**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to 1) assess for a change in condition related to increased shortness of breath and weakness for 1 of 3 residents (Resident 56), and 2) consistently follow physician orders to prevent constipation (unable to pass stool regularly, that eventually becomes hardened) for 1 of 3 residents (Resident 71) both reviewed for quality of care. Resident 56 experienced harm when their bowels became impacted (when you're unable to regularly pass stool or feces and it backs up inside your colon), pain, and required a hospital intervention for relief. This failure placed all residents at risk for delay of treatment, unmet care needs, and negative health outcomes. Findings included . Review of a policy titled, Best Practice in Change of Condition and Endorsement, dated 05/2016 showed when a change in condition was recognized for the ability to eat or drink, changes in weight/intake, or had a change in their medical condition they would be placed on a 24 hour report with no less than 3 days of documentation and an attempt to identify the cause of decline. The physician, resident, and resident responsible party would be notified, and the Director of Nursing Services (DNS) would review the changes for any needed follow-up. Review of the policy titled Bowel Protocol, dated 03/25/2025, showed when a resident did not have a BM in three days (nine shifts) the Licensed Nurse (LN) would implement the bowel protocol: • Shift one, administer Milk of Magnesia (MOM, a brand of medication that stimulates the bowels), may administer two additional shifts if no results; • If no results after the MOM, the next shift administer a Bisacodly suppository rectally (a brand of medication that stimulates the bowels); if no results in two to three hours; • Administer a saline enema rectally (Fleets, a brand of medication that stimulates the bowels, if no results in two to three hours notify the provider for additional instructions. Review of a policy titled Bilevel positive airway pressure and Continuous positive airway pressure [Bipap/CPAP, machines that use pressure to push air into the lungs], dated 05/2007, showed when a resident admitted with a bipap machine there would be a physician's order, the machine settings were to be verified, and if any changes, notify the provider. The policy additionally showed the resident would be reassessed as needed for changes in their condition. <Resident 56> Review of the resident's medical record showed they admitted on [DATE] with diagnoses to include a stroke (when blood and oxygen to the arteries in the brain become blocked by a blood clot), diabetes (lack of sugar in the blood), and kidney disease. The comprehensive assessment dated [DATE] showed Resident 56 had moderately impaired cognition, required substantial to maximum assistance for toileting and transfers, and was continent of their bowels. During an interview on 03/24/2025 at 12:00 PM, Resident 56 stated they had recently visited the hospital due to a bowel blockage [constipation]. Resident 56 stated their constipation caused them pain while trying to push out the hardened stool, so they needed to be sent to the hospital (03/14/2025) due to the pain. Review of Resident 56's Medication Administration Records (MAR) from January 2025 through March 2025 showed: • Orders on 01/23/2025 for the bowel protocol, and Miralax (a brand of medication for constipation) daily as needed for constipation (as needed [PRN] Miralax had not been administered in January, February, or March 2025). • Order on 03/12/2025 for Miralax daily for constipation and then changed on 03/14/2025 to three times daily for constipation. Review of Resident 56's bowel tasks (a record that showed how often the resident had a BM and what the size of the BM's were) showed: • 01/23/2025 evening shift through 01/28/2025 day shift, five days and one shift with no BM (the PRN MOM and Miralax were not administered per orders). • 01/30/2025 evening shift through 02/07/2025 evening shift, eight days and two shifts no BM (two shifts showed no documentation) (the PRN MOM, Bisacodyl, Enema, and Miralax were administered per orders). • 02/10/2025 night shift through 02/17/2025 day shift, six days and two shifts no BM (the PRN MOM, Bisacodyl, Enema, and Miralax were not administered per orders). • 02/27/2025 day shift through 03/03/2025, four days and one shift no BM (the PRN MOM and Miralax were not administered per orders). • 03/03/2025 night shift through 03/11/2025 night shift, seven days and two shifts no BM (the PRN MOM, Bisacodyl, Enema, and Miralax were not administered per orders). During an interview on 03/27/2025 at 12:04 PM, Staff K, Registered Nurse, stated when a resident was having constipation issues, they would notify the doctor for further orders. Staff K stated there was a clinical alert (a warning that appeared in the Resident's Electronic Health Record [EHR] that alerted LNs there needed to be an intervention) in the resident's EHR that would automatically alert the LNs when a resident had not had a BM in three days, and at that time they would start the bowel protocol. During an interview on 03/27/2025 at 5:56 PM, Staff B, DNS, stated they expected LNs to discuss recurring constipation with residents. Staff B stated the residents should be asked what their normal patterns were, what they have used in the past that helped, and then discuss those findings with the provider for better bowel management. Staff B stated after three days without a BM the LNs should have implemented the facility bowel protocol and would follow each step each shift, not each day, when there were no