Failure to Provide Timely and Appropriate Care for Chest Pain in Resident with Cardiac History
Penalty
Summary
A resident with a history of NSTEMI, Parkinson's disease, and atherosclerotic heart disease experienced multiple episodes of chest pain while under the care of the facility. The resident had physician orders for sublingual nitroglycerin to be administered every five minutes for up to three doses for chest pain, with instructions to notify the physician if pain persisted. On several occasions, nursing staff administered only one dose of nitroglycerin, documented the effect as 'Not Effective' or 'Somewhat Effective,' and failed to administer subsequent doses as ordered. Additionally, staff did not consistently reassess the resident's pain after administration, nor did they notify the physician or document the change in condition as required by facility policy. The facility also failed to monitor and document the resident's complaints of chest pain every shift for 72 hours following episodes of unrelieved pain, as outlined in their policy for changes in condition. There were delays in carrying out physician orders for diagnostic testing, including a stat EKG, which was performed several hours after being ordered. Furthermore, there was a significant delay in transferring the resident to an acute care hospital despite ongoing severe chest pain and abnormal vital signs, with emergency services not being called until hours after the resident's condition had deteriorated. Interviews with nursing staff revealed a lack of understanding and adherence to the physician's orders and facility protocols regarding the management of chest pain and notification of changes in condition. Staff admitted to not administering additional doses of nitroglycerin, not reassessing the resident, and not promptly notifying the physician or documenting the events. The resident ultimately suffered an acute myocardial infarction, was transferred to the hospital, and died after further cardiac events. The survey identified these failures as constituting Immediate Jeopardy due to the facility's noncompliance with professional standards of practice, care planning, and physician orders for the management of chest pain.
Removal Plan
- LVN 1 and LVN 2 were provided a one-to-one re-education and training by the DON focusing on the proper evaluation of resident's change in condition (COC) particularly about residents experiencing chest pain, accurate administration of medications, timely notification of physicians, laboratory and diagnostic testing procedures (verifying that the vendor will perform the testing without delay) and appropriate documentation practices.
- The DON and the Registered Nurse Supervisor evaluated all other 9 residents who were receiving Nitroglycerin for any change in condition (COC).
- The facility would designate RN or Nursing Supervisor to evaluate residents experiencing a COC, particularly chest pain, to ensure timely and appropriate interventions.
- The DON initiated daily morning meetings for COC audits, focusing on residents with chest pain, diagnosis of NSTEMI or with prescribed nitroglycerin.
- The DON will initiate in-services for all licensed nurses (LN) for proper evaluation of residents' change in condition, with an emphasis on residents experiencing chest pain, diagnosed with NSTEMI, and prescribed nitroglycerin. The Inservice will be repeated quarterly, and incorporated into the orientation program for newly-hired LN.