Failure to Document Cardiac Assessment and Resident Requests for ED Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate medical record documentation for a resident with extensive cardiac history who experienced acute chest pain. The resident’s diagnoses included acute diastolic congestive heart failure, prior TIA, cerebral infarction, atrial fibrillation, prior CABG, hypertension, ischemic cardiomyopathy, atherosclerotic heart disease, and prior STEMI. On the evening in question, the resident reported sudden left-sided chest pain radiating down the left arm, accompanied by shortness of breath and nausea, and believed he was having a heart attack. He activated his call light, informed staff of his symptoms, and requested to be sent to the ED. According to the resident and his family member, the resident repeatedly requested hospital evaluation and contacted his son multiple times, stating that staff were refusing to send him to the ED. A nursing assistant reported that the resident told her he might be having a heart attack and had severe left arm pain; she immediately notified the RN. The nursing assistant observed that the resident appeared very worried and repeatedly used the call light asking when the ambulance was coming, and estimated that the incident began around 5:00 p.m., with transport occurring after supper around 6:00 p.m. Progress notes later documented transfer to the hospital for chest pain rated 10/10, with vital signs recorded shortly after 6:00 p.m., and EMS activation and transport documented between approximately 6:03 p.m. and 6:34 p.m. The RN assigned to the resident stated he was informed by a nursing assistant that the resident wanted to see him and that the resident reported chest pain and appeared agitated. The RN stated he was unaware of the resident’s cardiac history and reported that he attempted to perform a cardiac assessment, but he could not describe what the assessment included and acknowledged that he did not document the cardiac assessment or the resident’s requests to go to the ED in the medical record. Review of the medical record confirmed there was no documentation of a comprehensive cardiac assessment or of the resident’s repeated requests for hospital evaluation at the onset of symptoms. The nurse manager and DON confirmed that the RN failed to document the cardiac assessment and the resident’s requests for emergent care, and that this information should have been documented. Requested facility policy on resident-identifiable records and documentation expectations was not provided.
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