results. Staff B stated they expected the LNs to start assessing bowel tones, abdomen distention, and pain after the nine shifts without a BM. Review of Resident 56's clinical alerts from 01/23/2025 to 03/27/2025 showed there were 29 shift alerts that showed Resident 56 had not had a BM in three or more days. Review of nursing progress notes dated 03/14/2025 showed: • 7:17 AM a PRN MOM was administered related to no BM in three days, • 8:45 AM a PRN Bisacodyl was given due to difficulty having BM, • 9:37 AM Resident 56 had been yelling out in discomfort because they were constipated. The note showed the Medical Director (MD) had been at the facility and gave orders to administer the Fleets enema and if no results administer a half a bottle of Magnesium Citrate (a brand of liquid medication that stimulates the bowels) and notify the provider if no results. • 3:16 PM Resident 56 had a couple small hard BMs and reported pressure pain in their rectum. The Contracted Advanced Registered Nurse Practitioner (ARNP) assessed Resident 56 to be impacted. The ARNP ordered a second Fleets enema to be given, not to administer the Magnesium Citrate ordered earlier, and if no results, send to the hospital. • 5:47 PM showed Resident 56 was sent to the hospital for evaluation due to their pain from trying to pass the hard stool. Review of the 01/23/2025 Care Plan (CP) showed Resident 56 experienced constipation related to decreased mobility. The CP showed no documented history, normal bowel patterns, or what the resident normally used to assist them with their constipation. Review of the 03/14/2025 hospital notes showed Resident 56 had a bowel impaction and required digital disimpaction (a medical procedure used to manually remove stool from the rectum, with a gloved finger, to break up and remove trapped stool. Typically performed when other methods of relieving constipation or fecal impaction have failed). Review of additional documentation provided by the facility, dated 12/12/2024 (prior to admission), showed Resident 56's Primary Care Provider documented the resident managed their constipation effectively by using dark chocolate (which was not documented or care planned). Review of the ARNP note dated 03/12/2025 (two days before being sent to the hospital), showed Resident 56 communicated they had chronic constipation and had several days without having a BM since being admitted to the facility. The ARNP gave new orders for Miralax to be given daily. Review of the ARNP note on 03/14/2025 (the day the resident was sent to the hospital), showed the LNs reported the resident experienced rectal pain and discomfort and Resident 56 had received PRN Bisacodyl and MOM that were ineffective. Per additional orders, the LN's administered the PRN Fleets enema and Resident 56 experienced pain and difficulty passing the stool, so the LN digitally removed some very hard stool. The note showed that later in the day Resident 56 yelled out for help and was having pain and was ordered to be sent to the hospital for evaluation. During an interview on 03/28/2025 at 2:44 PM, the MD stated they were notified of Resident 56's constipation issues in passing (while they were in the facility to see another resident) on 03/14/2025 and ordered a second Fleets enema to be given. The MD stated they had not been notified of Resident 56's constipation issues prior to 03/14/2025. <Resident 71> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses of respiratory failure with hypoxia (when you don't have enough oxygen in your blood from a lung or heart disease), pneumonia (a bacterial infection in the lungs), malignant cancer (when some of the body's cells grow uncontrollably and spread to other parts of the body) of the liver, right eye, and their bile duct, and sleep apnea (a condition that makes you stop breathing while you're sleeping). The 03/15/2025 comprehensive assessment showed Resident 56's cognition was intact and required substantial to maximum assistance with bed mobility and transfers. During a concurrent observation and interview on 03/24/2025 at 2:26 PM, Resident 71 was lying in bed., While the resident was speaking, they appeared short of breath, taking deep breaths in and out, while blowing out of their mouth in between words. Resident 71 stated they were tired and weak and had been on chemotherapy (a medicated treatment for cancer [a disease in which cells grow uncontrollably and spread to other parts of the body]). Resident 71 stated they had not felt tired and weak before but that had resolved with the pneumonia. Resident 71 stated the LN had been in to check their oxygen levels and they were okay. Additionally, there was a blue square medical equipment bag sitting on the nightstand to the right side of the resident (later referenced as a bipap machine). During an observation and concurrent interview on 03/25/2025 at 9:47 AM, showed Resident 71 lying in bed and continued to present with shortness of breath when talking, experienced nausea (a feeling of sickness in the stomach that could lead to vomiting) and had no appetite. Observed on the nightstand beside the bed was the blue medical equipment bag seen on 03/24/2025. Resident 71 stated the bag contained their bipap machine, but they were not using it because they were having issues. Resident 71 stated they had problems with the mask leaking so they were given a new mask and then the resident stated they did not have the energy to apply the mask at night themselves and did not receive offers to assist them with it so had the staff pack the machine back up. During an observation and concurrent interview on 03/26/2025 at 9:23 