The Case

An elderly patient, over 80 years of age, with a history of autism-spectrum disorder and requiring assistance with all activities of daily living and all transfers, lives in a group care home with several other disabled individuals who also require maximum assistance. She has been prescribed a daily dose of polyethylene glycol 3350 to prevent constipation, but she often has leakage of incontinent feces through pull-up diapers.

On weekends, patients in this group home are allowed to sleep up to two hours later than on weekdays, when they need to leave earlier for adult day care. There are only two certified nursing assistants (CNAs) staffing the facility on weekends (versus three on weekdays); the CNAs are responsible for giving medications, helping five residents to dress and shower, preparing meals, feeding residents, cleaning up, and doing laundry. One of these CNAs finds the patient soiled in bed from fecal leakage, transfers her to a wheelchair, and then to a shower chair. The CNA showers and fully dresses the patient, but in the process, the patient has another bowel accident contaminating the area. The CNA calls for help to their coworker, who is with four other residents in the kitchen and cannot safely leave. The CNA pivots the patient, who is now weak and disoriented, to the toilet, but the patient sits down prematurely, falling and hitting her head on the shower. With only two staff members on duty, four other high-need residents must be left unattended while both CNAs attempt to lift the 180-pound patient off the floor. After the nurse on call is notified and relief staff arrives, an ambulance is called to take the patient to the hospital for suturing, imaging, and medical evaluation. A physical therapist at the hospital determines that this patient needs a higher level of care in the bathroom (i.e., two-person assist) because of hazardous conditions, wet floors, showering and perineal care needs.

The Commentary

By Ron Ordona, DNP, FNP-BC, GS-C, WCC and Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN

Adult Residential Facilities (ARFs) are a type of community-based care facility, also commonly known as Board and Care that provide non-medical care and supervision to adults ages 18 to 59 years who cannot provide care for themselves. Those that serve persons 60 years of age and older are known as Residential Care Facilities for the Elderly (RCFEs). This commentary will refer to RCFEs, as the resident in this case is over 60 years of age.

Regulatory Requirements

RCFEs are non–medical facilities that provide room, meals, housekeeping, supervision, storage, and distribution of medication along with personal care assistance including basic activities of daily living (ADLs) like hygiene, dressing, eating, bathing, and transferring. This level of care and supervision is for people who are unable to live independently but who do not need 24-hour nursing care. Since they are considered non-medical facilities, they are not required to have nurses, certified nursing assistants, or physicians on staff, although there is typically a nurse on call if the administrator is not a nurse. ARF residents can stay in the same facility as they age if their needs are compatible with those of other residents and require the same level of care and supervision as the other residents and the licensee is able to meet their needs.¹

Staff in RCFEs include an Administrator and resident assistants. Most states require administrators to have at least a high school diploma, obtain initial training, and ongoing continuing education. It is not uncommon for the administrator to have a background as a health professional, although it is not required. Resident assistants also typically require basic training related to assisting residents with ADLs. Some RCFEs employ certified nursing assistants (CNAs), who can also assist with medication management if they have received extra training, although the cost of and demand for CNAs is higher, which may limit the ability to hire.^2,3 Staffing levels are dependent upon the number of beds in a facility, which may range from 4-200 beds. In general, facilities are expected to have competent staff in sufficient numbers to meet the residents’ needs.

States have varying staffing requirements and guidelines. For example, in California, Section 85065.5 of Title 22 provides for regulations on the Day-Staff Resident Ratio minimum requirement of one direct care staff to three residents as provisioned in the California Health & Safety Code Section 1530. In the regulations for ARFs and Residential Care Facilities for the Elderly (RCFEs), Certified Nursing Assistants (CNAs) or Licensed Vocational Nurses (LVNs) are not required, as facilities like these are not expected to provide skilled nursing care. However, prior to the admission of a resident, facilities are expected to determine whether the facility's program can meet the prospective resident's service needs. If the resident is to be admitted, then prior to admission, the facility is required to complete a written Needs and Services Plan, specified in Section 85068.2, which is expected to be updated as frequently as necessary to ensure its accuracy and to document significant occurrences that result in changes in the resident's physical, mental and/or social functioning.⁴ ARFs follow the Manual of Policies and Procedures of the Community Care Licensing Division under Title 22 Division 6 Chapter 6⁵ and similar to most states, are licensed under the Department of Social Services or its equivalent. Readers should check the requirements in their state; however, for purposes of this commentary, California’s requirements will be used.

Patient Safety Challenges of this Case

RCFEs commonly care for older residents with cognitive impairment or mental health issues such as autism spectrum disorder and who need assistance with activities of daily living and transfers as described in this case. Many ARFs and RCFEs have applied for and received Assisted Living Waivers (ALW), which allows them to provide care to residents who meet the criteria for nursing homes but prefer to live in the community as an alternative to a nursing home and to maintain a level of independence. This appears to be the situation in this case as they employed CNAs.

In this scenario, an 80-year-old resident weighing 180-pounds was prescribed a daily dose of polyethylene glycol 3350 (MiraLAX) to prevent constipation and presents with a history of leakage of incontinent feces through pull-up disposable underpants. It is not uncommon for patients taking polyethylene glycol daily to be constipated one day and have extremely loose stools the next day,^6,7 which can also cause dehydration and weakness and possibly make them disoriented and unable to follow or process verbal commands from the caretaker. Daily usage often causes fecal leakage even with adult disposable briefs and, like this case, efforts to clean up can lead to other accidents.

The submitter described that on the weekend, two CNAs staff the facility (usually staffed with three CNAs during weekdays) and are responsible for meeting resident needs that include medication administration, daily hygiene such as dressing and showering, preparing meals, feeding residents, cleaning up, and doing laundry. During this situation, there were four other high-need residents in the RCFE being monitored by one of the CNAs.

