SPOKANE, WA - A recent state inspection of Manor Care Health Services-Spokane uncovered significant failures in wound care management, constipation monitoring, and fall prevention protocols that placed residents at risk for delayed treatment, injury, and hospitalization.
Critical Gaps in Wound Care and Skin Monitoring
The facility demonstrated systematic failures in monitoring and treating residents' skin conditions, particularly for those with complex medical needs. The inspection revealed that nursing staff repeatedly failed to implement physician-ordered treatments and document wound assessments as required by professional standards.
One resident with Sjogren's syndrome, an autoimmune condition that causes dry skin, was observed with an exposed head wound that had gone without proper documentation or treatment orders. Despite the resident stating that staff "change the dressing if I need it every day," observations over multiple days showed the wound exposed without proper coverage. The facility's wound consultant had specifically instructed staff to apply moisturizing cream to all skin areas at least twice daily, but these orders were never implemented or documented in treatment records.
The same resident experienced multiple documented skin injuries between March and April 2025, including abrasions to the forehead, knees, and scalp. Most concerning was an 8-centimeter skin tear in April that required emergency hospital transfer, resulting in nine stitches and five adhesive strips. Despite this serious injury requiring invasive treatment, no physician orders for wound care were documented upon the resident's return to the facility.
Professional nursing standards require systematic assessment, diagnosis, planning, implementation, and evaluation of wound conditions. The facility's own policy mandated weekly skin observations with documentation of location, size, description, and treatment effectiveness. However, nurses completed only sporadic assessments without evaluating healing progress or adjusting treatments based on wound status.
Widespread Constipation Management Failures
The inspection documented extensive failures in managing residents' bowel health, with multiple residents experiencing prolonged periods without bowel movements despite physician standing orders for intervention after 48 hours. The facility's protocol clearly outlined a progressive treatment approach: lactulose administration after 48 hours, followed by Milk of Magnesia if ineffective, then suppositories, and finally enemas if needed.
One resident went 10 consecutive days without a bowel movement from March 20-29, despite having diagnosed constipation and being on opioid medications known to cause bowel complications. The resident reported that staff "did not monitor or track bowel movements" and they "often had to request a suppository or enema" rather than receiving proactive intervention. This resident had previously experienced hard impacted stool requiring emergency intervention in February, yet staff continued to neglect bowel monitoring.
Another resident experienced a six-day period without bowel movements, despite having both scheduled and as-needed laxative medications available. The resident, who had Parkinson's disease and was taking multiple constipation-inducing medications, reported having bowel movements only every 4-5 days at the facility compared to almost daily at home. The resident stated that no staff member had asked about their bowel patterns.
Chronic constipation poses serious health risks, particularly for elderly residents taking medications that slow intestinal motility. Fecal impaction can lead to bowel obstruction, severe abdominal pain, confusion, and in severe cases, bowel perforation requiring emergency surgery. The facility's failure to implement its own bowel protocols placed residents at risk for these preventable complications.
Inadequate Fall Prevention and Post-Fall Monitoring
The facility's fall prevention program showed critical deficiencies in both preventing falls and monitoring residents after fall incidents. Despite having a "Falling Leaves" program designed to identify high-risk residents, implementation was inconsistent and post-fall neurological monitoring was frequently incomplete or entirely absent.
One resident with severe dementia and a history of falls sustained five falls within six weeks of admission. The resident's first fall occurred just one hour and 50 minutes after arriving at the facility. Despite the facility's policy requiring neurological evaluations every 30 minutes for two hours, then hourly for four hours, and every eight hours for 72 hours following unwitnessed falls or head injuries, documentation showed significant gaps. In one instance, only five of twelve required vital sign sets were recorded. Another fall's neurological assessment sheet showed four missing assessments and eight missing vital sign recordings.
The neurological evaluation protocol exists to detect delayed complications such as subdural hematomas, which can develop hours or days after a fall. These bleeds can cause confusion, headaches, and potentially fatal increased intracranial pressure if not detected early. Missing even a single assessment in the monitoring schedule could mean the difference between early intervention and catastrophic outcomes.
Fall interventions were also inadequately implemented. Despite repeated falls, meaningful preventive measures were delayed. One resident's fall mat was repeatedly found pushed away from the bed during falls, yet no alternative solution was implemented until multiple incidents occurred. The facility's approach appeared reactive rather than proactive, implementing interventions only after injuries occurred rather than preventing them.
Medical Context and Industry Standards
These violations represent fundamental breakdowns in basic nursing care that every skilled nursing facility must provide. The American Nurses Association's Scope and Standards of Practice outlines six essential standards that were repeatedly violated: assessment, diagnosis, outcomes identification, planning, implementation, and evaluation.
Professional wound care standards require documentation of wound characteristics including size, depth, drainage, and signs of infection at regular intervals. This allows for early detection of deterioration and adjustment of treatment plans. The facility's failure to document wound assessments for days or weeks at a time eliminated the possibility of detecting complications before they became emergencies.
Similarly, bowel management protocols exist because constipation-related complications are among the most preventable causes of hospital transfers from nursing homes. Regular monitoring and timely intervention can prevent the cascade from simple constipation to fecal impaction, bowel obstruction, and potential perforation.
Additional Issues Identified
Beyond the major violations detailed above, the inspection uncovered numerous other deficiencies. A resident with psoriatic arthritis experienced severe skin flares with thick white flakes covering their entire forehead, face, and neck areas, yet had no treatment plan despite the resident reporting that they "never seem to get" their prescribed cream. Multiple residents sustained skin tears and abrasions that went undocumented in treatment records. The facility failed to implement wound consultant recommendations across multiple cases. Post-fall alert charting, meant to continue for 72 hours after incidents, was frequently discontinued early or never initiated.
These patterns of neglect suggest systemic issues with staff training, supervision, and quality assurance processes. The facility's own policies and procedures, had they been followed, would have prevented many of these violations. The gap between written policy and actual practice indicates fundamental organizational failures requiring immediate comprehensive intervention to ensure resident safety and well-being.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manor Care Health Services-spo from 2025-04-24 including all violations, facility responses, and corrective action plans.
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