AM, Resident 71 was sitting upright in bed and stated they did not have therapy the day before because they were too weak and tired. Resident 71 also stated they had nausea, and did not eat breakfast because they felt sick. Resident 71 stated they did not have pain in their mouth but that it was really dry and were observed to be short of breath and mouth breathing in between words. The bipap machine was observed unpacked from the blue bag and the mask straps were hanging up on a hook on the wall. Resident 71 stated they did not use the mask because the straps needed to be washed and were not dried. Resident 71 stated they had a very dry mouth and would require a drink of water every fifteen to twenty minutes and was asking the staff to constantly come in to replace the mask and this made them feel bad, so stopped asking for assistance or using the machine. Staff K entered the room and stated Resident 71's pneumonia had resolved, but they were recently being treated for thrush (a yeast infection that can grow in your mouth, throat and other parts of your body). During an interview on 03/27/2025 at 12:11 PM, Staff K stated the LNs received orders from the hospital for equipment residents would bring from home. Staff K stated the bipap machine had a preset setting and they would ask the resident or family who their sleep specialist was if they had issues. Staff K stated Resident 71 did not normally complain of being tired and weak and had not been told they were, nor was the resident normally short of breath. Staff K stated they knew the resident had experienced nausea and recently had their nausea medication increased but did not know why the resident had nausea. Staff K stated they had not tried to contact Resident 71's Oncologist (a cancer specialist) to inform them of the resident's shortness of breath, loss of appetite, nausea, or weight loss, nor were they able to verbalize what chemo medication they received or what those side effects to monitor were. Staff K stated they were not aware Resident 71 was not using their bipap machine. During an interview on 03/27/2025 at 2:30 PM, Resident 71stated they did not use the bipap machine the night before (03/26/2025) because they (staff) did not come in and put it on me. The resident stated they used their bipap machine since 2017 and always used it until now. Resident 71 stated they received chemotherapy (a type of cancer treatment that used medications to kill cancer cells) treatment every three weeks for their cancer and the last treatment was on 03/05/2025 and the next treatment was scheduled for 03/31/2025. Resident 71 stated they were not sure if they would follow through with the next treatment because the last one had made them so sick. Review of the March 2025 MAR showed an order on 03/13/2025 for an anti-nausea medication that was administered three times, once on 03/23/2025, and twice on 03/24/2025. Then on 03/24/2025, was an order to increase the anti-nausea medication. Review of the 03/13/2025 through 03/25/2025 Treatment Administration Records showed an order on 03/13/2025 to assist Resident 71 with applying the bipap machine at bedtime and as needed. The order showed the bipap had been applied nightly except for missing documentation for three of the 13 nights reviewed. Review of Resident 71's 03/13/2025 discharge hospital records showed the resident received a chemotherapy treatment on 03/05/2025 with a medication called Opdivo (a brand of cancer medication). Further review of the medication showed some of the medication's side effects consisted of shortness of breath, nausea and vomiting, weight loss, and skin rashes. Review of Resident 71's 03/13/2025 baseline CP showed no resident specific information for their cancer or their cancer treatment. The CP showed no information on the chemotherapy they received, the side effects, who their Oncologist was, or what to monitor. Additionally, the CP showed no resident specific information for use of the bipap machine, what the settings were, or if issues were to arise, who to contact. Review of Resident 71's progress notes showed on 03/19/2025 the Speech Therapist (ST, a specialist who diagnoses and treats communication and swallowing problems) communicated to the LN staff that Resident 71 had a thrush like rash on their tongue and the back of their throat. The note showed the the nurse assessed and asked the MD (provider) to assess as well. Review of nursing progress notes showed: • on 03/20/2025 showed Staff K documented they did not clean the bipap mask because did not use. • on 03/23/2025 showed the Resident received a new order for an antifungal medication for treatment of Resident 71's thrush (four days after the LN documented they assessed and notified the provider). • on 03/25/2025 showed that the [Resident 71] not feeling well so refused their medications. • review of the notes showed no assessment of the resident's difficulty breathing (other than clear lung sounds) when talking, increased tiredness and weakness, or why the resident had been experiencing nausea. The records further showed no notification had been made to the Oncologist and Sleep Specialists. During an interview on 03/28/2025 at 2:44 PM, the MD stated the facility or MD had received information on Resident 71's chemotherapy medication or what to monitor after receiving that medication. The MD stated they had seen the resident on 03/13/2025 and again on 03/17/2025 and were aware of the nausea, weakness, and tiredness but it was just a wait and see if it improved. The MD had not been notified Resident 71 was not using their bipap machine. Reference: WAC 388-97-1060 (1)(3)(vi)