F0684

D

Failure to Perform Timely Cardiac Assessment and Honor Resident’s Requests for ED Transfer

Faribault, Minnesota Survey Completed on 03-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely, comprehensive cardiac assessment and response for a resident with extensive cardiac history who reported acute chest pain and requested emergency evaluation. The resident had multiple serious cardiac diagnoses, including acute diastolic CHF, prior TIAs and stroke, atrial fibrillation on warfarin, prior CABG, multiple stents, prior MIs, ischemic cardiomyopathy, and atherosclerotic heart disease. Despite this history, the resident’s care plan did not include a cardiac-focused problem or individualized interventions to guide staff in monitoring and responding to changes in cardiac status. On the day of the incident, the resident reported sudden, severe left-sided chest pain radiating down the left arm, shortness of breath, nausea, and anxiety, and stated that the pain felt like a heart attack.

The resident activated the call light and initially spoke with a female staff member, telling her he was having chest pain that felt like a heart attack and wanted to go to the ED. A male nurse then came to the room; the resident reported telling him he was having chest pain radiating down his left arm, believed he was having a heart attack, and wanted to be sent to the ED. According to the resident, the nurse refused to call an ambulance, stating that the resident’s vital signs were fine and he did not need to go, and only checked blood pressure, pulse oximetry, and temperature without auscultating heart or lungs or performing a more detailed cardiac assessment. The resident stated he repeatedly requested transfer, attempted unsuccessfully to call 911 himself, and felt frantic and unsafe due to the delay. A nursing assistant later reported that the resident told her he might be having a heart attack, described severe left arm pain and prior heart attacks, and that she immediately notified the RN. She observed that it took a significant amount of time before the resident was transported, that this did not occur until after supper, and that during this period the resident was visibly distressed, repeatedly pressing the call light and asking when the ambulance was coming.

The resident’s family member reported receiving four frantic calls from the resident over a period of time, during which the resident stated he was having chest pain radiating down his left arm, believed he was having a heart attack, and that staff would not send him to the ED despite his requests. The family member contacted the administrator by text and phone, reporting that staff were refusing to send the resident despite his extensive cardiac history. The administrator confirmed receiving these messages and that the family member relayed the resident’s complaints of chest and arm pain and his belief he was having a cardiac episode. The nurse assigned to the resident stated he was unaware of the resident’s extensive cardiac history, was not aware of a specific facility policy for assessing cardiac symptoms, and could not clearly describe or document a comprehensive cardiac assessment or the resident’s request to go to the ED. The nurse manager later assessed the resident after being alerted that staff were reportedly refusing to send him, found the resident upset with left-sided chest pain and a history of multiple cardiac events, and obtained vital signs that were within normal limits. He stated that vital signs can be normal during a heart attack and that the resident wanted to go to the hospital immediately.

Facility documentation showed that the resident was ultimately transferred to the hospital for chest pain rated 10/10, with EMS called after 6:00 p.m. EMS records indicated they received an emergent call for chest pain, found the resident reporting crushing chest pain radiating down the left arm for approximately 30 minutes, and provided aspirin, nitroglycerin, and oxygen before transport. Facility progress notes documented vital signs and pain assessment but did not include a comprehensive cardiac assessment or detailed clinical evaluation of the reported chest pain. The ED record documented that the resident reported chest pain beginning around 5:00 p.m., similar to prior heart attacks, and that he stated it took staff a while to call EMS. The ED identified NSTEMI, severe anemia with hemoglobin 5.7, GI hemorrhage, hypoxia, and other conditions. The DON confirmed that no comprehensive cardiac assessment was documented, that staff had not received written education or competency testing on cardiac assessment and monitoring, and that the facility lacked a comprehensive cardiac assessment and monitoring policy, which was requested but not provided.