Failure to Develop and Implement Person-Centered Care Plan for Resident With Vomiting and Severe Pain
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a person-centered care plan with measurable interventions when a resident experienced ongoing vomiting and severe generalized pain. The resident, who had intact cognitive skills for decision-making, was dependent for all major ADLs and had significant medical conditions including irritable bowel syndrome, alcoholic cirrhosis with ascites, secondary esophageal varices, quadriplegia with contractures, and cervical spine disorders with myelopathy and spinal stenosis. Despite these complex conditions, when the resident began vomiting and reporting generalized pain rated 10/10, the facility did not timely initiate a change of condition process or create a care plan addressing these acute symptoms. Record review showed that the resident’s vomiting began on 11/20/25 and continued for several days, with documentation on 11/21/25 that the resident had been vomiting for three days, had a firm abdomen, and was placed NPO except for sips of water. Another note the same day documented that the resident had been vomiting throughout the day. However, there was no documented assessment of the vomitus (such as color or smell), no detailed abdominal assessment, and no vital signs recorded in connection with at least one of the vomiting episodes. The LVN on the 3 p.m. to 11 p.m. shift stated the resident vomited twice during his shift, that the first episode contained food, and that he did not observe the second episode, which was assessed by the RN supervisor. He acknowledged there was no documentation of a full assessment and stated that without documentation, the assessment was not done, and that the resident was not closely monitored. Further review and interview with the RN supervisor confirmed that although vomiting started on 11/20/25, the change of condition evaluation was not initiated until 11/22/25. The change of condition form indicated the resident was unable to eat or drink adequately and had nausea and vomiting starting on 11/20/25, with decreased appetite and inability to keep food down, and that the primary care physician was notified, but without documented date, time, or recommendations. The RN supervisor stated that the resident’s pain and vomiting were not care planned and acknowledged that a person-centered care plan with measurable interventions should have been created and implemented when the symptoms began. This failure occurred despite a facility policy requiring the interdisciplinary team to develop an individualized comprehensive care plan based on the resident’s assessment, to guide treatment and care tailored to each resident’s needs.
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