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On the days of the Complaint Survey through record review, hospital log review, review of hospital policy and procedure review, and interview, the governing body, in accordance with hospital policy, failed to ensure staff assessed the patient with chest pain, initiated its own protocol for treating chest pain, and failed to ensure its staff was knowledgeable in the administration of Nitroglycerin and followed safe standards of practice in the administration of Nitroglycerin to 1 of 1 patients with a documented history of Angina.


The findings are:


Cross Reference to A 0144: The hospital failed to ensure the Medical Oncology patient's right to receive care in a safe setting in accordance with its own policies and procedures and acceptable standards of practice for safe administration of medications(Nitroglycerin) and failed to ensure its staff provided the assessment and intervention based on its own protocols for chest pain.

Cross Reference to A 0385: The hospital failed to ensure that its nursing service was proactive in that the staff of the hospital's Medical Oncology unit failed to assess 1 of 1 patients for the complaint of chest pain, failed to initiate the hospital's guidelines for treating chest pain, and staff administered 25 tablets of nitroglycerin to the patient.

Cross Reference to A 0405: The hospital failed to provide safe practices for the administration of medication per its own policies and procedures and accepted standards for 1 of 1 patients on the Medical Oncology Unit. (Patient #1)

On the days of the Complaint Survey through record review, hospital log review, review of hospital policy and procedure review, and interview, the governing body, in accordance with hospital policy and accepted standards of practice, failed to ensure that specific patient care requirements of the Medical Oncology Unit were met for assessment of patients with chest pain and safe medication administration practices.


The findings are:


Cross Reference to A 0144: The hospital failed to ensure the Medical Oncology patient's right to receive care in a safe setting.

Cross Reference to A 0385: The hospital failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the medical oncology unit.

Cross Reference to A 0405: The hospital failed to provide safe administration of medication for 1 of 11 patient concurrent patient record reviews. (Patient #1)

On the days of the Complaint Survey based on record review, interview, and hospital policy and procedure, the hospital failed to promote and protect the patient right to to receive timely responses to verbal or written concerns expressed throughout the patient's hospital stay, failed to follow the hospitals policies and procedures to protect the patient's rights and dignity when restraints are required in that staff applied wrist restraints in addition to a Posey vest without physician orders, failed to ensure a staff knowledgeable and follows the hospital's policy for assessing patients with complaints of chest pain, and knowledgeable in the administration of medications to treat chest pain for 1 of 1 patients. (Patient #1)


The findings are:


On 5/24/13 at 1200, review of Patient #1's chart revealed a 78 year old patient admitted on May 7, 2013 with a chief complaint of pneumonia. Review of the physician progress notes dated 5/10/13 through 5/21/13 revealed the patient's family had expressed multiple concerns with the patient's care during the patient's hospitalization. On 5/24/13 at 1445, review of the hospital's grievance and complaint log dated from 11/12/2012 through 5/21/2013 showed no entries for any verbal concerns and/or grievances recorded in the hospital's grievance and complaint log for Patient #1 although documentation in the physician progress notes shows multiple concerns had been expressed by the patient's family.


On 5/23/2013 at 1415, review of Patient #1's medical record revealed a physician restraint order for a Posey vest restraint only. The physician order was written on 5/16/2013 at 0155 due to patient climbing out of bed. Review of the Restraint Flow Sheet on the patient's chart revealed staff restrained the patient using Posey vest and soft wrist restraints on 5/16/2013 beginning at 0200-0600. Staff had no physician order for wrist restraints.

On 5/23/13 at 1500, based on review of the nurse documentation in the patient's chart and based on interviews conducted on 5/24/13 from 0950 to 1300, the patient complained of chest pain at approximately 1800 on 5/21/2013 but there was no documentation of a nursing assessment for the chest pain on the 0700 to 1900 day shift nor on the 1900 to 0700 night shift on 5/21/2013. The only documented intervention in the nurse notes is a late entry documented on 5/22/13 at 1751 for 5/21/2013 at 2030 as regards the nurse giving 25 Nitroglycerin tablets to the patient on 5/21/2013 at 2030 that resulted in a rapid response and transfer to the heart center for monitoring.

