Failure to Assess and Intervene After Resident Emesis Leading to Neglect
Penalty
Summary
A licensed practical nurse (LPN) failed to initiate standing orders for a resident who experienced an episode of emesis (vomiting) in the dining room prior to the evening meal. After the incident, staff took the resident to his room to clean him up and then returned him to the dining room, where he was served and consumed a full regular meal. There was no documentation by the LPN of the emesis, no assessment of the resident's condition, no vital signs taken, and no changes made to the resident's diet, such as switching to clear liquids, despite reports from other staff that the resident was not feeling well and had stomach pains. The resident, who had multiple diagnoses including dementia, COPD, atrial fibrillation, diabetes, chronic kidney disease, PTSD, Parkinson's disease, and hypertension, and was severely cognitively impaired, later aspirated on his emesis and passed away in his room that night. Staff interviews confirmed that the LPN did not perform necessary assessments or initiate appropriate interventions following the emesis. The LPN also failed to communicate a comprehensive change of condition during shift reporting, only mentioning the emesis once and stating the resident was fine. Further review revealed ongoing concerns with the LPN's performance, including lack of safety measures, improper documentation, failure to assess residents' conditions, and medication administration errors. The LPN had previously undergone multiple coaching sessions and was under close supervision due to these issues. The deficiency was identified through facility-reported incident review, observation, record review, and staff interviews.