The following summary of the department's finding comes from the Missouri Coalition for Quality Care website:
The facility failed to notify the physician of abnormal vital signs and foul smelling emesis during the night shift beginning at 11 p.m. on 2/16/2008; failed to provide follow up assessments of concerns identified by a direct care staff and failed to provide appropriate nursing interventions to address the discomfort of one resident (Resident #1) who died on 2/17/2008 at 7:20 a.m. in the facility. The facility census was 116.
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