On the days of the Complaint Investigation based on review of the hospital's patient admission packet, review of the hospital's Patient Relations Grievance and Complaint logs, and hospital policy and procedure review, the hospital failed to demonstrate an active timely responsive process for addressing 1 of 1 patient/family continuous concerns with care and services received during 1 of 1 patient's hospitalization. (Patient #1)


The findings are:


On 5/24/13 at 1200, review of Patient #1's chart revealed a 78 year old patient admitted on May 7, 2013 with a chief complaint of pneumonia. Review of the physician progress notes dated 5/10/13 through 5/21/13 revealed the patient's family had expressed multiple concerns with the patient's care during the patient's hospitalization. On 5/24/13 at 1445, review of the hospital's grievance and complaint log dated from 11/12/2012 through 5/21/2013 showed no entries for any verbal concerns and/or grievances recorded in the hospital's grievance and complaint log for Patient #1 although documentation in the physician progress notes shows multiple concerns had been expressed by the patient's family.

Review of a physician's progress notes dated 5/10/13, read, "the son is present at bedside. He is a little bit concerned about the way things have been communicated up to this point in time...He also had some other issues with overall communication and wanted to make sure that we knew what was going on with his/her overall issues. He had some issues with nursing care at this point in time, which I have referred to the nurse manager....". Review of a physician progress note dated 5/12/13 at 1443, showed, "called and updated son this afternoon....". Review of a physician progress notes dated 5/16/13 at 1707, addendum reads, "son at bedside. Many concerns voiced regarding delirium, pneumonia, hypoxia, RESTRAINTS ARE LAST RESORT....I spent greater than 75 mins(minutes) on this patient with direct care and family discussion today.". Review of physician progress note dated 5/19/13 at 1422, reads, "I spent a long time d/w (dealing with) the son today. He had multiple concerns that were all addressed....>35 mins spent.". Review of a physician progress note dated 5/21/13 at 2137, reads, "Called to bedside due to pt (patient) given accidental overdose of nitro (nitroglycerin) tabs. Nursing staff was able to retrieve all except one tab. HD (hemodynamically) stable at this time. BP (blood pressure)-135/80. Will transfer to Cards (cardiology) tele (telemetry) for closer monitoring.".

Review of a nurse note dated 5/16/13 at 1430, reads, " PT (Patient son...., extremely upset that Pt was restrained with Posey and Wrist restraints and he was not informed. The Nurse Manager and AOD (Administrator on Duty) also informed that the PT. (patient) wanted to talk with her. The AOD said that the sons could stay anytime during the day or night."

On 5/24/13 at 1450, review of the hospital admission packet materials showed, "Your concerns are very important to us and we would appreciate the opportunity to resolve them. If you have a concern/grievance, please speak with the staff or request to speak with the unit/department supervisor/manager. If you would rather express the concern/grievance to a patient liaison, call Guest services at 803-434-6237. Staff is available to assist you anytime during your stay and will seek prompt resolution to your concern/grievance....".

Facility Policy, reads, "Patient Concern/Grievance Management, revised date: September 2006, 1.1 A patient brochure is distributed to each inpatient. Within this brochure are instructions for filing a complaint to the customer service line or organization. Patients are also informed through the Patient's Bill of Rights/patient brochure as to their right to contact a state agency and/or Joint Commission to file a grievance....".

On the days of the Complaint Survey through record review, hospital policy review, hospital log review, and interview, the hospital failed to ensure the Medical Oncology patient's right to receive care in a safe setting in accordance with its own policies and procedures and acceptable standards of practice for safe administration of medications(Nitroglycerin) and failed to ensure its staff provided the assessment and intervention based on its own protocols for chest pain.


The findings are:

On 5/23/13 at 1500, a review of Patient #1's chart revealed late entry documentation that the patient had been administered 25 pills of Nitroglycerin for complaint of chest pain on 5/21/2013 at 2030. Patient #1 had been transferred from an intensive care step down unit on 5/21/2013 at 1640. Based on interviews, Patient #1 began complaining of chest pain at approximately 1800. Review of the patient's chart showed no documentation for the 1900 to 0700 shift on 5/21/2013 that the patient was assessed for chest pain, that the hospital's guidelines for chest pain were instituted, and only a late entry revealed that the patient had received 25 pills of Nitroglycerin under the tongue. After the incident the patient, a rapid response was initiated, and the physician transferred the patient to the cardiac unit for closer monitoring.

On 5/23/13 at 1500, review of Patient #1's chart revealed the patient was admitted through the hospital's emergency department on 5/7/13 for Pneumonia. Review of the patient's history and physical dated 5/10/13 showed the patient history includes but is not limited to: Angina, Diabetes, Coronary Artery Disease with multiple angioplasties, Hypoxemia, Dysphagia, Anemia, Vertigo, and Dementia.

