complained of midabdominal (in the middle of the abdomen) pain (pain unrated). The SBAR Communication Form indicated Patient 1 “stating hurts - hurts” and “pointing” at Patient 1’s mid-abdomen. The SBAR Communication Form indicated Patient 1’s abdomen was hard to the touch, and Patient 1 had passed soft brown stool (amount was not indicated). During a review of Patient 1's MAR dated 7/8/2023, the MAR indicated Patient 1 complained of 6 out of 10 ([moderate pain] 1 to 2 least pain, 3 to 4 mild pain, 5 to 6 moderate pain, 7 to 8 increased/severe pain and 9 to 10 excruciating pain) pain level. The MAR indicated Patient 1 did not receive pain relief medication. A review of Patient 1’s Nursing Progress Notes, dated 7/8/2023, timed 7:30 pm, the notes indicated Patient 1 was transferred to GACH 2 at 7:20 pm. A review of Patient 1’s GACH 2 records titled, “Emergency Department General,” dated 7/8/2023, timed 7:43 pm, indicated Patient 1 was brought in by ambulance (BIBA) for evaluation of hypotension, tachycardia, bladder distention, and low appetite. The Emergency Department record indicated Patient 1 was admitted for UTI and sepsis. A review of Patient 1’s GACH 2 records titled “CT scan of the abdomen and pelvis (lower part of the trunk, between the abdomen and the thigh) Report,” dated 7/9/2023, the CT scan report indicated Patient 1 had a severe fecal impaction of the rectosigmoid colon (the end portion of the large intestine before reaching the rectum). The CT scan report indicated the fecal impaction created a mass-effect (pushing/blocking) on the urinary bladder. A review of Patient 1’s GACH 2 Consultation Records, the consultation records indicated the CT scan of the abdomen and pelvis, dated 7/9/2023 showed Patient 1 had severe fecal impaction of the rectosigmoid colon with mass effect on the urinary bladder. The Consultation Records indicated to clear fecal impaction with enemas (fluid inserted into the rectum and lower colon, to stimulate the elimination of feces from the rectum), suppositories (a small solid medication inserted into the rectum to relieve constipation), and oral laxatives (medication to help empty the bowels). During an interview on 7/12/2023, at 12:10 pm, with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated Patient 1 had been refusing her meals (unable to recall dates). During an interview on 7/12/2023, at 12:43 pm, with CNA 2, CNA 2 stated Patient 1 was incontinent of urine and BM. CNA 2 stated Patient 1 could speak short words like “pain, hurt, eat,” and was “able to point things.” During a telephone interview on 7/12/2023, at 1:58 pm, with CNA 4, CNA 4 stated she took care of Patient 1 on 7/8/2023 and Patient 1 pushed the breakfast tray away that morning (7/8/2023). CNA 4 stated Patient 1 drunk some juice and refused lunch. CNA 4 stated Patient 1 was crying. CNA 4 stated Patient 1 was “very agitated” (feeling troubled), and fidgety (restless). CNA 4 stated Patient 1’s cries and agitation were getting worst throughout the morning shift. CNA 4 stated she reported Patient 1’s condition (crying, fidgeting and agitation) to LVN 2. CNA 4 stated she recalled Patient 1 had a small BM (unidentified date and time) and Patient 1 was saying “hurt, hurt and doctor” while Patient 1 was pointing to Patient 1’s stomach. During an attempted telephone interview with MD 1 on 7/13/2023 at 1:50 pm, MD 1 was not available. During a concurrent interview with RN 2 on 7/13/2023, at 2 pm, and a review of Patient 1’s Progress Notes, dated 6/29/2023, RN 2 stated on 6/29/2023 Patient 1 complained of abdominal pain (pain unrated). RN 2 stated Patient 1 had a painful abdominal distention that was hard to the touch. RN 2 stated her assessment was focused on Patient 1’s bladder. RN 2 stated she did not assess the causes for constipation, the bowel sounds nor abdominal pain for Patient 1. RN 2 stated she did not recall giving Patient 1 pain relief medication. RN 2 stated abdominal assessment needed to include assessing Patient 1 for pain. During a second attempted telephone interview with MD 1, on 7/13/2023, 2:45 pm, MD 1 was not available. During a telephone interview on 7/13/2023, at 2:50 pm, with LVN 2, LVN 2 stated he took care of Patient 1 on the morning shift of 7/7/2023 and 7/8/2023. LVN 2 stated on 7/7/2023, LVN 2 observed Patient 1 had abdominal pain and abdominal distention. LVN 2 stated he assessed Patient 1’s abdominal distention but only focused his assessment on Patient 1’s urinary tract issues and not on the constipation issues because a CNA (unidentified) reported to him (LVN 2) that Patient 1 had a BM that morning (amount was not indicated). During a concurrent interview on 7/13/2023 at 3:50 pm, and a review of Patient 1’s Progress Notes, dated from 6/29/2023 to 7/8/2023 with the Director of Nursing (DON), the DON stated abdominal concern assessment needed to include bowel sounds assessment. The DON stated Patient 1’s Progress Notes dated from 6/29/2023 to 7/8/2023 did not have Patient 1’s bowel sound assessments. During a telephone interview with MD 1 on 8/1/2023, at 3:15 pm, MD 1 stated Patient 1 was difficult to manage due to Patient 1’s intellectual disabilities (ID, a term used when a person has certain limitations in cognitive functioning and skills). MD 1 stated she (MD 1) was not informed of Patient 1’s abdominal distention or constipation. MD 1 stated she could not recall if she was informed of Patient 1’s abdominal pain. MD 1 stated she was informed of Patient 1 bladder distention. MD 1 stated whatever was written on her progress record was her assessment. MD 1 stated she did not recall assessing Patient 1’s bowel sounds. MD 1 stated the steps in abdominal assessment in order included abdominal inspection, palpation (a method of feeling using fingers or hands during physical examination) and auscultation (the act of listening using a stethoscope (a device to listen to the sounds generated internally by the heart, lungs, and abdomen). During a review of facility undated policy and procedure (P&P) titled, “Bowel (Lower GIT) Disorders -Clinical Protocol,” indicated the abdominal assessment including for staff to listen for bowel sounds in area of suspected ileus (when the intestines stop functioning properly and food, fluids and gas are not able to pass through normally) or obstruction. The P&P indicated the staff and physician will monitor the overall degree or distress, frequency, severity, and the duration of abdominal pain. During a review of facility undated P&P titled, “Change in a Resident’s Condition or Status,” indicated prior to notifying the physician or healthcare provider, the nurses would make detailed observations and gather relevant and pertinent information for the providers, including information prompted by the SBAR. During