Home cited after resident dies

SPRINGFIELD, Mo. -- A Springfield nursing home was cited after investigators determined employees had not adequately addressed the needs of a patient who later died.

Christian Health Care: Springfield East received the state's most severe noncompliance citation.

State officials said the citiation followed an investigation into the Feb. 17 death of a resident, who has not been identified.

According to the investigators' report, the resident began vomiting a dark, foul-smelling substance the night of Feb. 16 and continued to be sick throughout the night.

The report said the resident complained of being sick and asked to be transferred from a bed to a wheelchair. According to the report, the patient's requests initially were denied, but an employee finally helped the patient sit up in bed. At that point, the report says, "the resident began to make gurgling sounds as if his/her lungs were filled with fluid."

The resident died shortly after 7 a.m. Feb. 17.

A doctor at the facility who was not on call the weekend of the death told investigators that the resident might have suffered a hearth attack.

"The physician said he would expect staff to notify him if a resident had dark, foul smelling (vomit)," the report said.

Besides not notifying a doctor, the Department of Health and Senior Services found fault with Christian Health Care for not adequately reporting changes in vital signs and failing "to provide appropriate nursing interventions to address the change in condition" of the resident who died.

The investigation, completed March 5, also found deficiencies in the care of other patients, including giving "inconsistent insulin dosage" to one patient and failing to obtain a urinalysis on a patient who might have been suffering a urinary tract infection.