Review of a nurse note recorded on 5/22/13 at 1751 as a late entry for May 21, 2013 at 2030 showed the patient's primary nurse for the 5/21/2013 night shift poured a bottle of nitro tablets into the patient's mouth for complaint of chest pain at 2030. The late entry nurse note dated 5/22/13 at 1751, reads, "Patient's son notified staff that he wanted to speak with the nurse. The charge nurse in the medicine room said he was calling about the patient's chest pain. I knew the chest pain had occurred before change of shift. I grabbed the patien'ts[sic] nitroglycerin bottle from the pyxis. Was met in the patient's room with immediate yelling and a complaint that it took me four minutes to get there. I told the son that I had her nitroglycerin with me. ....I opened the bottle of nitro and poured the contents under the patient's tongue and noticed multiple tablets. I swept the nitro out of the patient's mouth and then the son pushed me out of the way and began sweeping out the excess and Yankauer suctioned it, while I went to the computer to read the order. The patient's son had removed the nitro and at this time had the bottle in his hand. I confirmed the order and double checked the patient, noting that only one sublingual pill was in the patient's mouth. A rapid response was called, as the charge nurse was contemplating calling one before before any incident occurred."

Review of the hospital form, Rapid Response Team Record, dated 5/21/2013 at 2029, showed the the situation for the response was chest pain. In the assessment section, staff documented, "Pt. (patient) took entire bottle of Nitroglycerin. It was immediately pulled out of her mouth by son. suctioned pill frags (fragments) out of her mouth. Pt labs drawn EKG completed Pt CP (Chest Pain ) resolved." Vital signs were obtained and documented at
2035: Blood Pressure (BP) -103/58, Heart Rate(HR) 117, Respiratory Rate 28 or 38(unable to distinguish), SPO2 (Saturation Oxygen) 97, FIO2 3 Liters. 2040: BP 124/61, HR 105, RR 20 or 30(Unable to distinguish), SPO2 97, FIO2 3 liters. 2050: BP 141/66, HR 92, RR 20, SPO2 99, FIO2 3 liters. 2100: BP 135/72, HR 92, RR 20, SPO2 99, FIO2 3 Liters. Outcome recorded as Resolution of Symptoms.
Review of a physician progress note dated 5/21/2013 at 2139 showed the patient was transferred to a cardiac unit. The physician progress note reads, "called to bedside due to pt. being given accidental overdose of nitro tabs, nursing staff was able to retrieve all except tab. HD (Hemodynamically stable at this time. BP - 135/80, will transfer to Cards (Cardiac) telemetry for closer monitoring."

On 5/23/2013 at 1415, review of Patient #1's medical record revealed a physician restraint order for a Posey vest restraint dated 5/16/2013 at 0155 due to patient climbing out of bed. Review of the patient's Restraint Flow Sheet revealed staff restrained th patient with a Posey vest and soft wrist restraints on 5/16/2013 from 0200-0600 with no physician order for wrist restraints. On 5/16/2013 at 0751, a Physician Progress Note was written that stated "...sons at bedside. Many concerns voiced regarding delirium, hypoxia. RESTRAINTS ARE LAST RESORT..." Review of a nurses note dated 5/16/2013 at 1430, revealed, "...PT(Patient) SON DAVID EXTREMELY UPSET THAT PT WAS RESTRAINED WITH POSEY AND WRIST RESTRAINTS AND HE WAS NOT INFORMED."

On the days of the Complaint Survey based on record review and review of the hospital's policies and procedures, the hospital failed to ensure the use of restraints in accordance with the physician's order for 1 of 1 patient charts reviewed for a patient with a physician order for a Posey restraint that staff also restrained with wrist restraints. (Patient #1).


The findings are:


On 5/23/2013 at 1415, review of Patient #1's medical record revealed a physician restraint order for a Posey vest restraint only. The physician order was written on 5/16/2013 at 0155 due to patient climbing out of bed. Review of the Restraint Flow Sheet on the patient's chart revealed staff restrained the patient using Posey vest and soft wrist restraints on 5/16/2013 beginning at 0200-0600. Staff had no physician order for wrist restraints. On 5/16/2013 at 0751, a Physician Progress Note was written that stated "...sons at bedside. Many concerns voiced regarding delirium, hypoxia. RESTRAINTS ARE LAST RESORT..." Review of a nurses note dated 5/16/2013 at 1430, revealed, "...PT(Patient) SON DAVID EXTREMELY UPSET THAT PT WAS RESTRAINED WITH POSEY AND WRIST RESTRAINTS AND HE WAS NOT INFORMED."