The incident occurred when a CNA found the patient soiled in bed from fecal leakage, transferred her to a wheelchair, and then to a shower chair. Unfortunately, the resident had another incontinence episode just as the CNA was getting her dressed. In the CNA’s attempt to get the resident transferred to the toilet from the wheelchair, the resident missed the toilet seat apparently due to confusion and weakness and fell, hitting her head. With only two staff members on duty and four other high-need residents, the other four residents had to be left unsupervised as both CNAs attempted to lift the 180-pound resident off the floor, clean her up and return her to bed. The nurse on call was notified and a relief staff was provided, and the resident was then taken to the hospital for evaluation. A physical therapist at the hospital determined that this patient needed a higher level of care during toileting, requiring two-person assistance.

As far as the resident-to-staff ratio is concerned in this facility, staffing was within the 1:3 staffing ratio; however, there didn’t seem to be consideration of the resident acuity, the special circumstances and potential risks of the resident who was prescribed daily polyethylene glycol and the potential need for a two-person assist with transfer. The issue of fecal leaking seems to have been a well-known problem and the need for additional help should have been anticipated. It would have been a best practice if the administrator had notified the nurse on call or the resident’s primary care provider to discuss the frequent fecal leakage and perhaps the medication could have been adjusted, avoiding the fall. Additionally, the facility should have the appropriate equipment, in this case a Hoyer lift, that would not only enhance safe patient care but also help to prevent staff injury. The facility administrator is responsible for the overall care and well-being of the residents and the CNA is responsible for providing safe care during ADLs. It is difficult to understand how this problem was not anticipated in someone who had been on daily polyethylene glycol with known fecal leakage prior to this incident.

Regulatory Response

In many states, incidents such as what occurred at this facility are required to be reported to state licensing agencies. In California, administrators report using the LIC 624 Unusual Incident/Injury Report form,⁸ which can, depending on the nature of the incident reported, trigger a visit by a licensing program analyst (LPA). The LPA will typically evaluate the Needs and Services Plan of that resident to determine whether the resident was identified as requiring two-person assistance. If it is determined that the staff member ignored the plan and performed the transfer that required two-person assistance by themselves, the facility will more likely be cited for deficiency especially if an injury was sustained that clearly and directly can be attributed to the fact that there was only one staff member assisting. If, as in this case, the physical therapist was the first one to determine that the resident requires two-person assistance with transfers initially, then a citation may not be imminent, and instead, a Plan of Correction may be initiated.¹ Again, it is important to know the regulations of the state where you are working.

Another way that a facility can be cited or be required to implement a Plan of Correction is if it is determined that based on facility records, there was no proper training implemented in managing specific conditions such as transfers. In this case, although not stated, it may be possible that the CNA had a knowledge deficit related to safe and effective transfers, including the potential use of a Hoyer lift (if one was available). Additionally, the CNA may also have been unaware of the potential side effects of the resident’s medication. In all cases, the staff member or at the minimum, the facility administrator should know the risks of side effects associated with medications such as laxatives that include loose stools, urge incontinence, and possibly dehydration if not addressed.⁶ These side effects should have been noted in the care plan and the medication administration record. The ultimate responsibility in this case lies with the facility administrator, who should have on an ongoing basis, determined that residents may have higher care needs and scheduled staffing appropriately.

Take Home Points

• RCFE administrators are responsible for adequate numbers of staff to be available daily based on the residents’ needs to ensure safe care.
• Although RCFEs and ARFs are considered non-medical facilities, if they obtain an assisted living waiver and admit residents that need basic nursing care, they are obligated to plan for that care to include safe staffing levels.
• RCFE administrators are responsible for appropriate staff training based on the needs of the residents.
• It is critical to understand and adhere to the regulations that provide oversight of RCFEs in the state where you work.

Ron Ordona, DNP, FNP-BC, GS-C, WCC
Health Sciences Assistant Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health
rbordana@ucdavis.edu

Deb Bakerjian, PhD, APRN, FAANP, FGSA, FAAN
Co-Editor-in-Chief, AHRQ’s Patient Safety Network (PSNet)
Clinical Professor
Betty Irene Moore School of Nursing
UC Davis Health
dbakerjian@ucdavis.edu

References

1. California Behavioral Health Planning Council (2018). ​ Adult Residential Facilities (ARFs): Highlighting the critical need for adult residential facilities for adults with serious mental illness in California. State of California. [Free full text]
2. Hategan A, Bourgeois J, Hirsch CH, eds. On-Call Geriatric Psychiatry: Handbook of Principles and Practice. Springer; 2016. [Information]
3. Mitty E, Resnick B, Allen J, et al. Nursing delegation and medication administration in assisted living. Nurs Adm Q. 2010;34(2):162-171. [Available at]
4. Adult Residential Facilities. Title 22 Division 6 Chapter 6. Manual of Policies and Procedures CCLD. Section 85068.4. Accessed December 21, 2023. [Free full text]
5. Adult Residential Facilities. Title 22 Division 6 Chapter 6. Manual of Policies and Procedures CCLD. Section 85065. Accessed December 21, 2023. [Free full text]
6. Dabaja A, Dabaja A, Abbas M. Polyethylene glycol. InStatPearls [Internet] Treasure Island (FL): StatPearls Publishing. May 8, 2023. [Free full text]
7. Lammers E, Srivastava SB. Constipation treatment: a review. Orthop Nurs. 2020;39(3):194-198. [Available at]
8. California Department of Social Services Community Care Licensing Division. Lic 624 – Unusual Incident/Injury Report. Accessed December 21, 2023. [Free full text (PDF)]