POMONA, CA - Federal inspectors cited Inland Valley Care and Rehabilitation Center after finding nursing staff failed to properly assess and communicate a resident's deteriorating condition in the hours before their death.
Critical Assessment Failures Documented
The May 9, 2025 inspection revealed that multiple licensed nurses failed to conduct complete abdominal assessments despite a resident reporting severe constipation, abdominal pain, and distension. The resident, who had chronic obstructive pulmonary disease and chronic respiratory failure, had not had a bowel movement for two to three days.
According to inspection records, the resident complained of 8 out of 10 abdominal pain and had a visibly distended abdomen that staff described as "rock hard." Despite these critical symptoms, nursing staff failed to follow the facility's own assessment protocols.
Multiple Communication Breakdowns
The inspection documented a concerning pattern of incomplete communication with the attending physician. RN 3 admitted to inspectors that when notifying the physician about the resident's constipation, they failed to mention the abdominal distension, bloating, or pain level.
"Providing all pertinent information helped [the physician] determine the treatment needed for Resident 1," RN 3 told inspectors, acknowledging the critical oversight.
Similarly, RN 2 conducted an assessment revealing hypoactive bowel sounds, abdominal distension, and firmness, but did not relay these findings to the physician. RN 2 stated they believed the resident was experiencing severe pain but didn't communicate this assessment because "Resident 1's main complaint was constipation."
Facility Protocols Ignored
The facility's own policies required comprehensive abdominal assessments including checking for distension, hardness, and bowel sounds in all four quadrants of the abdomen. The protocols specifically mandated notifying physicians of abnormalities such as distended, hard abdomen or worsening pain.
Licensed Vocational Nurse 4 (LVN 4) told inspectors they failed to notify the physician when the resident experienced changes of condition, despite facility requirements. LVN 4 stated they "only informed [the RN] but did not notify [the physician] of Resident 1's [change of condition]."
Warning Signs Escalated Rapidly
The resident's condition deteriorated rapidly during the overnight shift. At 11:10 pm, the resident requested increased oxygen therapy due to breathing difficulties. Staff increased oxygen from 2 to 3.5 liters per minute but failed to assess oxygen saturation levels before making the adjustment.
By 12:15 am, the resident was experiencing severe abdominal pain rated 8 out of 10. Staff administered pain medication (Norco) but when LVN 4 returned 30 minutes later to reassess, they found the resident unresponsive.
A Certified Nursing Assistant described the resident's stomach as "rock hard" and reported that the resident was asking to be sent to the hospital. However, staff decided to wait for further instructions rather than pursuing immediate medical intervention.
Medical Consequences of Assessment Failures
Proper abdominal assessment protocols exist specifically to identify potentially life-threatening gastrointestinal complications. When a resident presents with severe constipation combined with abdominal distension, hardness, and severe pain, these symptoms can indicate serious conditions requiring immediate medical intervention.
The inspection noted that when emergency medical technicians arrived, they observed coffee-ground emesis on the resident's body and clothing. Coffee-ground emesis typically indicates gastrointestinal bleeding, a serious medical emergency that requires immediate treatment.
Hypoactive bowel sounds combined with abdominal distension and severe pain can signal bowel obstruction or other serious gastrointestinal emergencies. These conditions can rapidly progress to sepsis, organ failure, or death without prompt medical intervention.
Standard of Care Requirements
Nursing home residents with complex medical conditions like COPD and chronic respiratory failure require heightened monitoring for any changes in condition. Federal regulations require facilities to ensure residents receive proper medical care and that changes in condition are promptly identified and addressed.
The inspection revealed that multiple staff members recognized significant changes in the resident's condition but failed to follow established protocols for assessment and physician notification. This represents a fundamental breakdown in the standard of care required in skilled nursing facilities.
Regulatory Violations Identified
Inspectors cited the facility under federal regulation F641 for failing to ensure residents receive proper medical care. The citation specifically noted failures in assessment, communication, and following established protocols during a change of condition.
Additionally, the facility received a citation under F842 for inadequate documentation practices. The inspection found that staff failed to document complete assessments, potentially affecting the resident's treatment and outcomes.
The Director of Nursing acknowledged to inspectors that incomplete assessment reporting could affect a resident's treatment and outcome, stating that "Resident 1's condition may not improve and could worsen" when proper protocols aren't followed.
Industry Standards and Best Practices
Professional nursing standards require comprehensive assessment when residents report gastrointestinal symptoms, particularly when combined with pre-existing respiratory conditions. The combination of severe constipation, abdominal distension, and respiratory distress represents a complex medical situation requiring coordinated care.
Best practices in long-term care settings emphasize the importance of complete and accurate communication between nursing staff and physicians. All assessment findings, including subjective complaints and objective observations, must be communicated to ensure appropriate medical decision-making.
Facility Response and Corrective Actions
Following the inspection, Inland Valley Care and Rehabilitation Center must submit a plan of correction addressing the identified deficiencies. The facility must demonstrate how it will ensure proper assessment protocols are followed and that all changes of condition are appropriately communicated to physicians.
The inspection findings highlight the critical importance of thorough nursing assessments and complete communication in preventing adverse outcomes. Residents and families rely on nursing home staff to recognize and respond appropriately to changes in health status.
Federal regulators will continue monitoring the facility's compliance with corrective measures to ensure similar assessment and communication failures do not recur.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inland Valley Care and Rehabilitation Center from 2025-05-09 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.