F0842

D

Failure to Document Vital Signs and Nursing Interventions During Resident’s Acute Bleeding Episode

Long Beach, California Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure licensed nurses documented vital signs and nursing interventions in accordance with professional standards when a resident experienced a significant change in condition characterized by coughing up blood. The resident had a history of cerebrovascular disease and seizures, was unable to make reasonable decisions per the MDS, and was receiving Eliquis via gastrostomy tube with a care plan identifying risk for bleeding and requiring prompt identification and response to signs of blood loss. On the date of the incident, an SBAR form at 8:40 a.m. documented that the resident was coughing up blood with a blood pressure of 163/97 mmHg, and a nurse’s note at 9:02 a.m. recorded that the resident was coughing a moderate amount of blood with the same blood pressure and that the physician was notified with orders to transfer the resident to a hospital.

Subsequent nurse’s notes at 9:04 a.m. documented that a private BLS ambulance was called with an expected arrival time between 11:30 a.m. and 12 p.m. Later documentation at 12:05 p.m. indicated the resident was coughing more blood, had a clenched jaw, and required continuous oral suctioning, and that the private ambulance crew advised staff to call 911 for an emergency transfer. The paramedic run sheet recorded that EMS found the resident with uncontrolled bleeding from the mouth due to a tongue bite, with vital signs including blood pressure 162/94 mmHg, heart rate 70 BPM, respiratory rate 20, and oxygen saturation 96%, and that approximately 800–1,000 mL of blood was suctioned during transport. Hospital emergency department records documented profuse tongue bleeding and elevated blood pressure on arrival.

Review of the facility’s Weights and Vitals Summary for that day showed vital signs documented at 8:27 a.m. and 11:46 a.m., but there was no documentation of vital signs or monitoring at 8:40 a.m. when the resident was noted to be coughing blood, nor documentation of nursing interventions at that specific time related to the change in condition. The facility’s policy on Change in a Resident’s Condition or Status required licensed nurses to identify worsening conditions, promptly notify the physician, alter treatment as needed including transfer, and document all information related to changes in condition in the medical record. The surveyors found that, despite the documented change in condition and subsequent deterioration, the medical record lacked documentation of vital signs and monitoring at the time the resident was first reported to be coughing up blood, constituting a failure to maintain complete medical records in line with accepted professional standards.