Hospital Policy, Non-Violent Restraint effective 12/28/2010, states, "...INITIATION OF RESTRAINT, 1.1 A description of the patient's behavior, symptoms, and any alternatives/interventions to prevent the use of restraint shall be documented in the medical record. 1.2 The patient's family or primary contact will be notified by the nurse as soon as possible and the notification will be documented in the medical record. 1.3.1 states: "...When all attempts have failed, and following a comprehensive patient assessment, a RN may initiate restraint as follows: The admitting Physician shall be notified within 2 hours after the application of restraint and a written/electronic or verbal/telephone order obtained. Failure to obtain an order within 2 hours is viewed as an application of restraint without an order....".

On the days of the Complaint Survey based on record review and review of the hospital's policies and procedures, the hospital failed to ensure the documentation of use of least restrictive measures prior to the application of restraints for 1 of 1 open patient charts reviewed in that hospital staff failed to document that an assessment was completed for least restrictive measures prior to placing the patient in a Posey and wrist restraints. (Patient #1).

The findings are:


On 5/23/2013 at 1415, review of Patient # 1's medical record revealed that on 5/16/2013 at 0200, staff failed to document the use of alternative or least restrictive interventions and/or a comprehensive assessment prior to applying a Posey vest and wrist restraints to the patient. Review of hospital's Restraint Flow Sheet revealed the patient was restrained using Posey vest and soft wrist restraints on 5/16/2013 beginning at 0200 through 0600 without documentation of least restrictive measures used.

On the days of the Complaint Survey based on record review, hospital policy and procedure review, and interview, the hospital failed to ensure that patients received care and services in accordance with the hospital's policies and procedures and accepted Standards of Practice in the Medical Oncology unit for the assessment of chest pain, failed to initiate the hospital guidelines for chest pain, and for the safe administration of Nitroglycerin for the complaint of chest pain for 1 of 1 patient. (Patient #1)


The findings are:


Cross Reference A 0386: The hospital failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the medical oncology unit to ensure the staff are accountable for the assessment, documentation of assessment for chest pain, implements the hospital's guidelines for chest pain, and safely administers medications (Nitroglycerin) for 1 of 1 patients. (Patient #1)

Cross Reference A 0392: The hospital failed to ensure the nursing staff was assessing and documenting on patient's on an ongoing basis in accordance with accepted standards of practice and hospital policy.

Cross Reference to A 0395: The hospital failed to ensure the nursing staff was assessing and administering medications for patient's on an ongoing basis in accordance with accepted standards of practice and hospital policy for 1 of 1 patient. (Patient #1)

Cross Reference to A 0405: The hospital failed to provide safe administration of Nitroglycerin in that evidence showed that the nurse failed to follow physician orders and administered 25 tablets of nitroglycerin under the patient's tongue for 1 of 1 patient. (Patient #1)

On the days of the Complaint Investigation based on interview, record review and submitted data, the hospital failed to ensure a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care in the medical oncology unit to ensure the staff are accountable for the assessment, documentation of assessment for chest pain, implements the hospital's guidelines for chest pain, and safely administers medications (Nitroglycerin) for 1 of 1 patients. (Patient #1)


The findings are:


Observation and interview on 5/24/2013 at 1050, Registered Nurse #2, charge nurse on 0700-1900 on Medical Oncology Unit on 5/21/2013, revealed, "...Scan medication in the sealed packet, that we get meds(medication) from the pharmacy in. I have never given Nitroglycerin, so I am not familiar with how to give it...".

On 5/24/13 from 0950 to 1050, the Nurse Manager of the Medical Oncology unit was interviewed. The Nurse Manager reported she was informed on May 22, 2013 that a nurse had administered 25 Nitroglycerin pills to a patient. The Nurse Manager stated, " I spoke with the nurse, re-educating her about the medication administration policy and what transpires when this happens, but I did not document this." The only investigation documentation presented by the hospital was a timeline of notification of the incident occurrence.

On 5/23/12 at 1400, review of Patient #1's chart revealed a nurse had administered 25 nitroglycerin tablets sublingually to a patient with a nasogastric tube complaining of chest pain on 5/21/13 at 2030. Review of documentation provided by the hospital on 5/24/13 at 1900 revealed nursing administration had not assessed the staff on the Medical Oncology unit post incident and/or provided any documentation of education or re-education of staff for the assessment of a patient with chest pain and following the hospital's guidelines for the management of chest pain, and education for the safe administration of Nitroglycerin that would decrease the probability and/or potential of further incidents of this type occurring.

