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Based on review of medical records, review of facility documents, and Staff interviews, it was determined that the Hospital failed to meet the Condition of Participation: Nursing Services after the following was identified:

-The Registered Nurse failed to re-assess a patient prior to a determining a patients need to be transferred to the hospital. (A-0395)
-Failure to notify the Physician regarding the patient's deteriorating condition, which resulted in the patient becoming unresponsive, requiring CPR, and transfer to the hospital. (A-0386)
-The Nurse failed to report to the oncoming Nurse the patient's recent change in condition during hand-off communication. (A-0386)
-The Institutional Psychiatric Attendants (IAP) failed to conduct hand-off communication with the oncoming IAP. (A-0386)

These failures resulted in an Immediate Jeopardy, posing a serious risk of harm, impairment or death to all patients.

Findings are as follows:

A CMS authorized Substantial Allegation Survey was conducted from 9/12/2024 through 9/18/2024 at Eleanor Slater Hospital to determine compliance with the Condition of Participation for hospitals: 482.23 Nursing Services following an anonymous report alleging that a patient died due to a potential bowel obstruction.

On 9/16/2024 a finding which constituted an Immediate Jeopardy (IJ) was identified under 42 CFR 482.23 A-0385 Condition of Participation: Nursing Services, related to the Nursing Supervisor's failure to assess the patient prior to deciding not to transfer the patient to the hospital after the Physician and the unit Nurse discussed the patients condition and the physician and a verbal agreement was made to transfer the patient to an acute care hospital for an evaluation. The Nursing Supervisor deemed the patient's medical transfer was "unwarranted," claiming the patient was not in distress and only constipated. Additionally, the Nurse, Employee C, failed to notify the physician of the patient's status and recent change in condition, which resulted in the patient to become unresponsive, subsequently requiring CPR, and to be emergently transferred to the acute care hospital.

The hospital's Risk Manager and Chief Nursing Officer were informed of the Immediate Jeopardy, which was identified on 9/16/2024 and were provided with the Immediate Jeopardy template at approximately 2:40 PM on this date.

On 9/17/2024 the hospital submitted the Immediate Plan of Correction (IPOC) indicating the immediate actions the hospital would take to prevent serious harm from occurring or recurring. This IPOC indicated that the following would be immediately implemented:

- Revision of the nursing policy on hand-off communication to include a provision for escalation of care in the chain of command.

- All clinical staff will be educated on the hand-off communication policy and attest their understanding of the expectations on immediately reporting any changes in a patient's clinical presentation or symptoms of distress and the provisions for escalation of care.

- Nursing staff will attest to the receipt of this education and policy review prior to providing any patient care.

On 9/18/2024 an audit was completed by the state surveyors and the IPOC was verified as being fully implemented by verifying policy changes, review of education provided, and interviews with staff who received the education. As of 9/18/2024 the IJ was removed.

Based on record review and staff interview, it has been determined the hospital failed to ensure that licensed nurses who provide services in the hospital adhere to the policies and procedures of the hospital for 1 of 1 patient reviewed who experienced a change in condition and required an emergent transfer to an acute care hospital.

Findings are as follows:

The hospital's policy titled; "Hand-Off Communication" last reviewed in September of 2020 states in part:

"...Hand-off is defined as the provision of verbal and/or written information from one healthcare provider to another so that care, treatment needs as well as the patient's current condition and any recent or anticipated changes are accurately communicated...
Policy...

...Shift reports from the nurse to the nurse and from the nurse to the nursing assistant and from the nursing assistant to the nurse...
Change of Shift report from the nursing assistant to the nursing assistant...

Nurse to Physician...

3. Hand-off communication shall include pertinent up-to-date information regarding the patient's treatment, care, and services, as well as current status and any recent changes or anticipated changes in the patient's condition ..."

Record review for Patient ID #1 revealed she/he was admitted to the hospital in July of 2024 following an admission to another hospital due to worsening psychosis with agitation and disorganized behavior. His/her diagnoses include, but are not limited to, schizoaffective disorder and intellectual disability.

Record review revealed that on 9/6/2024 during the 7:00 AM through 3:00 PM shift, Patient ID #1 complained of stomach pain, stated she/he had not moved his/her bowels in 3 to 4 days and had vomited.

