Failure to Transfer Resident with Severe Abdominal Pain
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease, alcohol-induced pancreatitis, anxiety, and diaphragmatic hernia experienced severe, unresolved abdominal pain over a 12-hour period. The resident initially reported pain after dinner, which was treated unsuccessfully with a laxative, famotidine, and Zofran. Despite ongoing complaints of pain, vomiting, and diarrhea, the resident remained in the facility, and the physician was notified multiple times. Orders were given for an enema, abdominal X-ray, and pain medication, but the interventions did not alleviate the resident's symptoms. Throughout the night, the resident continued to express severe pain, including screaming out and requesting additional pain medication. The resident's family was involved, with the daughter arriving at the facility and discussing the possibility of hospital transfer or leaving against medical advice (AMA). Nursing staff and supervisors did not facilitate a transfer to a higher level of care, and at one point, EMS was called but reportedly sent away. Staff interviews indicated that the nurse supervisor did not agree that hospital transfer was necessary, and there was confusion regarding communication with emergency services. Ultimately, the resident called 911 independently and was transferred to the hospital, where they were diagnosed with ischemic bowel with bowel infarction. The facility's transfer and discharge policy did not address the resident's right to contact emergency medical services. The failure to transfer the resident in a timely manner, despite persistent and severe symptoms, resulted in a deficiency related to providing appropriate treatment and care according to orders, resident preferences, and goals.