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32 | [Cont. from LIC 9099]
Regarding the allegation that licensee neglect resulted in the hospitalization of R1, interviews revealed that R1 was first checked on by S1 at approximately 0430 hours on 02/01/2025 and was awake without reporting abdominal pain. At approximately 0655 hours, S1 checked on R1 again, at which time R1 reported abdominal discomfort. S1 notified S2, who instructed S1 to administer Tylenol. When S1 returned at approximately 0813 hours to assist R1 with breakfast, R1 reported that the pain had worsened. S1 contacted emergency services, and paramedics arrived shortly thereafter. R1 was transported to a medical center, where R1 was diagnosed with Ogilvie’s syndrome, a rare condition that can develop rapidly and is difficult to detect without imaging unless a patient reports pain. Interviews and bowel movement logs indicated that R1 had been having regular bowel movements and had not reported abdominal pain prior to 02/01/2025. Records confirmed that R1 denied abdominal pain or distention prior to hospitalization.
Regarding the allegation that licensee neglect resulted in delayed medical care for R1, interviews and records reviewed showed that R1 had not complained of abdominal pain prior to 02/01/2025 and was having documented, regular bowel movements. Staff reported that R1 was not exhibiting nausea, vomiting, or other signs of distress until the morning of 02/01/2025. When R1 first reported abdominal discomfort at approximately 0655 hours, S1 contacted S2 and administered Tylenol as instructed. When R1 later reported worsening pain at approximately 0813 hours, S1 contacted emergency services immediately. Paramedics responded within minutes and transported R1 to the hospital for evaluation. Medical professionals reported that Ogilvie’s syndrome can occur rapidly and without early warning signs, and that the condition would not have been identifiable without imaging unless the resident expressed pain.
Regarding the allegation that the licensee did not report R1’s change in condition, interviews and records support that R1 did not exhibit any change in condition prior to 02/01/2025. Staff reported no signs of distress, confusion, or discomfort beyond R1’s baseline, and interviews consistently indicated that R1 did not experience or report abdominal pain until the morning of 02/01/2025. Records review of R1’s bowel movement log confirmed normal bowel activity with no noted abnormalities or interruptions in routine, including documented movements on 01/31/2025. Facility charting reflected no concerns or reported changes in condition leading up to the incident. Once R1 stated experiencing abdominal pain at 0655 hours, staff notified supervisory personnel, and when symptoms escalated at 0813 hours, staff immediately contacted emergency medical services. [Cont. on LIC 9099-C pg. 1] |