At 1:00 PM on 9/6/2024, the Physician, Employee A, indicated in the record that he evaluated the patient and identified that she/he had "diffuse tenderness" to his/her abdomen, "denied passing gas, had positive bowel sounds on all quadrants of the abdomen and had no signs of rebound." The Physician then concluded that the patient was experiencing constipation and ordered a clear liquid diet for 24 hours, Miralax, a laxative solution, with prune juice, and lactulose, a laxative. The Nurse, Employee B, then administered these orders to the patient at 1:15 PM.

According to Employee B, the patient reported she/he vomited twice after taking the Miralax, prune juice, and lactulose. Staff B also reported the patient refused an additional dose of Miralax and prune juice when they were offered again at 3:15 PM because she/he had vomited.

Record review revealed a nursing note dated 9/6/2024 at 8:40 PM, in which the Nurse, Employee C, stated that Patient ID #1 was complaining of constipation and the last dose of Miralax, and prune juice were administered. She described the patient as "irritable" and indicated that the patient stated she/he was full. Employee C stated in her note that the patient's stomach was "distended," she/he had positive bowel sounds and had denied she/he vomited or felt nauseous.

Employee C further revealed in her note that earlier in the evening, at 7:40 PM, Patient ID #1 received a fleet enema, a medication used for constipation, via his/her rectum and she/he tried to move his/her bowels but was unsuccessful and sat on the bathroom floor for 15 minutes before returning to his/her room.

Employee C stated that she then obtained an order for Magnesium Citrate, a laxative solution, but the patient only ingested a quarter of the bottle and yelled at her, "I am full!"

Record review of a progress note dated 9/7/2024 at 1:45 AM completed by the on-call Psychiatrist, Employee D, revealed that at 9:54 PM on 9/6/2024, she was told by telephone that Patient ID #1 had not moved his/her bowels, was refusing to drink liquids, was irritable, and swearing at the nurse and a discussion about sending the patient to the emergency room took place.

At 10:04 PM according to the on-call Psychiatrist's timeline which was provided by the on-call Psychiatrist from her cell phone, Employee C had reported that the Nursing Supervisor did not feel that the emergency room visit was warranted.

The record failed to reveal evidence that the Supervising Nurse, Employee F, re-evaluated the patient prior to making this decision.

Further review of nursing progress notes revealed that at 10:30 PM on 9/6/2024, Employee C stated that Patient ID #1, "continued to be irritable" and lied down on the floor three times during the shift "complaining of stomach discomfort" and refused to drink fluids but described him/her as "not in distress." Additionally, Employee C stated that the patient's bowel sounds were, "sluggish" on both sides of the lower abdomen.

At 11:00 PM, Employee C stated in her note that Patient ID #1's abdomen was distended and she/he "took a sip of water," and refused the rest of the Magnesium Citrate. She indicated that the Psychiatrist on-call, Employee D, was informed but did not provide new orders during a "previous call."

Employee C, indicated in her note that she informed the on-call Psychiatrist, however evidence provided by the psychiatrist revealed that the last call by Employee C was at 10:04 PM. The next call that she received was at 12:55 AM, by Employee E stating that 911 had been called for Patient ID #1.

Record review of a nursing note dated 9/7/2024 at 2:30 AM completed by the Nurse, Employee E, revealed that at 12:55 AM on this date, Patient ID #1 complained of abdominal pain, his/her stomach was visibly distended, she/he placed himself/herself on the floor and was "unable to stay still." Employee E stated that Patient ID #1 returned to his/her room after this episode and she returned to the nurses' station to call the Supervising Nurse, and the Psychiatrist on-call who gave the order to transfer the patient to the hospital. Employee E revealed in her note that while on the phone with 911, a staff member "ran to the nursing station" to inform her and the Supervising Nurse, who was now on the unit and at the nurses' station, that Patient ID #1 vomited a large amount of "dark liquid" and was "unresponsive." Employee E further stated in her note that a code blue was announced, CPR was started, and an Automated External Defibrillator (AED) was placed on the patient.

At 1:06 AM, Employee E informed the Psychiatrist On-Call that Patient ID #1 was unconscious. She indicated that the rescue then arrived at 1:12 AM and transferred him/her to the hospital at 1:37 AM.

Record review revealed that while in the Emergency Department, Patient ID #1 continued to receive multiple rounds of CPR before the return of spontaneous circulation. The patient was described as having a "rock hard abdomen" and after a surgical consult, an abdominal fasciotomy (a surgical procedure that involves cutting through the connective tissue of the abdomen to relieve pressure) took place at the bedside which revealed the patient had "bowel ischemia (damage caused by a lack of blood supply) and multisystem organ failure."

