F0684

J

Failure to Monitor Brain Shunt, Manage Pain, and Respond to UTI/Sepsis Signs

Buffalo, Missouri Survey Completed on 02-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care according to physician orders, resident preferences, and goals for a resident with complex medical needs, including a brain shunt, urostomy, history of UTIs, acute pyelonephritis, and sepsis. The resident’s face sheet and care plan did not include a diagnosis of a brain shunt, and there were no physician orders or care plan interventions for monitoring the shunt. Staff were not documented as being trained or informed about shunt care, and there was no systematic monitoring of head, neck, or shunt-related symptoms despite frequent complaints of headaches and pain. The facility’s pain management policy required evaluation of pain upon admission and with changes in condition, use of appropriate pain assessment tools, and development and revision of interventions, but documentation repeatedly lacked characteristics of the pain, including location and quality, and did not reflect consistent reassessment or escalation when pain was not relieved.

The facility also failed to effectively address increasing pain in the resident’s head, neck, and shoulder areas and did not consistently notify the physician of unrelieved or escalating pain. MAR and progress note reviews showed numerous PRN administrations of Tramadol and Acetaminophen for pain scores ranging from 3 to 9 out of 10, including generalized body aching, back pain, and neck and shoulder pain, with multiple instances where pain remained at 5–7 out of 10 after medication. Progress notes frequently omitted the characteristics or location of the pain, and when pain was not relieved, there was no documentation that the physician was notified. Interviews with CNAs indicated the resident complained of daily headaches, described the head as "blowing up or exploding," cried from pain, and reported pain at the shunt site, yet these complaints were only reported verbally to nurses and not reflected in detailed clinical documentation or care plan revisions. A roommate reported the resident’s head appeared swollen and that the resident became confused several days before hospital transfer.

In addition, the facility failed to timely recognize and respond to signs of possible UTI and sepsis, and did not complete or follow up on ordered labs for elevated WBCs. The resident had a history of UTIs, kidney infections, and sepsis, and a WBC of 14.4 was documented in December, followed by a WBC of 16.8 on 01/06/26. There was no prompt physician notification documented for the increasing WBC, and although a physician note later referenced leukocytosis with a plan to recheck the CBC, no new lab orders appeared on the POS and no follow-up lab documentation was found. The care plan required monitoring and reporting of signs of kidney infection and sepsis, including no output, deepening urine color, and other symptoms, but MARs showed inconsistent urine output documentation, with multiple days lacking any recorded output. CNAs reported decreasing urine output from several bag drainings per shift to sometimes once per day, and described dark, tea-colored, and burnt orange urine, as well as the resident’s decreased eating, confusion, hallucinations, low blood pressure, puffy face, and distended abdomen. Although these findings were eventually reported to nursing staff, there was a delay in sending the resident to the hospital, and management initially discussed treating the resident in-house and attributing confusion to new medication. The resident was ultimately transferred to the hospital, where documentation showed diagnoses of hydrocephalus requiring shunt removal/replacement and urosepsis with septic shock, with the resident intubated and sedated in the ICU and a WBC of 43.7.