PUEBLO, CO - Federal inspectors found significant violations at Life Care Center of Pueblo during an August 7, 2024 complaint investigation, citing the facility for failing to protect residents from inappropriate care and inadequate discharge planning that left a vulnerable resident without essential medications for nearly two weeks.
Investigation Reveals Concerning Medical Procedure Practices
The most serious violation involved a registered nurse's administration of a suppository to a resident who had requested constipation relief. According to the inspection report, the incident occurred in the early morning hours when the nurse performed digital fecal removal followed by suppository insertion. The resident's roommate reported hearing the resident "repeatedly yell for the nurse to stop" and stated she "had heard her scream."
The resident later told facility investigators that the nurse "had inserted more than three fingers inside her rectum, moving them around" during the procedure. When the resident asked the nurse to stop because it was causing pain, the nurse reportedly continued the procedure. The resident also stated she was told by the nurse "not to push her call light again after the incident" and expressed feeling unsafe in the facility.
A certified nursing aide who assisted with the procedure confirmed that the nurse had to remove feces to place the suppository and reported that the nurse told the resident, "I can't stop because I am trying to pull feces out so I can put the suppository in."
Medical Standards and Proper Procedure Protocols
Digital fecal disimpaction is a recognized medical procedure used when other methods of constipation relief have failed. According to medical literature cited in the report, the procedure should be performed "using ample lubrication and gently removing the impacted stool with the index finger." Professional standards emphasize that patients should not experience pain during suppository administration, though they may feel pressure.
The inspection revealed multiple documentation failures surrounding this incident. The nurse failed to record the digital disimpaction procedure, the suppository administration, or the required nursing assessments in the resident's medical record. Professional nursing standards require documentation of all medications given, including time, dose, route, pre-administration assessments, and therapeutic effects.
Additionally, the facility's standing orders for constipation management specify a graduated approach beginning with gentler interventions. Records showed the resident had gone four days without a bowel movement, yet no prescribed as-needed medications were administered according to the medication administration record, representing a failure to follow established physician orders.
Flawed Investigation and Administrative Response
The facility's internal investigation into the incident revealed significant procedural deficiencies. The nursing administrator acknowledged that interviews should have been conducted by qualified social workers or management team members, not by a certified nursing aide without social work credentials. The director of nursing removed herself from the investigation because the accused nurse was her sister, but failed to ensure proper oversight of the process.
Critically, the facility failed to interview all staff members working during the incident and did not investigate potential physical mistreatment, despite evidence suggesting forceful administration of care. The nursing home administrator later acknowledged that his "first instinct would have been that there had been potential physical abuse," but admitted he did not recognize it at the time.
The investigation also revealed gaps in resident interviews. While the facility questioned other residents about sexual inappropriateness, they failed to ask about experiences with forceful physical care, missing an opportunity to identify patterns of concerning behavior.
Dangerous Discharge Planning Failures
The same resident experienced serious discharge planning violations when she left the facility following the incident. Federal regulations require nursing homes to assist residents in developing safe and appropriate discharge plans, including coordination with healthcare providers and ensuring continuity of care.
Instead, facility administrators forced the resident's daughter to sign against-medical-advice (AMA) discharge paperwork, despite the family's request for time to prepare for the resident's complex medical needs. The resident required a mechanical Hoyer lift for transfers due to a below-the-knee amputation and had multiple medical conditions including end-stage renal disease requiring dialysis.
The facility failed to provide essential discharge elements required by their own policies, including written discharge instructions, medication lists, and coordination with the attending physician. No discharge summary was prepared, and the physician was never notified of the resident's departure. Adult Protective Services, which should be contacted for AMA discharges according to facility practice, was never notified.
Medication Management Catastrophe
The discharge planning failures had immediate and dangerous consequences for the resident's health. The facility sent no medications or medication lists with the resident, leaving her without critical prescriptions including blood thinners for nearly two weeks. This gap in medication management created serious health risks for a dialysis patient with multiple chronic conditions.
The resident's daughter, who worked as a certified nursing aide and emergency medical technician, reported having to secure medical equipment and coordinate care without facility assistance. Even the dialysis center social worker had to personally obtain oxygen supplies for the resident, highlighting the complete breakdown in discharge coordination.
Industry Standards and Required Protocols
Federal nursing home regulations mandate comprehensive discharge planning that includes assessment of post-discharge needs, coordination with receiving care providers, and ensuring medication continuity. When residents wish to leave against medical advice, facilities must evaluate decision-making capacity, provide education about risks, and still ensure safe transitions.
Proper constipation management requires following established protocols that begin with conservative measures and escalate systematically. Documentation of all interventions is not merely administrative requirement but essential for ensuring resident safety and care continuity. When medical procedures are performed, particularly invasive ones like digital disimpaction, thorough documentation protects both residents and providers.
Additional Issues Identified
The inspection revealed other concerning practices including inadequate documentation of bowel elimination tracking and failure to follow established constipation protocols. The facility's medication administration records did not reflect treatments that nursing staff claimed to have provided, indicating broader documentation and medication management concerns.
Staff interviews revealed confusion about proper procedures and responsibilities, suggesting inadequate training and oversight. The medical director confirmed that physician notification and involvement should have occurred for the AMA discharge but was never contacted about the resident's departure.
The violations represent failures across multiple domains of nursing home care: resident rights and protection, medical treatment and documentation, discharge planning, and medication management. These interconnected failures created a cascade of safety risks for a vulnerable resident with complex medical needs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Pueblo from 2024-08-07 including all violations, facility responses, and corrective action plans.
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