On the days of the Complaint Survey based on record review, interview, review of staffing plans and unit schedules, medication administration records and other data, the hospital failed to ensure its nursing staff provided nursing care to patients experiencing chest pain through assessment, its own guidelines for treating chest pain, and for failing to ensure safe practices for the administration of medications in that 25 pills of Nitroglycerin was administered to 1 of 1 patients on the Medical Oncology unit. (Patient #1)


The findings include:


On 5/23/13 at 1500, review of Patient #1's chart revealed the patient was admitted through the hospital's emergency department on 5/7/13 for Pneumonia. Review of the patient's chart on 5/23/13 at 1500 revealed Patient #1 was transferred from the Step Down Surgical Unit to the 11 East- Medical Oncology Unit on 5/21/13 at 1650.

On 5/23/13 at 1500, based on review of the nurse documentation in the patient's chart and based on interviews conducted on 5/24/13 from 0950 to 1300, the patient complained of chest pain at approximately 1800 on 5/21/2013 but there was no documentation of a nursing assessment for the chest pain on the 0700 to 1900 day shift nor on the 1900 to 0700 night shift on 5/21/2013. The only documented intervention in the nurse notes is a late entry documented on 5/22/13 at 1751 for 5/21/2013 at 2030 as regards the nurse giving 25 Nitroglycerin tablets to the patient on 5/21/2013 at 2030 that resulted in a rapid response and transfer to the heart center for monitoring.

Review of a nurse note recorded on 5/22/13 at 1751 as a late entry for May 21, 2013 at 2030 showed the patient's primary nurse for the 5/21/2013 night shift poured a bottle of nitroglycerin tablets into the patient's mouth for complaint of chest pain at 2030. The late entry nurse note dated 5/22/13 at 1751, reads, "Patient's son notified staff that he wanted to speak with the nurse. The charge nurse in the medicine room said he was calling about the patient's chest pain. I knew the chest pain had occurred before change of shift. I grabbed the patien'ts[sic] nitroglycerin bottle from the pyxis. Was met in the patient's room with immediate yelling and a complaint that it took me four minutes to get there. I told the son that I had her nitroglycerin with me. ....I opened the bottle of nitro and poured the contents under the patient's tongue and noticed multiple tablets. I swept the nitro out of the patient's mouth and then the son pushed me out of the way and began sweeping out the excess and Yankauer suctioned it, while I went to the computer to read the order. The patient's son had removed the nitro and at this time had the bottle in his hand. I confirmed the order and double checked the patient, noting that only one sublingual pill was in the patient's mouth. A rapid response was called, as the charge nurse was contemplating calling one before before any incident occurred."

On 5/24/13 between 1115 and 1140, during an interview, Registered Nurse #8 who was the patient's primary nurse on the day shift on 5/21/2013 verified the patient had complained of chest pain before shift change at 1800.

On 5/23/13 at 1500, review of the patient's nursing notes for 5/21/2013 showed no documentation of an assessment of the patient's chest pain from the patient's admission to the Medical Oncology unit at 1650 until the patient's transfer to the heart center at 2330 which was recorded by the nurse receiving the patient at the heart center,or that the stat 12 lead EKG order was placed for the patient's complaint of chest pain per the hospital's own guidelines for chest pain.

On 5/24/13 at 1115, RN #8 stated, "When the night shift RN came in, I told her about the son and then reviewed the patient's complaint of chest pain. I told her the nitroglycerin was ordered but it wasn't available and for her to be on the lookout for it to arrive."

On 5/24/13 between 1148 and 1300, during an interview with RN #7, he/she revealed: "After the patient had complained of chest pain, I went into the room with the Nitro. I was greeted with abrasive yelling by the son because it took me four (4) minutes. I think I said, I'm sorry. I either showed him or he asked if I had the nitro. He stated, "you're not going to take twenty minutes to put this medicine in." We skipped putting in the pain score. I scanned the ID on her wrist and the medication. The son tried to grab the Nitro out of my hand, but he didn't get it. I walked to the computer and it popped up. I scanned the medicine. I didn't sign it off. I walked over, and not being familiar with how Nitroglycerin is packaged, I thought there was one tablet in the bottle- like one (1) dose. I instructed the patient to lift up her tongue, and I poured the contents under her tongue. There were 25 tablets poured. I realized there was something odd about this. I was concerned that maybe it wasn't the right dose. I tried to do a finger sweep, and the son pushed me out of the way, and said "did you overdose her?" He grabbed the Yankauer suction and started removing it. He obtained the bottle by snatching it out of my hand. I don't know if there were any tabs left. I don't know where the bottle went- he may have taken it to the next floor. I was trying to figure out what the deal with the medication was. I knew it was 0.4 mg(milligrams) but didn't know the dose. I went back to the patient less than a minute later to make sure there weren't any more tablets in her mouth. I only saw one tablet. I only documented one tablet on the Medication Administration Record (MAR) because that's all I saw. Another nurse entered the room with the EKG machine, but I thought since her Angina was frequent enough because she has chronic Angina that she would not need an EKG. The process for administering oral medication is to scan the ID band, scan the medicine, put oral medications into a cup, confirm the patient's name and date of birth. That's all. I asked the charge nurse how to give it before I went into the room, and she said to just pour it under the patient's tongue. I did as instructed. I did no documentation on this patient. I may could have done her neuro assessment, but I didn't. The chart is still available to me if I need to document. The Administrator on Duty (AOD) told me that I only had to document an occurrence report and nothing else. When I spoke to my manager the next morning, she instructed me to come back in that day to put a note in the computer."

