F0684

J

Failure to Assess and Respond to Repeated Chest Pain Complaints After Acute Change in Condition

Lakewood, Ohio Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with significant cardiac history. The resident had diagnoses including acute on chronic congestive heart failure, atrial fibrillation, atherosclerotic coronary heart disease, hypertensive heart disease with heart failure, muscle weakness, and ischemic cardiomyopathy. The admission MDS showed the resident had intact memory, modified independence for decision-making, and required varying levels of assistance with ADLs. Physician orders included PRN Maalox for antacid use, but there were no PRN orders for chest pain.

On the night in question, the resident repeatedly used the call light beginning around 11:07 P.M. and continuing into the early morning hours. CNA staff reported that the resident complained multiple times of chest pain and chest tightness and appeared to be in distress. CNA #208 stated the resident first complained of not having had a bowel movement since the hospital, was assisted with a bedpan, and later had a large bowel movement. About 20 minutes after that, the resident complained of chest pain, which CNA #208 reported to RN #207. CNA #208 stated the nurse did not get up right away, and after another call light and another complaint of chest pain, she again informed RN #207, who responded that she had given Maalox and the resident needed to give it time to work. CNA #208 and other CNAs reported that the resident continued to ring the call light approximately every 20 minutes, repeatedly complaining of chest pain and, at one point, chest tightness. CNA #136 and CNA #153 also reported that the resident complained of chest tightening or chest tightness and looked like he was in distress, and they informed RN #207.

RN #207 stated that when informed of the complaint, she reviewed the physician’s orders, saw only PRN Maalox, and then went to see the resident. She reported that the resident described indigestion, that she administered PRN Maalox, and that she took his blood pressure, which was initially elevated and then normal after repositioning, but she did not document these vital signs or an assessment in the medical record. The eMAR showed Maalox was administered at 12:28 A.M., but there was no documentation of an assessment, vital signs, or chest pain at that time. The device activity report showed multiple call light activations between 11:07 P.M. and 12:48 A.M. RN #207 later documented at 4:21 A.M. that the Maalox was effective, but there was no corresponding assessment or vital signs documented. She stated that at some point she saw the resident sleeping and did not recall the time. Around the time of her medication pass, she noticed the resident did not look right, entered the room, and found him unresponsive, at which point 911 was called and CPR initiated.

The EMS run report documented that EMS was dispatched shortly after 5:14 A.M. and arrived to find the resident unresponsive, not breathing, pulseless, with rigor mortis in the jaw and mottling throughout the body. Nursing staff told EMS that the resident had complained of chest pain earlier in the night and that they had checked on him at 4:00 A.M. The resident was wearing a Full Code wristband, and EMS confirmed asystole in multiple leads before a physician pronounced death at 5:28 A.M. Review of the facility’s Acute Condition Changes-Clinical Protocol showed that nurses are to assess and document baseline information such as vital signs, pain level, and changes in condition, and that direct care staff are to be trained to recognize and report significant changes to the nurse. Despite this policy, there was no documented evidence that the resident’s repeated complaints of chest pain and tightness were adequately assessed, that vital signs and assessments were documented, or that the physician was notified of the change in condition, leading to the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals following an acute change in condition.

Removal Plan

• Remove RN #207 from work.
• Review the change in condition policy with the DON and Administrator before staff education.
• Review records of all residents for changes in condition to ensure they are properly reported and addressed.
• Run a report for all residents with cardiac diagnoses and review for any need for reassessment or recent change in condition.
• In-service all certified nursing assistants (CNA) on the need to immediately notify the nurse if there is a change in condition or emergency and on the facility protocol for obtaining assistance during an emergency situation, including what to do if a nurse is unavailable or not responding.
• Instruct CNAs to escalate up the chain to the charge nurse or DON if a nurse is unavailable or not responding.
• Do not permit any CNA to work until in-servicing is completed.
• In-service all licensed nurses on the facility policies and procedures related to change in condition, appropriate assessments and documentation, timely notification to physician of change in condition, and how to respond to emergency situations.
• Do not permit any licensed nurse to work until in-servicing is completed.
• Hold an ad hoc QAPI meeting with the Medical Director, Administrator, DON, and nursing staff to discuss the incident, follow-up measures and action plan, and to review relevant policies.
• Begin monitoring all shift reports and nurse's notes to ensure all changes in condition are timely reported to the physician and appropriately addressed.
• Conduct audits daily for two weeks and then three times a week for six weeks.
• Have the QA Committee monitor the results of the audits and follow up as needed.