SPOKANE, WA - Federal inspectors identified significant violations at Spokane Health & Rehabilitation regarding professional nursing standards, constipation management, and fall prevention protocols that affected multiple residents and created safety risks.
Professional Nursing Standards Violations Impact Patient Care
During an April 2025 inspection, federal surveyors found that the facility failed to meet professional standards of practice for 12 of 13 sampled residents, particularly in wound care, skin condition monitoring, and treatment follow-through. The violations centered on staff's failure to properly assess conditions, implement physician orders, and monitor residents for complications.
One resident with Sjogren's syndrome, a chronic autoimmune condition that causes dry skin, repeatedly developed abrasions and skin tears that went untreated despite clear documentation of the issues. Staff documented various skin conditions from March through April 2025, including abrasions to the forehead, knees, and scalp, but failed to implement proper treatment protocols. On April 12, 2025, the resident sustained an 8-centimeter skin tear requiring hospital transfer for nine stitches and five adhesive strips.
Medical analysis reveals that untreated skin conditions can lead to serious complications. Skin integrity is the body's first line of defense against infection, and when compromised, bacteria can enter through open wounds. For residents with autoimmune conditions like Sjogren's syndrome, the risk is elevated because their immune systems are already compromised. Proper wound assessment should include documentation of size, depth, drainage, and signs of infection, with regular monitoring to track healing progress.
According to nursing standards established by the American Nurses Association, proper care requires systematic assessment, diagnosis, outcome identification, planning, implementation, and evaluation. The facility's own policy required weekly skin observations and documentation of treatment effectiveness, but inspectors found these protocols were not consistently followed.
Another resident experienced severe psoriatic arthritis flares with thick, white dry skin covering their forehead, face, neck, and ears. Despite the resident stating "I have a cream to help but I have to request it and I never seem to get it," no treatment plan was documented in their care record. The resident explained the condition was itchy and irritating, requiring time to calm down after flare-ups.
Constipation Management Protocols Ignored
The facility maintained detailed standing orders for constipation management, requiring progressive interventions starting 48 hours after a resident's last bowel movement. The protocol specified administering Lactulose every two hours, followed by Milk of Magnesia if ineffective after six hours, then Bisacodyl suppository, and finally Fleet enema if necessary. Providers were to be notified if residents went more than three days without a bowel movement.
Despite these clear protocols, multiple residents experienced extended periods without bowel movements while receiving no interventions. One resident taking medications known to cause constipation, including cardiac and Parkinson's medications, went six days without a bowel movement on multiple occasions. The resident reported having bowel movements every 4-5 days at the facility compared to daily movements at home, stating "I wonder about it because I'm still not pooping. Maybe I should mention it to [the staff]. That would make me go poop. I'd like that."
Chronic constipation poses serious health risks, particularly for elderly residents taking multiple medications. Prolonged constipation can lead to fecal impaction, bowel obstruction, and severe abdominal pain. Certain medications commonly prescribed in nursing homes, including opioids, antidepressants, and cardiac medications, significantly increase constipation risk by slowing intestinal motility. The facility's own care plans acknowledged these risks but failed to implement preventive measures.
Another resident taking scheduled opioid medication experienced recurrent constipation lasting up to 10 days between bowel movements. Previous provider notes documented the resident's struggle with hard, impacted stools, yet no preventive bowel regimen was consistently implemented. The resident reported "[The facility] did not monitor or track BMs and often went 9-10 days without a BM... it was painful to have a BM after 10 days, staff did not offer bowel interventions and often had to request a suppository or enema."
Fall Prevention and Post-Fall Monitoring Failures
The facility's fall prevention program included a "Falling Leaves" system using leaf stickers to identify high-risk residents requiring frequent monitoring. However, when falls occurred, staff consistently failed to implement required neurological monitoring protocols, particularly for unwitnessed falls or those involving potential head injuries.
One resident with severe cognitive impairment and a history of falls sustained five separate falls within six weeks of admission. Despite facility protocols requiring neurological evaluations every 30 minutes for two hours, then hourly for four hours, then every eight hours for 72 hours after unwitnessed falls, documentation showed significant gaps in monitoring. For one fall, only five of 12 required vital sign sets were documented, while another fall showed omissions in four neurological assessments and eight vital sign recordings.
Post-fall neurological monitoring is critical for detecting delayed complications. Head injuries can cause gradual brain swelling or internal bleeding that may not be immediately apparent. Changes in vital signs, mental status, or neurological function can indicate serious complications requiring immediate medical intervention. The facility's monitoring protocol was designed to catch these potentially life-threatening changes, but inconsistent implementation left residents at risk.
Industry standards require comprehensive fall risk assessments that identify contributing factors such as medications, mobility limitations, cognitive impairment, and environmental hazards. Effective prevention programs combine environmental modifications, assistive devices, staff education, and individualized interventions based on each resident's specific risk factors.
Additional Issues Identified
The inspection revealed several other concerning patterns:
- Inconsistent wound consultant recommendations implementation despite clear instructions for twice-daily moisturizing cream application - Missing treatment orders for documented skin conditions requiring antibiotic ointment and specialized dressings - Gaps in provider notification when residents experienced extended periods without bowel movements - Inadequate documentation of fall prevention interventions after repeated incidents - Failure to obtain physician orders for wound monitoring and care following injuries
These violations represent systemic breakdowns in professional nursing standards that could impact resident health outcomes. Proper implementation of established protocols for skin care, bowel management, and fall prevention requires consistent staff training, clear documentation requirements, and regular monitoring to ensure compliance with professional standards of practice.
The facility's administrators acknowledged the deficiencies during interviews with inspectors, stating they expected staff to follow established protocols for wound care, constipation management, and post-fall monitoring procedures.
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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