ARLINGTON, WA - Arlington Health and Rehabilitation faced an immediate jeopardy citation after state inspectors found nursing staff failed to properly assess and monitor a resident experiencing severe abdominal pain over multiple days, ultimately leading to the resident's death from septic shock.
Failure to Monitor Deteriorating Resident
The August 2024 inspection revealed that Resident 1, who had a history of atrial fibrillation, diabetes, and stroke, experienced escalating abdominal discomfort from July 22-24, 2024, but nursing staff failed to conduct proper assessments or timely physician notification during the critical period.
According to inspection records, the resident first reported abdominal discomfort on July 22 at 9:45 PM and received antacid medication twice without relief. The discomfort continued through July 23, with nursing notes documenting that the resident had only small bowel movements over 48 hours and "needed to be assessed" - yet no assessment was documented.
The situation deteriorated significantly during the overnight shift of July 23-24. A nursing assistant reported that the resident was "calling out all shift, placing their call light on as soon as they would leave the room." The resident's continuous crying and calling for help became so disruptive that staff moved the roommate to another room down the hall.
Despite these clear signs of distress, the licensed practical nurse on duty failed to conduct vital sign checks or physical assessments. The nurse only notified the physician by fax at 4:19 AM on July 24, approximately two hours after documenting that the resident was "calling out, crying and disruptive" and that staff were "unable to relieve discomfort with antacids."
Critical Medical Deterioration Goes Undetected
The inspection revealed that vital signs, a fundamental monitoring tool in healthcare, were not checked for over 14 hours during the resident's acute decline. Records show the last documented vital signs were taken at 3:52 PM on July 23, with no additional monitoring until 6:00 AM on July 24 when the day shift discovered the resident in severe distress.
When the morning nursing assistant arrived for the 6:00 AM shift, they found the resident's door closed - unusual for this particular resident who preferred their door open. The room was cold with an open window, and the resident had no covers with bare legs exposed. Most critically, the call light was not within the resident's reach.
The nursing assistant found the resident covered in dark brown, coffee-colored vomit with discolored lips and very cold skin. The resident's oxygen saturation had dropped to 85% from a baseline of 96%, and they were experiencing shortness of breath with decreased lung sounds on both sides.
"The resident was saying help, help," the nursing assistant reported during interviews. "They were not making sense, and this was not Resident 1's baseline, so they ran to get a nurse."
Systemic Communication Breakdowns
The inspection uncovered significant failures in the facility's communication protocols. The overnight licensed practical nurse acknowledged during interviews that they "should have called the physician earlier as the abdominal discomfort had been occurring for a couple of days" and admitted they "did not check on the resident after they shut the door to the room" between 5:00-5:30 AM.
Even more concerning, the day shift registered nurse receiving report was unaware of the resident's multi-day abdominal pain and restlessness until after the resident was sent to the hospital. This communication breakdown meant critical information about the resident's deteriorating condition was not properly transferred between shifts.
The facility's own nursing manager confirmed that staff should have completed vital sign assessments and head-to-toe physical examinations whenever a resident experienced a change in condition. The Director of Nursing Services stated their expectation was that "the physician was called for any urgent matter or change in condition" and that licensed staff should "assess and monitor the resident continuously."
Medical Context: Why These Failures Matter
Abdominal pain in elderly residents, particularly those with complex medical histories, requires immediate and thorough assessment. The resident's medical background included anticoagulant therapy, which increases bleeding risks, and diabetes, which can mask pain and delay healing responses.
Coffee-ground emesis - dark brown vomit resembling coffee grounds - indicates upper gastrointestinal bleeding and represents a medical emergency requiring immediate intervention. This symptom, combined with the resident's dropping oxygen levels and altered mental status, pointed to severe internal bleeding and potential septic shock.
Septic shock occurs when bacterial infections spread throughout the bloodstream, causing widespread inflammation, organ dysfunction, and potentially fatal drops in blood pressure. Early recognition and treatment are critical, as survival rates decrease significantly with delayed intervention.
Vital sign monitoring serves as an early warning system for detecting clinical deterioration. A 14-hour gap in monitoring during an acute illness represents a fundamental breach of nursing care standards. Regular assessment would have detected the resident's declining oxygen levels, changes in blood pressure, and other indicators of systemic illness hours before the crisis point.
Hospital Emergency Response Confirms Severity
Emergency department records from July 24 revealed the true severity of the resident's condition when they arrived at 7:57 AM. Hospital physicians documented that the resident "appeared toxic and altered" with coffee-ground emesis, weakness, and low blood pressure.
The emergency physician expressed immediate concern about sepsis and septic shock, noting "acute critical illness with potential for imminent deterioration." Laboratory results confirmed a significantly elevated white blood cell count, indicating severe infection.
Despite intensive care interventions, the resident was transferred to the ICU at 11:44 AM. Hospital physicians documented struggles with breathing and dangerously low heart rate. Medical staff advised the family that the resident would likely survive only a few more hours. The resident passed away at 3:43 PM the same day.
Additional Issues Identified
The inspection also documented violations of basic safety protocols during the critical night shift. Nursing staff closed the resident's door and placed the call light out of reach while the resident was experiencing acute distress. This action prevented the resident from summoning help during what may have been the most critical hours of their decline.
The facility's notification policy, revised in April 2020, clearly required prompt physician notification for changes in residents' physical, mental, or psychosocial status. The two-day delay in recognizing the severity of the resident's condition and the use of non-urgent fax communication instead of direct phone calls violated these established protocols.
Staff interviews revealed knowledge gaps regarding proper assessment techniques and physician notification procedures, despite facility policies requiring immediate notification for urgent changes in resident condition.
Corrective Actions Implemented
Following the inspection, Arlington Health and Rehabilitation terminated the staff members who failed to properly assess and notify the physician of the resident's condition. The facility conducted audits of all resident records and implemented enhanced staff education programs focused on recognizing changes in resident condition and identifying potential abuse and neglect.
The facility developed a comprehensive plan of correction to maintain ongoing compliance with federal nursing home regulations. The immediate jeopardy citation was removed on August 19, 2024, after inspectors determined the facility had addressed the systemic issues that contributed to this preventable death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Arlington Health and Rehabilitation from 2024-08-23 including all violations, facility responses, and corrective action plans.
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