Failure to Assess Resident Following Chest Pain Complaint
Penalty
Summary
A deficiency occurred when a resident, admitted with chronic kidney disease (CKD) and diabetes mellitus (DM), reported experiencing chest pain on the left side that had persisted for several weeks. The resident's cognition was noted to be intact. Following the complaint, the physician ordered a 12-lead EKG to assess the resident's chest discomfort. However, there was no documentation or evidence that the resident was assessed for chest pain or discomfort by the registered nurse (RN) who received and carried out the EKG order. The RN acknowledged that an assessment should have been performed, especially since the EKG was ordered due to chest discomfort, which could be related to serious conditions such as a heart attack. Further review revealed that facility policy required nurses to make detailed observations and gather pertinent information prior to notifying the physician or healthcare provider about a change in a resident's condition. The RN supervisor's job description also included the responsibility to identify changes in residents' physical or psychological conditions. Despite these requirements, there was no documentation of an assessment or monitoring of the resident's status following the complaint of chest pain, resulting in a lack of knowledge regarding the resident's medical status at the time.