BEAVER DAM, WI - State inspectors found serious lapses in medical care at Beaver Dam Health Care Center, where staff failed to properly maintain a resident's feeding tube and left another resident without prescribed pain medication for nearly a week.
Critical Feeding Tube Care Deficiencies
The inspection revealed alarming neglect of a stroke patient's gastrostomy tube (G-tube), a medical device surgically placed through the abdomen to provide nutrition when swallowing becomes unsafe. The resident, who had the feeding tube inserted in November following a stroke that caused difficulty swallowing, was not receiving the required maintenance care to keep the tube functional.
When inspectors arrived on March 20, they discovered the tube site had thick, mucous drainage with dried dark red discharge around it. Multiple nursing staff told inspectors they "do not do anything" with the resident's G-tube, despite hospital discharge instructions specifically requiring ongoing flushes every eight hours to maintain tube patency.
The medical implications of this neglect are significant. Feeding tubes that are not properly maintained can become blocked, infected, or dislodged. The drainage observed by inspectors suggests possible infection at the insertion site, which can lead to serious complications including sepsis if left untreated. Even unused feeding tubes require regular flushing with water or saline to prevent blockages that could necessitate surgical replacement.
The facility had no care plan or nursing orders for the feeding tube until the day of the inspection - more than four months after the resident's admission. This represents a fundamental failure in care coordination, as proper G-tube maintenance is a basic nursing responsibility that requires physician orders and systematic monitoring.
Prolonged Pain Crisis Due to Medication Delays
Inspectors also documented severe pain management failures involving a resident with rhabdomyolysis, a serious condition where muscle tissue breaks down, causing severe pain and muscle damage. Despite having multiple pain medications prescribed, the resident went without one critical medication - diclofenac - for six consecutive days due to insurance authorization delays.
Daily pain assessments showed the resident consistently rating pain between 8-10 on a 10-point scale, with multiple staff members documenting that she "cries every day" due to the pain intensity. The resident told inspectors her pain was "excruciating" and that she "cries every day because of the pain."
Pain management protocols require facilities to have contingency plans when medications are unavailable. The delay occurred because the facility's pharmacy, located in Chicago, required insurance pre-authorization for the anti-inflammatory medication. While staff documented the missing medication daily, they failed to implement alternative pain control measures or escalate the issue appropriately.
Medical Standards and Required Interventions
Federal regulations require nursing homes to provide comprehensive pain management consistent with professional standards. This includes both pharmacological and non-pharmacological interventions. Effective pain management is crucial not only for quality of life but also for healing, as uncontrolled pain can impair immune function, delay recovery, and worsen depression.
For feeding tube care, clinical standards mandate regular assessment of tube placement, routine flushing to maintain patency, and monitoring of the insertion site for signs of infection or complications. The tube site should be cleaned daily and assessed for redness, swelling, drainage, or other signs of problems.
When asked about non-pharmacological pain interventions such as heat/cold therapy, positioning, or relaxation techniques, the resident reported that "no one had ever offered her any non-pharmacological interventions for treatment of her pain." This represents a missed opportunity to provide comfort measures while addressing the medication access issue.
Systemic Care Coordination Failures
Both violations point to broader problems with care coordination and clinical oversight. The feeding tube patient lacked appropriate physician orders and nursing care plans for months, while the pain management case revealed inadequate protocols for handling medication delays and insufficient communication between nursing staff and administration.
The facility's Director of Nursing acknowledged during the inspection that the feeding tube patient should have had proper orders and care plans in place. Similarly, when the administrator was informed about the week-long medication delay, he was unaware of the situation despite the resident's repeated reports of severe pain.
Additional Issues Identified
Inspectors noted other concerning patterns, including nursing staff describing a lack of urgency in responding to pain complaints. One nursing assistant reported that when residents request pain medication, some nurses respond with "I will get there when I get there," indicating potential attitude problems affecting patient care quality.
The inspection also revealed that the pain management resident was unaware she wasn't receiving one of her prescribed medications, highlighting communication gaps between staff and patients about their treatment.
These findings underscore the critical importance of proper clinical protocols, staff training, and administrative oversight in ensuring residents receive the medical care they require and deserve.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bedrock Hcs At Beaver Dam LLC from 2025-03-20 including all violations, facility responses, and corrective action plans.
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