The record indicated that Patient ID #1 was placed on comfort measures as requested by his/her family and later expired at 1:02 PM on 9/7/2024.

During a surveyor interview on 9/16/2024 at 10:48 AM with Institutional Attendant (IAP), Employee G, she stated that on 9/6/2024, she worked second shift and was assigned to a patient on the unit who required one-on-one supervision. She revealed that upon returning to the unit from her break, she was again assigned to the patient who required one-on-one supervision between 8:00 PM and 11:15 PM and was sitting across from Patient ID #1's room. During this time, Employee G indicated that Patient ID #1 asked to use the bathroom, and she unlocked the door for him/her. She stated that Patient ID #1 was in the bathroom for a while before returning to his/her room. She explained that Patient ID #1 later asked to use the bathroom again, but this time, she observed Patient ID #1 lying on the bathroom floor and another IAP, Employee H, who found him/her said, "Someone needs to call 911." Employee G states she observed the nurse in the bathroom attempting to give Patient ID #1 a drink, which she/he refused. She indicated that Patient ID #1 then got up from the bathroom floor and laid down in the hallway and the nurse told him/her to return to his/her room, which she/he did. Employee G revealed that she saw Patient ID #1 sitting on his/her bed later in the evening with his/her back against the wall, saying, "Help me, I can't breathe." She stated that she had previously reported the patient's discomfort and his/her "big hard abdomen" to the Nurse Employee C, earlier in the evening, The nurse stated to Employee G, she was aware, and informed Employee G that the patient was constipated. Additionally, she confirmed that she did not provide a change of shift report to the oncoming IAP as required per hospital policy.

During a surveyor interview with the evening Supervising Nurse (SRN) Employee F, on 9/12/2024 at 11:30 AM she revealed that after she received her evening supervisor report she later went up to the floor to follow up with Employee C. She then stated that she saw the patient and identified that the patient had a history of constipation and "was not in distress." Employee F, stated she had received a call from Employee C regarding the transfer of Patient ID #1 to the hospital for further evaluation. She then asked Employee C for the patient's vital signs, then informed her "How can we send someone out that is not in distress." She stated she thought the situation could wait until morning because the patient was only constipated. Employee F was then asked if she was aware that Patient ID #1 had vomited, to which she replied, "I was not aware of this," despite her having access to the shift-to-shift report which indicated the patient had vomited x2 unwitnessed on the day shift.

During an additional surveyor interview on 9/16/2024 at 2:35 PM with Employee C, she revealed that SRN, Employee F, did not assess the patient before making the decision to halt the transfer the patient to the hospital because he was "not in distress". When asked if she was requested by Employee H to call 911 for Patient ID #1 between approximately 9:00 PM to 10:00PM, she replied that she was notified by Employee H and she was told that the patient just vomited. She acknowledged that she saw vomit on the floor, which she described as 15-20 milliliters of an orange saliva type mixture and revealed that she did not mention this to the oncoming Nurse, Employee E, that the patient had an episode of vomiting. Employee C then stated that when her shift ended Patient ID # 1's abdomen was "slightly distended" and acknowledged that she knew that he/she was uncomfortable.

During a surveyor interview on 9/16/2024 at 12:04 PM with Nurse, Employee E, she stated that on 9/6/2024 she started her shift at 11:15 PM and received report from Employee C. When asked what she was told about Patient ID #1 during report, she stated that Employee C told her that the patient had a problem with constipation, and she told her she administered all of the orders provided to her by the doctor. When asked if she was told if the patient vomited, she stated, "I don't think that there was vomiting on second shift." She stated that after receiving report, she gave the IAPs report, and checked on the patient through the door, and saw that Patient ID #1 "was sleeping." She revealed that around 12:55 AM on 9/7/2024, she heard a cry and when she exited the nurses' station, she saw Patient ID #1 in the hallway "rolling over" and moving and could not obtain an oxygen level because of this and noticed at this time that the patient's abdomen was "visibly distended." She indicated that other staff brought the patient to his/her room where she/he later "passed out" after vomiting.

