The breakdown in communication left the resident without the prescribed bowel care for months, according to a September inspection report from state health officials.
Resident 2 lives with multiple conditions stemming from spina bifida, a birth defect affecting the spine. The resident has hydrocephalus, which causes abnormal fluid buildup around the brain, plus neurogenic bladder and bowel — conditions where nerve damage makes it difficult to control basic bodily functions.
On January 3, the spina bifida specialist sent an after-visit summary directly to the facility's nursing supervisor. The summary included a clear directive: "Please see attached order for daily SS enema."
The specialist's formal recommendation was specific: "Perform a rectal soap suds enema daily with 300-500mL warm, soapy water, with a diagnosis of Neurogenic bowel to be started on 1/24/25."
Nobody at Neffsville acted on those orders.
State inspectors found no progress note in the resident's facility record documenting the specialist consultation. They found no evidence that staff contacted the resident's primary care provider to communicate the new treatment orders.
The resident's primary doctor remained unaware of the specialist's recommendations. A physician's note dated February 26 — more than seven weeks after the specialist visit — shows no knowledge of the consultation or its treatment plan.
The facility's medication administration record confirms no soap suds enema order was ever entered to begin on January 24 as the specialist directed.
During a September 10 interview, the Director of Nursing acknowledged there was no evidence the consultation recommendations were ever addressed with the primary care provider.
The communication failure represents a fundamental breakdown in coordinating care for a resident with complex medical needs. Neurogenic bowel, a complication of spina bifida, requires careful management to prevent serious complications including bowel obstruction, infections, and autonomic dysreflexia — a potentially life-threatening condition where blood pressure spikes dangerously.
Soap suds enemas help residents with neurogenic bowel maintain regular elimination when their damaged nerves cannot properly signal the need to defecate. Without this intervention, waste can accumulate in the bowel, leading to impaction, pain, and medical emergencies.
The specialist's January recommendation came with the expectation that facility staff would coordinate with the resident's primary physician to implement the new treatment protocol. Instead, the orders sat unaddressed while the resident continued without the prescribed bowel management.
Federal regulations require nursing homes to provide treatment and care according to physician orders and professional standards. The failure to communicate specialist recommendations and implement prescribed treatments violates these basic care requirements.
For Resident 2, the oversight meant living for months without medical care specifically designed to manage their neurogenic bowel condition. The specialist had identified a treatment plan to address the resident's needs, but the facility's communication breakdown prevented that care from reaching the resident.
The inspection classified the violation as causing minimal harm or potential for actual harm, though the long-term consequences of untreated neurogenic bowel can be severe. The finding affects few residents, suggesting this was an isolated case rather than a systemic communication problem.
State inspectors cited the facility for failing to provide appropriate treatment and care according to orders, noting the violation of Pennsylvania nursing services regulations. The facility must develop a plan of correction to address the deficiency and prevent similar breakdowns in specialist care coordination.
The case illustrates how communication gaps between specialists, nursing homes, and primary care providers can leave vulnerable residents without prescribed treatments. For residents with complex conditions like spina bifida, such coordination failures can have serious medical consequences.
Resident 2's experience shows how a simple administrative failure — not forwarding specialist recommendations to the primary doctor — can derail an entire treatment plan, leaving residents to manage serious medical conditions without the care their specialists deemed necessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Neffsville Nursing and Rehabilitation from 2025-09-10 including all violations, facility responses, and corrective action plans.
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