§ 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.
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Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to provide prescribed treatment necessary to manage constipation and promote normal bowel activity to prevent related complications and demonstrate timely and thorough assessment of a resident for one resident out of seven sampled (Resident 1).
Findings include:
According to the American Academy of Family Physicians primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week).
A review of the clinical record revealed that Resident 1 was admitted to the facility on January 15, 2024, with diagnoses to include stage 3 kidney disease, urinary retention, a history of constipation and fecal impaction and anxiety.
An admission history and physical dated January 17, 2024, completed prior to the resident's the facility revealed that she was hospitalized for multiple health issues to include having severe constipation, not having a bowel movement at home for 2 weeks. She had a fecal impaction, was disimpacted and Miralax (laxative) daily was initiated.
An admission MDS Assesment (Minimum Data Set - a federally mandated standardized assessment process conducted periodically to plan resident care) January 21, 2024, revealed that the resident was mildly cognitively impaired, required staff assistance with activities of daily living, including toileting, and was always incontinent of bowel.
A review of a care plan dated January 15, 2024 revealed that the resident was "at risk for constipation" with a goal for the resident to have a normal bowel movement at least every 3 days. Planned interventions were to follow facility bowel protocol for bowel movements and record bowel movement pattern each day.
A physician order dated January 15, 2024, was noted for a bowel regimen that included Milk of Magnesia (MOM - a laxative to relieve occasional constipation) 30 ml by mouth every 72 hours as needed for no bowel movement (BM), Dulcolax suppository (Bisacodyl a stimulant laxative) 10 mg, one rectally as needed after MOM is administered and Fleets enema (rectal enema combination medicine used to treat constipation) 7-19 gms, one application rectally as needed after MOM and Dulcolax if no BM, which was the facility's standing bowel protocol.
The resident also had an additional current physician order initially dated January 16, 2024, for Polyethylene Glycol 3350 powder 10 gm/15 mg, give 17 gms (mixed in water) by mouth every day (used to treat constipation, a laxative solution that increases the amount of water in the intestinal tract to stimulate bowel movements)for constipation.
According to the resident's January 2024 Medication Administration Record (MAR) Resident 1 received the Polyethylene Glycol daily throughout the month of January 2024.
A review of Resident 1's bowel movement record revealed that she did not have a bowel movement from January 15, 2024, through January 17, 2024.
A review of a January 2024 MAR (medication administration record) revealed that Resident 1 received MOM on January 17, 2024 at 9:30 P.M, which did not produce a bowel movement in response to the medication.
Further review of the January 2024 MAR revealed that Resident 1 received a Polyethylene Glycol enema on January 18, 2024 at 12:43 PM. There was no documentation in the clinical record why the resident did not receive the physician ordered bisacodyl suppository as per the facility protocol. In response to the enema, the resident had a large BM at 2 PM on January 18, 2024.
A review of a nurses note dated January 18, 2024 at 5:33 PM revealed, at approximately 3:50 PM, Resident 1's daughter called the nursing supervisor to state "I want my mother sent to the hospital immediately! She is in excruciating pain!" Nursing assessed the resident and noted no pain. The physician assistant was contacted and the PA-C suggested testing the resident in the facility but the resident's daughter insisted on sending her mother to the hospital for evaluation. The resident was sent to the ER at 6 PM.
There was no corresponding documented pain assessment or abdominal assessment of the resident, in the resident's clinical as noted in the nurse's note dated January 18, 2024, indicating that the resident was assessed and had no pain, available for the review at the time of the survey ending May 14, 2024.
A review of hospital emergency room documentation dated January 18, 2024 at 6:04 P.M. revealed that the resident had complaints of right hip pain, possible multiple falls. The resident was complaining of some abdominal pain and perhaps also some hip pain earlier today according to the ER documentation.
A CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) of the resident's abdomen and pelvis was completed with the following results: bowel: There is marked fecal impaction (Stool can become impacted, or stuck, in your colon, blocking waste from leaving the body. This often causes pain and bloating. Treatment can include laxatives or procedures to remove the stool) with significant distention of the sigmoid colon the sigmoid colon measures approximately 8.3 cm in transverse diameter. The remainder of the colon is decompressed, although limited in evaluation without oral contrast. The resident's stomach is distended.
