Failure to Provide Timely Assessment and Intervention for Chest Pain by Unlicensed Nurse
Penalty
Summary
The facility failed to provide timely and appropriate nursing assessment, monitoring, and interventions for a resident who experienced ongoing chest and abdominal pain for approximately nine hours. The resident, who had a history of hypertension, gastric outlet obstruction, stroke, recent ventral hernia repair, and a recent non-ST elevated myocardial infarction (NSTEMI), was under the care of a staff member who was unlicensed and using another individual's RN license. Despite physician orders for nitroglycerin to be administered for chest pain and instructions to call 911 if pain persisted, the medication was not given, and emergency services were not initiated in a timely manner. Record reviews revealed that the unlicensed nurse did not document comprehensive pain assessments or nursing interventions beyond the administration of PRN pain medications, and there was no evidence that nitroglycerin was administered at any point during the resident's episode of chest pain. The resident's pain was not relieved by pain medication, and symptoms included increased respiration, moaning, groaning, facial grimacing, and physical signs of distress. Documentation also showed discrepancies in the administration and issuance of controlled substances, and there was no record of timely physician notification or appropriate escalation of care. Interviews with facility staff, including the DON, ADON, and nurse supervisor, confirmed a lack of awareness regarding the unlicensed status of the nurse and failures in following physician orders and facility policies for pain assessment, medication administration, and response to significant changes in condition. The resident was eventually transferred to the hospital, where nitroglycerin was administered by EMS, but the resident expired shortly after arrival due to an acute ST elevation myocardial infarction and cardiac arrest.