During an interview on 9/12/2024 at 12:15 PM with on-call Psychiatrist, Employee D, she stated she was the On-Call Physician and had not received any information on the patient during the Physician handoff report. She revealed she was called three times by the Nurse, Employee C, and at 9:54 PM she received a call from Staff C stating the patient was in discomfort, still had not had a bowel movement and was only taking sips of fluids. Employee D stated that she and Employee C discussed sending the patient out to the Emergency Room for further evaluation and a "verbal agreement was made to send the patient out". The On Call Psychiatrist then stated that Employee C was asking her questions regarding the process for sending the patient out and she stated that she told Employee C to contact the SRN for the current procedure.

Based on record review and staff interview, it has been determined that the hospital failed to ensure the care of a patient was evaluated in accordance with accepted standards of nursing practice for 1 of 1 Supervising Registered Nurse (SRN) who failed to assess a patient prior to determining that he/she did not require transfer to an acute care hospital transfer for further evaluation. SRN, Employee F.

Findings are as follows:

Record review for Patient ID #1 revealed she/he was admitted to the hospital in July of 2024 following an admission to another hospital due to worsening psychosis with agitation and disorganized behavior. His/her diagnoses include, but are not limited to, schizoaffective disorder and intellectual disability.

Record review revealed that on 9/6/2024 during the 7:00 AM through 3:00 PM shift, Patient ID #1 complained of stomach pain, stated she/he had not moved his/her bowels in 3 to 4 days and had vomited.

At 1:00 PM on 9/6/2024, the Physician, Employee A, indicated in the record that he evaluated the patient and identified that she/he had "diffuse tenderness" to his/her abdomen, denied passing gas, had positive bowel sounds on all quadrants of the abdomen and had no signs of rebound. The Physician then concluded that the patient was experiencing constipation and ordered a clear liquid diet for 24 hours, Miralax, a laxative solution, with prune juice, and lactulose, a laxative. The Nurse, Employee B, then administered these orders at 1:15 PM.

According to Employee B, the patient reported she/he vomited twice after taking the Miralax, prune juice, and lactulose and later refused an additional dose of Miralax and prune juice when they were offered again at 3:15 PM because she/he had vomited.

Record review revealed a nursing note dated 9/6/2024 at 8:40 PM, in which the Nurse, Employee C, stated that Patient ID #1 was complaining of constipation and the last dose of Miralax, and prune juice were administered. She described the patient as "irritable" and indicated that the patient stated she/he was full. Employee C stated in her note that the patient's stomach was "distended," she/he had positive bowel sounds and had denied she/he vomited or felt nauseous.

Employee C further revealed in her note that earlier in the evening, at 7:40 PM, Patient ID #1 received a fleet enema, a medication used for constipation, via his/her rectum and she/he tried to move his/her bowels but was unsuccessful and sat on the bathroom floor for 15 minutes before returning to his/her room.

Employee C stated that she then obtained an order for Magnesium Citrate, a laxative solution, but the patient only ingested a quarter of the bottle and yelled at her, "I am full!"

Record review of a progress note dated 9/7/2024 at 1:45 AM completed by the on-call Psychiatrist, Employee D, revealed that at 9:54 PM on 9/6/2024, she was told by telephone that Patient ID #1 had not moved his/her bowels, was refusing to drink liquids, was irritable, and swearing at the nurse and a discussion about sending the patient to the emergency room took place.

At 10:04 PM according to the on-call Psychiatrist's timeline which was provided by the Psychiatrist from her cell phone, Employee C had reported that the Nursing Supervisor did not feel that the emergency room visit was warranted. The record failed to reveal evidence that the Supervising Nurse, Employee F, re-evaluated the patient prior to making this decision.

Further review of nursing progress notes revealed that at 10:30 PM on 9/6/2024, Employee C stated that Patient ID #1, "continued to be irritable" and lied down on the floor three times during the shift "complaining of stomach discomfort" and refused to drink fluids but described him/her as "not in distress." Additionally, Employee C stated that the patient's bowel sounds were, "sluggish" on both sides of the lower abdomen.

At 11:00 PM, Employee C stated in her note that Patient ID #1's abdomen was distended and she/he "took a sip of water," and refused the rest of the Magnesium Citrate. She indicated that the on-call Psychiatrist, Employee D, was informed but did not provide new orders during a "previous call." Employee C, indicated in her note that she informed the on-call Psychiatrist, however evidence provided by the psychiatrist revealed that the last call by Employee C was at 10:04 PM. The next call that she received was at 12:55 AM, by Employee E stating that 911 had been called for Patient ID #1.

