Edgerton Care Center, Inc

The facility failed to accurately assess and monitor R6 for constipation, decreased fluid intake and output as well as changes in R6's mental status, resulting in frequent visits to the emergency department.

The facility failed to notify R6's primary care physician of his level of inadequate fluid intake and significant increases in urine output.

Between 1/1/25 and 3/31/25, R6 has been send to the hospital several times requiring IV (intravenous) fluid administration.

R16 experienced sudden onset of four (4) projectile coffee ground emesis (forceful vomiting of dark digested blood).

The facility waited 2+ hours to send R16 to the ED (emergency department).

R24 had a change of condition and focused assessments were not completed for continued monitoring of changes.

R2 had a changes in her physical condition that were not addressed by the facility as a change in condition.

This is evidenced by:

The facility policy entitled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, dated 9/2017, states, in part: . 1. As part of the initial assessment, the staff and physician will help identify individuals with previously identified lower gastrointestinal tract conditions and symptoms.

This should include a review of gastrointestinal problems during any recent hospitalization s . 2.

Examples of lower gastrointestinal tract conditions and symptoms include: . f. alteration in bowel movements; . h.

Residents taking antidiarrheal medications or medications related to bowel mobility . 3. In addition, the nurse shall assess and document/report the following: . c. change in mental status or level of consciousness; . e.

Signs of dehydration (altered level of consciousness, lethargy, dizziness, recent change in mental status, dry mucous membranes, decreased urine output); f.

Abdominal assessment; .

Treatment/Management . 3.

The staff and physician will address significant complications due to bowel dysfunction .

Monitoring and Follow-Up . 2.

The physician will adjust interventions based on identification of causes, resident responses to treatment, and other relevant factors. 3.

Before prescribing additional courses of medications, the physician should carefully evaluate and examine directly an individual who has not responded as expected to an initial course of treatment such as antidiarrheal medication, changes in the bowel regimen, etc.

525241

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525241 B.

Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534

During a NOC (night) shift on 11/28/24 to 11/29/24, CNA H (Certified Nursing Assistant) heard R46 calling for help. CNA H (Certified Nursing Assistant) observed R46 to be bright red and shaking with fresh blood on his right forearm (from a skin tear) and bedding. R46 stated, CNA F (Certified Nursing Assistant) and LPN G (Licensed Practical Nurse), both agency staff, wouldn't let him get up and held his hands down.

This allegation was not thoroughly investigated and the facility did not provide training to staff regarding physically restraining residents to ensure this does not occur again.

Evidenced by:

525241

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525241 B.

Wing 03/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Edgerton Care Center, Inc 313 Stoughton Rd Edgerton, WI 53534