On 5/24/13 from 0950 to 1050, the Nurse Manager of the Medical Oncology unit was interviewed. The Nurse Manager reported she was informed on May 22, 2013 that a nurse had administered 25 Nitroglycerin pills to a patient. The Nurse Manager revealed, "The primary nurse involved called about 0715 after her shift ended and informed me of the previous night event: The patient in room 1149 called out for chest pain. Report from the day shift nurse was that Nitroglycerin had been ordered and had not been available before the day shift nurse left. The night charge nurse suggested calling the Rapid Response Team, however, the primary nurse wanted to give the Nitroglycerin first to see if pain was relieved. The charge nurse agreed. The primary nurse stated that the patent's son was yelling as she entered the room and couldn't believe it took four minutes for her to get there. The nurse stated she was trying to scan the Nitroglycerin bottle and the son was trying to take it out of her hand. Prior to the nurse coming into the patent's room, it was reported that Sarah asked the charge nurse how to administer Nitroglycerin and the response back was to put the medication under the patent's tongue. The primary nurse stated she opened the bottle and poured the entire contents of the bottle into the patent's mouth; the son yelled, scooped the pills out,, grabbed the Yankauer suction from the wall and suctioned the remainder of the pills from the patient's mouth. The son hit the nurse call light and told the Unit Secretary that a rapid response needed to be called. The RR Team arrived. The AOD and Physician were notified. The physician came and assessed the patient. He ordered for the patient to be transferred to the heart floor to be monitored over night. " The Nurse Manager stated, " I spoke with the nurse, re-educating her about the medication administration policy and what transpires when this happens, but I did not document this."

Facility Policy, Guidelines for Treating Chest Pain, Symptomatic and Pulseless Arrhythmias, reads, ".... 1. Chest Pain- 1.1 Oxygen at 2 L/ min via nasal cannula will be placed on all patients with chest pain. 1.2 An order for stat 12 lead EKG ill be placed on all patients with chest pain. 1.3 Units that have 12 lead EKG machines will perform stat 12 Lead EKG's(Electrocardiogram)....".

Hospital Policy, Systems Review Documentation, reads, ".... Rules: 1. A systems review of major body system(s) will be documented every 12 hours, with any change in patient condition, or as unit standard dictates....".

Hospital Policy, reads, "Medication Administration, effective: 9/13/2012, 1.4. Nursing Responsibilities- the nurse: 1.4.4. Knows the following before administering a medication: usual dosage range; route (s) of administration; desired effects; risks; side effects and adverse drug reactions....2.1.1 The nurse safely administers prescribed medications (5 Rights- patient, medication, dose, route, time) and by checking the following with each drug....2.1.2 Medications are not to be pre-poured to administer.... 2.1.4 The nurse monitors the patient's response to all medications and notifies the patient and/or family about clinically significant adverse reactions for new medications....".

On the days of the Complaint Survey based on interview, record review, review of the hospital policy and procedures, and other submitted data, the hospital failed to ensure supervision and direction of its nursing staff for assessing patients with chest pain, implementing its own guidelines for chest pain, and oversight in the administering of Nitroglycerin for patients with a complaint of chest pain on an ongoing basis in accordance with accepted standards of practice and hospital policy for 1 of 1 patient. (Patient #1)


The findings are:


On 5/23/13 at 1500, a review of Patient #1's chart revealed late entry documentation that the patient had been administered 25 pills of Nitroglycerin for complaint of chest pain on 5/21/2013 at 2030. Patient #1 had been transferred from an intensive care step down unit on 5/21/2013 at 1640. Based on interviews, Patient #1 began complaining of chest pain at approximately 1800. Review of the patient's chart showed no documentation for the 1900 to 0700 shift on 5/21/2013 that the patient was assessed for chest pain, that the hospital's guidelines for chest pain were instituted, and only a late entry revealed that the patient had received 25 pills of Nitroglycerin under the tongue. After the incident the patient, a rapid response was initiated, and the physician transferred the patient to the cardiac unit for closer monitoring.