Record review of a nursing note dated 9/7/2024 at 2:30 AM completed by the Nurse, Employee E, revealed that at 12:55 AM on this date, Patient ID #1 complained of abdominal pain, his/her stomach was visibly distended, she/he placed himself/herself on the floor and was "unable to stay still." Employee E stated that Patient ID #1 returned to his/her room after this episode and she returned to the nurses' station to call the Supervising Nurse, and the on-call Psychiatrist who gave the order to transfer the patient to the hospital. Employee E revealed in her note that while on the phone with 911, a staff member "ran to the nursing station" to inform her and the Supervising Nurse, who was now on the unit and at the nurses' station, that Patient ID #1 vomited a large amount of "dark liquid" and was "unresponsive." Employee E further stated in her note that a code blue was announced, CPR was started, and an Automated External Defibrillator (AED) was placed on the patient.

At 1:06 AM, Employee E informed the on-call Psychiatrist that Patient ID #1 was unconscious. She indicated that the rescue then arrived at 1:12 AM and transferred him/her to the hospital at 1:37 AM.

Record review revealed that while in the Emergency Department, Patient ID #1 continued to receive multiple rounds of CPR before the return of spontaneous circulation. The patient was described as having a "rock hard abdomen" and after a surgical consult, an abdominal fasciotomy (a surgical procedure that involves cutting through the connective tissue of the abdomen to relieve pressure) took place at the bedside which revealed the patient had "bowel ischemia (damage caused by a lack of blood supply) and multisystem organ failure." The record indicated that Patient ID #1 was placed on comfort measures as requested by his/her family and later expired at 1:02 PM on 9/7/2024.

During a surveyor interview with the evening Supervising Nurse (SRN) Employee F, on 9/12/2024 at 11:30 AM she revealed that after she received her evening supervisor report she later went up to the floor to follow up with Employee C. She then stated that she saw the patient and identified that the patient had a history of constipation and "was not in distress." Employee F stated she had received a call from Employee C regarding the transfer of Patient ID #1 to the hospital for further evaluation. She then asked Employee C for the patient's vital signs, then informed her "How can we send someone out that is not in distress." She stated she thought the situation could wait until morning because the patient was only constipated. Employee F was then asked if she was aware that Patient ID #1 had vomited, to which she replied, "I was not aware of this," despite her having access to the shift-to-shift report which indicated the patient had vomited x2 unwitnessed on the day shift.

During a surveyor interview on 9/16/2024 at 10:48 AM with Institutional Attendant (IAP), Employee G, she stated that on 9/6/2024, she worked second shift and was assigned to a patient on the unit who required one-on-one supervision. She revealed that upon returning to the unit from her break, she was again assigned to the patient who required one-on-one supervision between 8:00 PM and 11:15 PM and was sitting across from Patient ID #1's room. During this time, Employee G indicated that Patient ID #1 asked to use the bathroom, and she unlocked the door for him/her. She stated that Patient ID #1 was in the bathroom for a while before returning to his/her room. She explained that Patient ID #1 later asked to use the bathroom again, but this time, she observed Patient ID #1 lying on the bathroom floor and another IAP, Employee H, who found him/her said, "Someone needs to call 911." Employee G states she observed the nurse in the bathroom attempting to give Patient ID #1 a drink, which she/he refused. She indicated that Patient ID #1 then got up from the bathroom floor and laid down in the hallway and the nurse told him/her to return to his/her room, which she/he did. Employee G revealed that she saw Patient ID #1 sitting on his/her bed later in the evening with his/her back against the wall, saying, "Help me, I can't breathe." She stated that she had previously reported the patient's discomfort and his/her "big hard abdomen" to the Nurse Employee C, earlier in the evening, The nurse stated to Employee G, she was aware, and informed Employee G that the patient was constipated.

