Failure to Assess and Monitor Resident After Complaint of Radiating Pain and Shortness of Breath
Penalty
Summary
A resident with a history of chronic obstructive pulmonary disease (COPD), mild dementia, intermittent atrial fibrillation, sick sinus syndrome, and left shoulder pain due to degenerative joint disease reported experiencing left shoulder pain radiating to the chest, increased heart rate, and shortness of breath. The resident's care plan included monitoring for pain and shortness of breath, with instructions to notify the physician if pain worsened or was not controlled by medication. On the evening in question, the resident complained of these symptoms, and a nurse administered as-needed medication but failed to document which medications were given, perform a thorough assessment, or monitor the effectiveness of the interventions. There was no documentation of a pain assessment, pain scale, or detailed evaluation of the resident's respiratory or cardiac status at that time. Following the initial complaint, the resident was not reassessed, and no further monitoring or documentation occurred throughout the night. The nurse did not report the incident or the administration of as-needed medication to the incoming nurse, and no additional checks were performed on the resident. The next morning, the resident was found unresponsive, with no pulse or respirations, and was pronounced deceased. Interviews with staff revealed that the nurse did not assess the resident's shoulder pain, breath sounds, or heart sounds, and did not notify the physician, as the resident had expressed a desire to wait and see if he felt better. Additionally, staff limited nighttime checks on the resident due to his preference for minimal disturbance, which contributed to the lack of follow-up. The facility's policy required immediate assessment and communication of any change in resident condition, including new or worsened pain, but this was not followed. The nurse failed to perform a comprehensive assessment or ongoing monitoring after the resident's complaint of radiating pain and shortness of breath, and there was a lack of communication between staff regarding the resident's change in condition and the interventions provided. The absence of reassessment and monitoring after the initial complaint and intervention directly contributed to the deficiency identified in the report.