Failure to Assess, Document, and Notify After Resident Vomiting Episode
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and facility policy when a resident experienced vomiting after dinner. The resident had significant neurological diagnoses, including subdural hematoma, hydrocephalus, and dementia, and was documented as having severely impaired cognition and requiring extensive assistance with eating and bed mobility. On the evening in question, the resident ate dinner in their room with assistance and later vomited a small amount of undigested food, with vomitus observed on clothing and bed linens. Staff interviews and documentation show that the resident was described as alert, talking, and not in distress at that time. According to the facility’s policies on Notification of Changes and Falls/Occurrences, any accident, incident, or significant change in condition requires immediate notification of the physician and, as appropriate, the resident’s representative, as well as supportive documentation including vital signs, full physical assessment, and therapeutic interventions. The LPN reported in an investigative statement that vital signs were taken after being informed of the vomiting and that the resident was stable, but there was no documented evidence in the medical record that vital signs were recorded. There was also no documented evidence that the RN supervisor or the physician were notified of the vomiting episode, despite the facility’s policy and the RN supervisor’s later statement that such a change in condition should have been reported. Later that same evening, during bed linen changes, the resident was turned in bed and accidentally hit their head on the closet, resulting in a laceration and hematoma to the forehead. The LPN then notified the RN supervisor, who assessed the resident, noted changes in communication and mental status, obtained vital signs showing hypotension and bradycardia, and initiated emergency measures when the resident became unresponsive and pulseless. Subsequent interviews with the RN supervisor, DON, and Medical Director confirmed that the LPN did not notify the supervisor at the time of the vomiting and did not document the vital signs taken after the vomiting episode. The deficiency centers on the lack of timely notification and incomplete documentation following the resident’s vomiting, contrary to professional standards and the facility’s own policies.
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