Failure to Notify RN and Provider of Resident's Chest Pain
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of practice for one resident. The resident, who had a history of depression, anxiety, and hypertension, reported chest pain to a nurse aide, which was then communicated to an LPN. The LPN documented that the resident's vital signs were within normal limits and noted the resident's concern about possible atrial fibrillation (AFib), but did not notify the RN or the resident's provider about the complaint of chest pain. There was also no evidence of any diagnostic testing being performed to assess for AFib or other causes of the chest pain. Additionally, the LPN did not communicate the resident's complaint during the change of shift report. Subsequently, the resident called 911 after feeling that her concerns were not addressed, and was later transferred to the hospital where she was diagnosed with a pleural effusion and lower extremity edema. Interviews with facility leadership confirmed that neither the RN nor the provider was notified of the resident's chest pain, and the information was not passed on during shift change. The facility's policies and job descriptions require that significant changes in a resident's condition, such as chest pain, be reported to the RN and provider, which did not occur in this instance.