During a surveyor interview on 9/16/2024 at 11:52 AM with Employee H, IAP, she revealed that sometime after 9:00 PM on 9/6/2024, she was conducting safety checks on the unit and Patient ID #1 requested to use the bathroom again. Employee H revealed she checked on Patient ID #1 numerous times as she/he was in the bathroom for a while and asked him/her if she/he was okay and if she/he was breathing, to which the patient replied that she/he was, but stated, "I still don't feel good," and eventually returned to his/her room. Employee H indicated the patient requested to use the bathroom again and she saw him/her vomit "a little bit" while sitting in the hallway waiting for the bathroom door to be unlocked and then vomited "brown liquid" when she observed him/her lying on his/her side on the bathroom floor. She stated that she told the patient, "why don't you sit on the toilet" but the patient told her "I can't do it" and described his/her face as "bad." Employee H stated she called the Nurse, Employee C, and told her to call 911, because the patient was "not looking good," and described his/her face as "very pale." She stated that the nurse told her she knew and that she told the doctor already. Employee H stated she did not know what else to do, she must listen to the nurse.

During a surveyor interview on 9/16/2024 at 12:04 PM with Nurse, Employee E, she stated that on 9/6/2024 she started her shift at 11:15 PM and received report from Employee C. When asked what she was told about Patient ID #1 during report, she stated that Employee C told her that the patient had a problem with constipation, and she told her she administered all of the orders provided to her by the doctor. When asked if she was told if the patient vomited, she stated, "I don't think that there was vomiting on second shift." She stated that after receiving report, she gave the IAPs report, and checked on the patient through the door, and saw that Patient ID #1 "was sleeping." She revealed that around 12:55 AM on 9/7/2024, she heard a cry and when she exited the nurses' station, she saw Patient ID #1 in the hallway "rolling over" and moving and could not obtain an oxygen level because of this and noticed at this time that the patient's abdomen was "visibly distended." She indicated that other staff brought the patient to his/her room where she/he later "passed out" after vomiting.

During an interview on 9/12/2024 at 12:15 PM with on-call Psychiatrist, Employee D, she stated she was the on-call Physician and had not received any information on the patient during the Physician handoff report. She revealed she was called three times by the Nurse, Employee C, and at 9:54 PM she received a call from Staff C stating the patient was in discomfort, still had not had a bowel movement and was only taking sips of fluids. Employee D stated that she and Employee C discussed sending the patient out to the Emergency Room for further evaluation and a "verbal agreement was made to send the patient out". The on-call Psychiatrist then stated that Employee C was asking her questions regarding the process for sending the patient out and she stated that she told Employee C to contact the SRN for the current procedure.

During an additional surveyor interview on 9/16/2024 at 12:23 PM with the on-call Psychiatrist, Employee D, she stated that she was unaware that the patient vomited during the day and the evening and stated this would have raised her suspicion for a bowel obstruction. Additionally, she indicated that she was unaware that the patient's abdomen was "hard and big" or that the patient was pale. Employee D then stated that if these symptoms would have been reported to her, she would have insisted on sending the patient to the hospital.

During a surveyor interview on 9/12/2024 at 3:07 PM with Nurse, Employee C, she stated she received in report that the patient was constipated and was told the patient had unwitnessed vomiting. She revealed that the patient refused his/her Miralax and noticed that the patient went to the bathroom multiple times. She indicated that after additional medications such as lactulose and a fleet enema, the patient did not move his/her bowels despite having the urge to go to the bathroom. She indicated that the patient continuously yelled at her that she/he felt full. Employee C revealed that she called Employee D for the third time and stated, " I think we need to send [him/her] out, there is nothing more we can give [her/him]", to which Employee D said, "we will send [him/her] out". Employee C indicated that she then called the SRN, Employee F, who asked for the patient's vital signs and said, "We cannot send the patient out if [she/he] is not in distress." Employee C was then asked by the surveyor how do you evaluate if someone is in distress? to which she responded, look at their skin color and see if they are having trouble breathing. Employee C stated she called Employee D back to let her know what the SRN said and that the transfer was cancelled based on the SRN's recommendation.

During an additional surveyor interview on 9/16/2024 at 2:35 PM with Employee C, she revealed that SRN, Employee F, did not assess the patient before making the decision to halt the transfer the patient to the hospital because he was "not in distress". When asked if she was requested by Employee H to call 911 for Patient ID #1 between approximately 9:00 PM to 10:00PM, she replied that she was notified by Employee H and she was told that the patient just vomited. She acknowledged that she saw vomit on the floor, which she described as 15-20 milliliters of an orange saliva type mixture and revealed that she did not mention this to the oncoming Nurse, Employee E, that the patient had an episode of vomiting. Employee C then stated that when her shift ended Patient ID # 1's abdomen was "slightly distended" and acknowledged that she knew that he/she was uncomfortable.