Forest Park Nursing: Resident Dies After Ignored Low BP - TX

Licensed Vocational Nurse A discovered the dangerously low blood pressure at 10:23 a.m. on June 8, 2024, at Forest Park Nursing & Rehabilitation. The resident also had an oxygen level of just 88 percent and was vomiting.

Instead of calling the doctor, LVN A gave the resident 120 milliliters of orange juice and "more fluid" — a potentially dangerous decision for someone on dialysis who was supposed to be on strict fluid restrictions.

LVN A checked the resident's blood pressure again at 12:08 p.m. It had risen slightly to 101/54, but was still well below normal. Then he stopped monitoring entirely.

"He checked his vitals several times throughout the day and was not sure why he did not document those readings," LVN A later told investigators. "He forgot to document it because it was the end of the shift but knew he should have documented that."

The night shift nurse, LVN B, never checked on the resident during her 10 p.m. to 6 a.m. shift. She told investigators that LVN A hadn't told her about the resident's condition.

"If he did, she would have called his Dr. and did another BP check to see what the Dr. wanted to do," LVN B said. "She would not play around with someone's life."

By Sunday morning, the resident's condition had deteriorated catastrophically. At 8:37 a.m., LVN A found his blood pressure had dropped further to 83/44. The resident was "very weak, nausea, vomiting, poor eating" but still alert.

Only then did LVN A call the physician assistant, who immediately ordered the resident sent to the hospital by ambulance.

The resident arrived at the emergency department "minimally responsive with poor oral care." He was hypotensive and had a rapid, irregular heartbeat that responded only briefly to emergency fluid treatment. His white blood cell count was elevated at 13.64, indicating severe infection.

Hospital doctors diagnosed septic shock — a life-threatening condition where widespread infection causes organ failure. The resident required pressors to maintain his blood pressure and was placed on a ventilator when he began vomiting and couldn't protect his airway.

"Following arrival to the ICU, the patient was noted to have large volume emesis that progressed to possible coffee ground emesis," hospital records show. "Due to concern for inability to protect airway, the patient was intubated."

The resident never recovered. When investigators visited the hospital on June 11, he remained on life support in the medical intensive care unit, nonresponsive on a ventilator.

The resident had been admitted to Forest Park in August 2023 with multiple serious conditions including kidney failure requiring dialysis, diabetes, heart infection, anemia and high blood pressure. His care plan specifically warned of "potential for fluid overload related to kidney failure" and required monitoring for changes in condition.

His dialysis center had ordered a renal diet with fluid restrictions of just 32 ounces per day — but Forest Park had never added this critical order to the resident's chart. The facility's own physician assistant wasn't even sure if he had fluid restrictions.

"If the residents who were on dialysis were to have too much fluid they could get fluid overload, which could collect in their lungs and make it hard for them to breathe," the resident's dialysis nurse manager explained.

When LVN A gave the resident orange juice and additional fluids on June 8, he violated basic dialysis care protocols.

"If a resident who was on dialysis had a drop in their BP, she would never give them fluids because they could retain the fluids and could get fluid overload," another nurse at the facility told investigators. "Especially if the Doctor did not order additional fluids."

The facility's own nurses understood the stakes. RN E told investigators that dangerously low blood pressure "could cause the resident to have a significant declination and become lethargic, confused and beyond their baseline."

LVN G was blunt: "If a resident's BP dropped, they could pass out."

LVN B described the potential consequences in stark terms: "If a resident's BP dropped, they could shut down and go into respiratory distress especially if their BP was low. A resident might end up dying and pass away."

The facility had clear policies requiring nurses to notify doctors of abnormal vital signs and document all care. LVN A violated both requirements.

"Not documenting resident's vitals could make it very hard to follow up and compare previous conditions and limit communication because the documentation was missing," he acknowledged to investigators.

The Director of Nursing discovered another failure that compounded the resident's crisis. On June 3, the resident had abnormal lab results showing an elevated white blood cell count of 12 — an early warning sign of infection. But when Assistant Director of Nursing AA faxed the results to the physician assistant on June 5, she failed to follow up when no response came back.

"In hindsight she should have called Resident #1's PA/MD for clarification," ADON AA told investigators. The elevated white blood cell count went unaddressed for days while the infection that would eventually kill the resident took hold.

Federal inspectors determined the facility's failures placed the resident in immediate jeopardy. The Administrator suspended LVN A and planned to terminate him. LVN B received a written warning for failing to document her care.

The facility scrambled to retrain its 117 employees on recognizing changes in condition, monitoring vital signs, and notifying doctors. They posted signs at nursing stations: "NOTIFY MD/NP OF LOW BLOOD PRESSURES. SYSTOLIC LESS THAN 95."

"If residents had a change in condition and the PA/MD was not notified, could result in the deterioration of the resident and exacerbation of the resident's symptoms," the Administrator told investigators.

The Director of Nursing was more direct about the consequences: "Not monitoring the residents and notifying the PA/MD could cause the staff to miss something that could delay care. It could further delay getting the resident evaluated resulting in a number of things such as a worsening condition or death."

The facility scheduled a meeting with the resident's dialysis center to finally coordinate proper orders for his care — a meeting that came too late.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Forest Park Nursing & Rehabilitation from 2024-06-14 including all violations, facility responses, and corrective action plans.

Additional Resources

• View all inspection reports for Forest Park Nursing & Rehabilitation
• Browse all TX nursing home inspections