On 5/23/13 at 1500, review of Patient #1's chart revealed the patient was admitted through the hospital's emergency department on 5/7/13 for Pneumonia. Review of the patient's history and physical dated 5/10/13 showed the patient history includes but is not limited to: Angina, Diabetes, Coronary Artery Disease with multiple angioplasties, Hypoxemia, Dysphagia, Anemia, Vertigo, and Dementia. Review of the patient's chart on 5/23/13 at 1500 revealed Patient #1 was transferred from the Step Down Surgical Unit to the 11 East- Medical Oncology Unit on 5/21/13 at 1650.

Review of a nurse note recorded on 5/22/13 at 1751 as a late entry for May 21, 2013 at 2030 showed the patient's primary nurse for 5/21/2013 night shift poured a bottle of nitro tablets into the patient's mouth for complaint of chest pain at 2030. Review of a physician order dated May 21, 2013 at 1814, showed "Nitrostat 0.4 mg(milligrams) = 1 tab, SL(sublingual) q (every) 5 min (minutes) PRN (As Needed) Chest Pain times 3 doses." The documentation showed the nurse failed to follow the physician orders and hospital policy and procedure for the safe administration of Nitroglycerin which resulted in a rapid response and a transfer to the cardiac unit for closer monitoring by the physician.

The nurse note dated as a late entry on May 22, 2013 at 1751 reads, "Patient's son notified staff that he wanted to speak with the nurse. The charge nurse in the medicine room said he was calling about the patient's chest pain. I knew the chest pain had occurred before change of shift. I grabbed the patien'ts[sic] nitroglycerin bottle from the pyxis. Was met in the patient's room with immediate yelling and a complaint that it took me four minutes to get there. I told the son that I had her nitroglycerin with me. .....I opened the bottle of nitro and poured the contents under the patient's tongue and noticed multiple tablets. I swept the nitro out of the patient's mouth and then the son pushed me out of the way and began sweeping out the excess and Yankauer suctioned it, while I went to the computer to read the order. The patient's son had removed the nitro and at this time had the bottle in his hand. I confirmed the order and double checked the patient, noting that only one sublingual pill was in the patient's mouth. A rapid response was called, as the charge nurse was contemplating calling one before before any incident occurred."

On 5/24/13 at 1115, RN #8 stated, "When the night shift RN came in, I told her about the son and then reviewed the patient's complaint of chest pain. I told her the nitroglycerin was ordered but it wasn't available and for her to be on the lookout for it to arrive."

On 5/24/13 between 1148 and 1300, an interview with RN #7 revealed the following: " After the patient had complained of chest pain, I went into the room with the nitro. I was greeted with abrasive yelling by the son because it took me four (4) minutes. I think I said, I'm sorry. I either showed him or he asked if I had the nitro. He stated, "you're not going to take twenty minutes to put this medicine in." We skipped putting in the pain score. I scanned the ID on her wrist and the medication. The son tried to grab the nitro out of my hand, but he didn't get it. I walked to the computer and it popped up. I scanned the medicine. I didn't sign it off. I walked over, and not being familiar with how nitroglycerin is packaged, I thought there was one tablet in the bottle- like one (1) dose. I instructed the patient to lift up her tongue and I poured the contents under her tongue. There were 25 tablets poured. I realized there was something odd about this. I was concerned that maybe it wasn't the right dose. I tried to do a finger sweep and the son pushed me out of the way and said "did you overdose her?" He grabbed the Yankauer suction and started removing it. He obtained the bottle by snatching it out of my hand. I don't know if there were any tabs left. I don't know where the bottle went- he may have taken it to the next floor. I was trying to figure out what the deal with the medication was. I knew it was 0.4 mg but didn't know the dose. I went back to the patient less than a minute later to make sure there weren't any more tablets in her mouth. I only saw one tablet. I only documented one tablet on the Medication Administration Record (MAR) because that's all I saw. The process for administering oral medication is to scan the ID band, scan the medicine, put oral medications into a cup, confirm the patient's name and date of birth. That's all. I asked (charge nurse #1), how to give it before I went into the room and she said to just pour it under the patient's tongue. I did as instructed. I did no documentation on this patient. I may could have done her neuro assessment, but I didn't. The chart is still available to me if I need to document. The Administrator on Duty (AOD) told me that I only had to document an occurrence report and nothing else. When I spoke to my manager the next morning, she instructed me to come back in that day to put a note in the computer."