The physician discharge documentation stated was "awaiting on discharge patient back to nursing home with a prescription for milk magnesia. However, the resident's daughter called complaining that patient was being sent to nursing home with a fecal impaction seen on CAT scan. Gave patient dose of milk magnesia here in the ER and wait till the morning to wait for the patient to have a bowel movement. Did prescribe patient Milk of Magnesia to take at the nursing home."
The resident returned to the facility January 19, 2024 at 6 A.M.
A nurses note dated January 19, 2024 at 1:39 P.M. revealed "Nursing spoke with the daughter regarding her recent visit to the ER. The daughter is concerned about her mother because the hospital told her the resident had a sever fecal impaction. Reviewed scans from ER visit and it was noted on the CT impression. Daughter stated when her mother was at the hospital in December 2023, she also had a fecal impaction. The nurse practitioner made aware of same. New order received to give a dose of lactulose ( a liquid medication sometimes used for constipation) 30 ml now and obtain KUB (abdominal x-ray). Continue the lactulose over the weekend and obtain another KUB on January 22, 2024."
A physician order dated January 19, 2024, was noted for the resident to receive Lactulose Oral Solution 10 GM/15 ML, Give 30 ml by mouth once daily for Constipation for 3 Days
A review of the January 2024 MAR indicated that Resident 1 received the Lactulose daily from January 19, 2024, through January 11, 2024.
There was no evidence at the time of the survey that the hospital recommendation for daily MOM was initiated upon the resident's return to the facility on January 19, 2024.
A repeat mobile X-Ray completed at the facility, KUB X-Ray, dated January 19, 2024 revealed, mild constipation, no bowel obstruction or fecal impaction.
There was no documented professional nursing assessment of the resident abdomen prior to the administration of the enema to Resident 1. The facility did not follow the physician ordered bowel protocol (step 2, MOM 30 mls). Further, there was no pain assessment or abdominal assessment completed prior to this residents transfer to the hospital at her daughter's request.
There was no nursing documentation as to why the physician prescribed bowel regimen was not implemented after the initial dose of MOM was not effective or the reason the enema was given in lieu of the following the prescribed steps in the protocol. The resident did have a BM after the administration of the enema, but there was no documentation of the status and condition of the resident's abdomen despite her daughter noting the resident's abdominal pain.
During an interview May 14, 2024 at 2 P.M., the Director of Nursing confirmed that the facility failed to administer the physician ordered bowel protocol to the resident during period of time without normal bowel activity and that nursing staff failed to demonstrate a thorough assessment of the resident's abdomen and pain prior to the resident's hospital transfer at family request.
28 Pa Code 211.12 (d)(3)(5) Nursing Services
28 Pa. Code 211.5 (f) Medical records
| | Plan of Correction - To be completed: 05/27/2024
Wesley Village submits that its policies, systems, and procedures related to resident care and comprehensive quality improvement program for monitoring of resident care are appropriate. Additionally, it is important to make clear that the submission of this plan of correction is not to be construed as an admission that the cited deficiencies are accurate or that at the time of the survey, Wesley Village did have policies, procedures and systems in place to maintain compliance with federal and state requirements; however, in an effort to enhance the care furnished to our residents, we have augmented some of our existing policies, procedures and systems.
- What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice?
Resident 1 is no longer in the facility and past events can not be corrected.
- How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All other residents who are at risk for constipation (as per their care plan) will be reviewed by the IDT to ensure appropriate Bowel Protocol is in place. Residents who are placed on the bowel protocol will receive a pain assessment if accompanied by documented abdominal pain as well as an abdominal assessment prior to the enema, which is the final tier of the bowel protocol.
- What measures will be put into place or what system changes will you make to ensure that the deficient practice does not recur?
Our licensed clinical staff will be re educated on our bowel protocol. This will include but is not limited to the three tiers of medication administration, if, when, and how to conduct pain and abdominal assessments, as well as the need for appropriate documentation if the physician or physician assistant disagree and or alter the current facility approved bowel protocol.
- How the corrective action will be monitored to ensure that the deficient practice will not recur; i.e., what quality assurance programs will be established?
The nursing home administrator or designee will conduct an audit of the current residents placed on bowel protocols 5x/week for 4 weeks to ensure appropriate measures are followed and that documentation is present. The results of this audit will be discussed at the quarterly quality assurance performance improvement meeting.
- Corrective action plan will be complete on 5/27/2024
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