Failure to Assess and Document After Resident Vomiting Episode
Penalty
Summary
The facility failed to complete and document a comprehensive assessment, including a head-to-toe physical evaluation, blood pressure, heart rate, temperature, and blood glucose measurements, after a resident experienced vomiting. The resident in question had multiple significant diagnoses, including pneumonia, diabetes, gastrostomy status, dependence on supplemental oxygen, and heart failure, and was noted to have severely impaired cognition and total dependence on all activities of daily living. Despite these complex medical needs, after the resident vomited, the responsible nurse did not perform or document the required assessments and vital sign checks. Interviews with facility staff confirmed that the expected protocol following a change in condition, such as vomiting, was not followed. The Director of Nursing stated that staff should conduct a head-to-toe assessment and check vital signs after such events to identify and address potential problems early. Review of facility policy also indicated that a detailed observation and collection of pertinent information should occur after a significant change in a resident's condition. However, documentation and staff statements confirmed that these steps were not taken in this instance.