Failure to Assess and Intervene for Resident with Persistent Nausea and Vomiting
Penalty
Summary
The facility failed to provide adequate and timely assessment and intervention for a resident who experienced nausea and vomiting over a four-day period. Despite the resident's ongoing symptoms, including repeated vomiting and refusal of food and medications, the clinical record lacked documentation of vital signs or bowel assessments during this time. The care plan for the resident, who had a history of anemia, atrial fibrillation, heart failure, benign prostatic hyperplasia, and constipation, required staff to assess bowel sounds and abdomen and to report abnormalities to the primary care physician, as well as to follow bowel protocols and administer as-needed medication for constipation. Nursing progress notes indicated that the resident was seen by a doctor and treated for a suspected urinary tract infection, with antibiotics and anti-nausea medication prescribed. However, the resident continued to experience nausea, vomiting, and a decline in functional status, including increased lethargy and weakness. Staff interviews revealed that vital signs and bowel assessments were not consistently performed or documented, and staff were uncertain about the expectations for monitoring residents on antibiotics. The Director of Nursing confirmed that there was no policy on resident change in status and that standard of care was to be followed, but could not provide a specific resource for staff guidance. The resident was eventually sent to the emergency department after continued deterioration, where he was found to have a small bowel obstruction with perforation and septic shock. Hospital records documented hypotension, tachycardia, and significant abdominal findings. The resident was transferred for possible surgical intervention and later returned to the facility, where he subsequently passed away. The lack of timely assessment and intervention, including failure to monitor vital signs and bowel status, contributed to the deficiency identified by surveyors.