Hospital Guidelines for Treating Chest Pain, Symptomatic and Pulseless Arrhythmias, reads, ".... 1. Chest Pain- 1.1 Oxygen at 2 L/ min (liters/minute) via nasal cannula will be placed on all patients with chest pain. 1.2 An order for stat 12 lead EKG (electrocardiograph) will be placed on all patients with chest pain. 1.3 Units that have 12 lead EKG machines will perform stat 12 Lead EKGs....".

Hospital Policy, Systems Review Documentation, reads, ".... Rules: 1. A systems review of major body system(s) will be documented every 12 hours, with any change in patient condition, or as unit standard dictates....".

On the days of the Complaint Investigation based on interview, patient record review, and review of hospital policy and procedure, the hospital failed to provide safe administration of Nitroglycerin in that evidence showed that the nurse failed to follow physician orders and administered 25 tablets of nitroglycerin under the patient's tongue for 1 of 1 patient concurrent patient record reviews. (Patient #1)


The findings include:


On 5/23/13 at 1500, a review of Patient #1's chart showed a nurse note dated 5/22/13 at 1751 recorded as a "late entry" for May 21, 2013 at 2030 that showed the patient's primary nurse for 5/21/2013 night shift poured a bottle of Nitroglycerin tablets into the patient's mouth for complaint of chest pain at 2030. The nurse failed to follow the physician orders for the administration of the medication.

Review of a physician order dated May 21, 2013 at 1814, showed "Nitrostat 0.4 mg(milligrams) = 1 tab, SL(sublingual) q (every) 5 min (minutes) PRN (As Needed) Chest Pain times 3 doses."

Review of the nurse late entry note dated 5/22/13 at 1751, reads, "....Patient's son notified staff that he wanted to speak with the nurse. The charge nurse in the medicine room said he was calling about the patient's chest pain. I knew the chest pain had occurred before change of shift. I grabbed the patien'ts[sic] nitroglycerin bottle from the pyxis. Was met in the patient's room with immediate yelling and a complaint that it took me four minutes to get there. I told the son that I had her nitroglycerin with me. .....I opened the bottle of nitro and poured the contents under the patient's tongue and noticed multiple tablets. I swept the nitro out of the patient's mouth and then the son pushed me out of the way and began sweeping out the excess and Yankauer suctioned it, while I went to the computer to read the order. The patient's son had removed the nitro and at this time had the bottle in his hand. I confirmed the order and double checked the patient, noting that only one sublingual pill was in the patient's mouth. A rapid response was called, as the charge nurse was contemplating calling one before before any incident occurred."


On 5/24/2013 at 1700, Registered Nurse (RN)#2 verified he/she was on duty on the Medical Oncology on 5/21/2013 between 2000 and 2030, and RN #2 stated, "... Around 2000-2030, I saw the nurse (RN #7) coming out of room 1149 and go into the medication room...". RN #2 stated that he/she heard the patient's son yelling at the nurse to hurry that it had already been 4 minutes, and they should be able to give the patient the Nitroglycerin faster than this. RN #2 stated that he/she was in the patient's room and he/she saw the nurse (RN #7) trying to scan the medication into the computer prior to giving the medication, and the son was trying to grab the bottle out of the nurse's (RN #7) hand. RN #2 stated that the nurse(RN #7) turned to the patient and dumped the bottle of Nitroglycerin into the patient's mouth. RN #2 reported, "...Immediately the son and the nurse(RN #7) scooped the medication out of the patient's mouth and called a Rapid Response.

On 5/24/2013 at 1230, during an interview with RN #1 who verified that he/she was on duty on the Medical Oncology Unit on the 7 PM-7 am night shift on 5/21/2013 as the charge nurse. RN #1 stated, "...On that night of 5/21/2013, I recall the patient in room 1149 had been transferred from CCU(Coronary Care Unit) to us with a serious heart condition and was preparing for discharge. RN #1 stated, "When I did my rounds at 1915-1945, the patient was fine. One of the technicians told me a little later that the patient was having chest pain. I stopped the nurse caring for the patient and told the nurse that the patient was having chest pain." RN #1 stated that the nurse told her chest pain was normal for this patient from a report received earlier from the transferring unit." RN #1 stated the nurse and I went to the pyxis and got the Nitroglycerin, and he/she was going to administer the medication to the patient." RN #1 stated another nurse in the patient's room came out of the patient's room and stated "we need to call a Rapid Response." RN #1 reported, "I called a Rapid Response." RN #1 stated that she had considered calling one earlier but when the nurse had stated chest pain was normal for the patient, she didn't call it. RN #1 reported that the patient's son told us that he had to take several Nitroglycerin pills out of the patient's mouth. RN #1 stated the nurse told her. "I did not realize that Nitroglycerin was in a multidose vial and had thought that the bottle held only one dose."