Medilodge Of Ludington

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident R1 stated that she felt like the nurse ignored her concerns and did not assess the problem. Review of an SBAR communication Form for Resident R1, dated 07/06/25 and written by LPN C reflected: (a) resident requesting to go to emergency room, feels she may have a blood clot behind her knee, (b) other relevant findings .resident assessed. No additional information was documented regarding an assessment of the right leg and the status of circulation, i.e., color and temperature of the skin, capillary refill time, whether pulses could be felt in the right leg, (c) that a STAT ultrasound of Resident R1's right leg had been ordered by the physician

on 07/05/25 and had not yet been completed, and (d) RN assessment-what do you think is going on with

the resident, LPN C documented UTI (urinary tract infection). Review of emergency room progress notes for Resident R1 dated 07/06/25 at 3:30 PM revealed . acute right lower limb ischemia (lack of blood flow) .right leg pain with pallor (pale), coolness, unable to palpate distal pulses and unable to obtain pulses with a doppler .will emergently obtain a CT of the pelvis to rule out an occluded artery. Contacted (a level 1 trauma hospital in Grand Rapids) and we reviewed the films, Resident R1 had a complete occlusion (blockage) of the right iliac artery the main blood supply to the lower leg and located at the top of the leg in the groin area).

Unfortunately, Aero Med is not flying at this time because of bad weather. We will initiate a priority 1 transfer for immediate vascular surgery. Resident #2 (Resident R2)Review of an admission Record revealed Resident R2 was a [AGE] year-old-female, last admitted to the facility on [DATE REDACTED], with pertinent diagnoses of multiple sclerosis and constipation. Review of a bowel elimination task monitoring for Resident R2, completed each shift by direct care staff, reflected Resident R2 had a medium size bowel movement the afternoon of 08/15/25. Resident R2 did not have another bowel movement until the early morning of 08/18/25, which was documented as small in size. This was the last documented bowel movement before Resident R2 was urgently sent to the hospital on [DATE REDACTED]. (18 shifts between bowel movements). Review of an electronic medication administration record (Emar) for Resident R2, dated August 2025, reflected the following PRN (as needed) orders for bowel protocol: (a) Milk of Magnesia give 30 milliliters (ml's) by mouth every 72 hours as needed for no bowel movement for 3 days, (b) Dulcolax Suppository as needed for constipation if no result from Milk of Magnesium after 9 shifts, (c) Fleets Mineral Oil enema if no result from Dulcolax after 10 shifts and if no results call the doctor. Documentation revealed none of the above listed medications were administered to Resident R2 nor was the doctor notified. Review of a Transfer Form for Resident R2 dated 08/24/25 at 1:00 PM revealed Resident R2 was sent to the hospital for abdominal distention and rigidity with brown emesis (vomit) and nausea. Review of a Hospital Progress Note dated 08/27/25 reflected that Resident R2 had extreme constipation with large stool burden and distal impaction.During an

interview on 08/29/25 at 9:30 AM, the Director of Nursing stated the facility became aware of the bowel management concern with Resident R2 yesterday (08/28/25) and were looking into the matter.

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