Failure to Assess and Act on Repeated Chest Pain Complaints
Penalty
Summary
The facility failed to adequately assess and respond to repeated complaints of pleuritic and gastrointestinal distress, specifically heart pain, for a resident with moderate cognitive impairment and significant medical history including heart failure and use of anticoagulants. The resident had a standing as-needed order for Maalox to treat indigestion or heartburn, which was administered multiple times by staff. However, documentation in the medical record did not consistently include the symptoms prompting administration, nor did it provide evidence of assessment to distinguish between cardiac and gastrointestinal causes of the pain. Vital signs and symptom characteristics were not always recorded, and there was a lack of follow-up to determine the effectiveness of the intervention or to reassess the resident after medication was given. Staff interviews revealed that the resident had a history of voicing complaints such as "my heart hurts" and "my stomach hurts" over a long period, with staff typically providing Maalox in response. Some staff reported occasionally taking vital signs, but not consistently with each complaint. There was also uncertainty among staff regarding whether the resident's physician was aware of the ongoing symptoms, despite the repeated use of as-needed medication. The care plan included interventions for cardiac and respiratory conditions but did not address the resident's gastroesophageal reflux disease or provide specific interventions for this diagnosis. The medical record lacked evidence that the resident's symptoms were evaluated in real-time or retrospectively to determine their cause, nor was there documentation that the physician or medical team had been notified about the persistent symptoms and repeated use of as-needed medication. The director of nursing confirmed that the expected process for assessment, documentation, and physician notification was not followed, and acknowledged that the medical record did not reflect appropriate evaluation or communication regarding the resident's ongoing complaints.