Hill Haven Nursing Home

Based on staff interviews and record reviews conducted during an Abbreviated Survey (complaint #NY00098494) completed on 3/17/11, it was determined that for one of three residents reviewed for quality of care, the facility did not provide the necessary interventions to meet the residents' highest level of physical functioning. The issue involved lack of adequate bowel management for Resident #1. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #1 has diagnoses including dementia, chronic diarrhea, a history of gastrointestinal (stomach) bleeding, and currently being treated for influenza A. The 2/29/11 physician (MD) orders included Imodium, 2 milligrams (mg) twice daily, for chronic diarrhea, Dulcolax , 10 mg daily by mouth, and Milk of Magnesia (MOM), two tablespoons daily, as needed for constipation. The resident's Medical Orders for Life-Sustaining Treatment revealed her desire for no cardio pulmonary resuscitation, no feeding tubes, and no hospitalizations other than for comfort.

Review of the nursing progress notes on 3/16/11 revealed:

a) On 2/22/11 at 11:15 p.m., the resident complained of nausea.

b) On 2/23/11 at 2:20 p.m., the resident had a poor appetite.

c) On 2/23/11 at 11:30 p.m., the resident's temperature was elevated and the record was flagged for medical staff to review in the morning.

d) On 2/24/11, a night shift note indicated the resident complained of nausea, had two episodes of brown emesis (vomiting), including some coffee ground emesis, decreased bowel sounds, a firm abdomen, with no documented bowel movement (BM) in the last seven days. A suppository was given at this time with no results.

e) On 2/24/11, a day shift note indicated that the resident continued with two episodes of liquid brown emesis and had a medium formed BM. Her Imodium was held (for the first time) for constipation, and an enema was ordered and given with negative results. There is no documentation that the resident was visually seen by medical staff since 2/21/11, but a Fleet's enema was ordered.

f) The 2/24/11 evening shift nursing note revealed the resident had three more episodes of emesis of coffee ground color.

g) A 2/25/11 night shift note revealed that the resident had passed away related to multiple comorbities.

Review of the Bowel Shift Chart revealed that the resident did not have any documented BM for 19 consecutive shifts (8 hours) from 2/17/11 through 2/24/11. Review of the February 2011 Medication Administration Record revealed the resident received Imodium twice daily from 2/1 through 2/23/11 and no MOM or Dulcolax until 2/24/11.

In an interview on 3/16/11 at 12:00 p.m. and again at 1:50 p.m., the Licensed Practical Nurse (LPN) Nurse Manager (NM) stated that the facility's bowel protocol includes that the Certified Nursing Assistants (CNA) will chart all BMs in the computer every shift. Every evening team leaders (nurses) pull a report from the computer for all residents who have not had a BM for nine shifts and then give the residents' prescribed medications and follow the facility's bowel protocol. The LPN/NM said that Resident #1 was known to self-toilet on occasion. The LPN/NM also said that if a resident had no documented BM for nine shifts and may have self-toileted, she would still expect staff to do an abdominal assessment. She did not know why this was not done/documented.

In an interview on 3/16/11 at 1:30 p.m., a LPN stated that Resident #1 did self toilet at times. The LPN confirmed that the facility's bowel protocol includes that staff should do an abdominal exam on a resident who goes nine shifts with no BM and staff are not sure and that the bowel protocol would be started. She added that it is the responsibility of the evening shift to pull this report every evening.

In an interview on 3/16/11 at 1:40 p.m., the CNA confirmed that she was Resident #1's primary CNA and that while the resident did toilet herself now and then, she would usually put her call bell on when she went in the bathroom or she would tell staff that she went. The CNA said that the resident had not had any episodes of diarrhea recently.

Review of the facility's policy entitled, "Bowel Elimination Policy," dated June 2001, directs that at the end of the day shift, nursing will review the BM report and list all residents who have not had a BM for three days or nine shifts. This list is given to the evening nurses who will administer laxatives as ordered. The night shift will then follow-up on the results and administer further medications if indicated. If there are no results, the Nurse Manager will be notified in the morning and notify medical staff and obtain orders as necessary. It also indicated that for residents with dementia who may go on their own, a comprehensive assessment is necessary and could include changes in facial expressions, change in appetite, firm or distended abdomen, and possibly a rectal exam.

[10 NYCRR 415.12]