F0600

D

Failure to Assess and Respond to Resident’s Repeated Requests for Hospital Transfer

Kittanning, Pennsylvania Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect a resident from neglect by not assessing and responding to repeated complaints of abdominal pain and constipation and requests to go to the hospital. The facility’s abuse, neglect, and exploitation policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress. The RN Supervisor (Employee E1), whose job description required ensuring compliance with policies, assessing changes in resident status, notifying the physician and family, and documenting accordingly, was on duty when the resident repeatedly requested to be sent to the hospital. The resident had been admitted with diagnoses including constipation, hypertension, and cervicalgia, and admission documentation and the discharge transition packet showed his last bowel movement had been approximately eight days prior to admission.

On the day of the incident, progress notes documented that the resident’s last bowel movement was on 2/5 and that later that day he requested to go to the hospital for abdominal pain and constipation, ultimately calling 911 himself. A NA (Employee E2) reported that around mid-afternoon the resident rang and asked to see the RN Supervisor to go to the emergency room; the NA notified the RN Supervisor, who stated she had done his paperwork and was not going back, and the NA did not see her go to the resident’s room. The NA further stated that the RN Supervisor told the resident he could not come back to the facility while the ambulance workers were there. An LPN (Employee E3) corroborated that the resident had been asking all day to be sent to the hospital, reported that the RN Supervisor was made aware, and described hearing the RN Supervisor say she had done his paperwork and did not know what else she could do, and later, when the call bell rang again, saying from the desk that she already knew what the resident wanted.

The LPN (Employee E3) stated that when she returned to the resident’s room, he was on the phone with 911, and that the RN Supervisor later asked if she should send the resident out if he wanted to go, with the LPN responding yes and telling the resident she would call 911 after dinner. Another LPN (Employee E4) explained that the facility’s bowel protocol should be initiated if a resident has not had a bowel movement in three days, that last bowel movements are assessed on admission, and that medications for the bowel protocol are automatically put in place upon admission, with staff able to review discharge paperwork for this information. LPN E3 also stated the resident was having abdominal pain from a bowel obstruction and that the resident had an order for citrate of magnesium from the prior facility, which she did not believe he received. The DON and Nursing Home Administrator confirmed that the RN Supervisor refused to assess the resident and refused to send him to the hospital despite staff reports that he was requesting to be sent out, and confirmed the facility failed to protect the resident from neglect.