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Based on observations, record reviews and staff interviews, the hospital failed to protect and promote patient rights as evidenced by the failure to properly notify a patient after receiving a grievance. In addition, the hospital failed to notify the patient of the hospital's decision, actions taken to investigate the grievance, the results of the grievance, or the date of completion for the grievance for 1, (#1) out of 10 patients sampled for grievances (A123).

The hospital failed to follow policy in care of the patient with chest pain and placing the patient in the appropriate setting for monitoring 1 of 10 patients sampled, resulting in the potential for adverse outcomes for all patients presenting to the Emergency Department (ED) (A144).


The hospital failed to treat and document changes in a patient's condition by a physician for 1 (#1) out 10 patients sampled ( A359).


The hospital failed to plan and ensure nursing care was provided for each patient, evidenced by the hospital failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled ( A385, A 396).



The hospital failed to have completed patient records which include all practitioners' orders, nursing notes, and vital signs for Patient #1, out of 10 records sampled (A467).



The cumulative effect of these systemic problems resulted in the facility's inability to protect and promote each patients' rights as required by the Patients' Rights Condition of Participation (CoP).

Based on observation, record reviews and staff interviews, the hospital failed to properly notify a patient after receiving a verbal grievance. In addition, the hospital failed to notify the patient of the hospital's decision, actions taken to investigate the grievance, the results of the grievance, or the date of completion for the grievance for 1 (#1) out of 10 patients sampled.


The findings include:


A review was conducted of a grievance dated 11/17/2017 from Patient #1, who called the hospital at 3:44 PM and spoke with Risk Management staff and voiced the following concerns:

1) Patient reported, "I was having a heart attack and was left in the ER hallway for 3 hours before anyone realized what was going on."

2) Patient reported she was told by a female physician that they were just waiting for the labs to return, but the patient said no labs were taken.

3) Patient reported at that time labs were performed, it was already determined she had a blockage & a heart catheterization was needed.

4) Patient reported that the Cardiologist apologized to her & said the delay should have never happened.



A review of the hospital investigation conducted by Employee F, Registered Nurse (RN) on 11/21/2017 at 11:25 AM for the grievance received by Patient #1 revealed (which she documented): "It does appear from the patient medical record that the patient did not have labs draws for 3 hours, which resulted in delay of her care."



A review of the grievance investigation conducted by Employee L, (MD) on 12/8/2017 at 3:30 pm, documented: "A review of Patient #1's record reveals there was a delay in blood draw and this was embarrassing and detrimental to patient's safety."



An interview with Employee G, Physicians' Assistant (PA) on 1/9/2018 at 5:15 PM, confirmed that before today (1/9/2018), the facility had not discussed with him the delay in care to Patient #1, which she experienced while under his care. He stated, "I was just told today that this patient's care was being reviewed. I see so many patients on a daily basis, there is no way I could remember her care."



A review of the facility's grievance report for Patient #1 revealed documentation was not entered to verify the physician was notified, nor was the patient who made the grievance contacted. Upon further review of the grievance, the type of event was listed as a communication error, instead of the correct event of delay in care.



An interview with Employee A, Risk Manager (RM), on 1/9/2018 at 1:35 PM confirmed the grievance for Patient #1 was not entered correctly and was listed as a communication error, and should have been documented as a delay in care, and an Incident Report should have been completed. The RM also confirmed the hospital was to send the patient a letter within 7 days of receiving the grievance, but could not find the letter or documentation that Patient #1 was ever notified of the hospital's acknowledgment of the grievance.


A review of the facility's Incident/Accident Reports revealed no incident or event report was done with the concerns made by Patient #1.


A review of the Hospital Patient Complaint/Grievance Resolution Policy Stat # 2811079 E, effective date 9/20/93 and revised 10/10/16 reads: A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, if it is postponed for later resolution, if it requires investigation, and/or if it requires further action for resolution. All grievances will be investigated promptly, but occasionally, a grievance is complicated and may require and extensive investigation. All grievances will be resolved within 45 days of initiating the grievance."



An interview with the Hospital Risk Manager on 1/9/2018 at 2:05 PM confirmed the grievance for Patient #1 was over 45 days, and had not been resolved. In addition, the RM confirmed Patient #1 had not been notified of the status of the grievance. She stated, "It was an oversight on our part and I can't find the letter where the patient has been contacted."

Based on patient record reviews and staff interviews, the facility failed to follow policy in care of the patient with chest pain, failed to document changes in a patient's condition by a physician and placing the patient in the appropriate setting for monitoring for 1 of 10 patients sampled (Patient #1), resulting in the potential for adverse outcomes for all patients presenting to the Emergency Department (ED).


The findings include:


A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).


A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, 9 out of 10 with the pain going from her back to her chest.



A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "Heavy like someone is sitting on me."The patient made complaints her pain was a numeric pain scale of 10 and described it as, "the worst pain ever."


It was also found that the patient stayed in the hallway area versus placing the patient in an ED Bay/Room for monitoring.




A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs, nor assessments for Patient #1, from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.



A review of the Hospital Standards of Care reads: "Implement Emergency Department chest pain guideline orders, EKG to be done within 10 minutes, Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications."



An interview with Employee F, RN, on 1/9/2018 at 4:07 PM, confirmed no documentation could be found in Patient #1's record of vitals signs, nor nursing assessment being conducted from 12:57 - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.



A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (#3312809), effective date 10/1/1987 last revised date of 4/7/2017 reads, "Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: record vital signs as indicated and after administration of medications, Monitor EKG and patient's condition."



An interview with Employee E on 1/9/2018 at 2:40 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.



A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor, was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and Abnormal EKG, and required emergency heart catheterization and stent placement.



A review of the physician's documentation for Patient #1's heart catheterization dated 11/9/2017 at 4:37 PM revealed MD
elected to take her to the cath lab urgently, because of ongoing chest pain. Findings included: Left ventricular systolic function was normal. Ejection fraction was estimated in the range of 55% to 60 % and stent.



An interview with Employee E, (MD) on 1/9/2018 at 2:51 PM confirmed Patient #1 did not receive the proper care and treatment for almost 2 hours after arriving to the Emergency Room with chest pain, per facility operating procedure for a patient arriving with complaints of chest pain. Employee E confirmed Patient #1 needed Troponin level done due to her age and her type of complaint of chest pain and stated, "I don't know why it wasn't done. That's an anomaly." The Employee was asked if the hospital had a certain time frame where the Troponin level should be drawn and he said a patient should be seen and treated by the physician within 10 minutes from arrival."



An interview with Employee D, Physicians' Assistant (PA), conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017 and did not follow the hospital procedure for chest pain for Patient #1. He stated, "I don't know why I didn't run the test, unless she complained of something different when I saw her." Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain of 9/10 out of 10, and did not receive the proper emergent treatment.

Based on review of clinical records, staff interviews and a review of hospital documentation for the care and services provided in the Emergency Department (ED), the hospital's Quality Assurance and Performance Improvement (QAPI) Program failed to monitor the effectiveness and safety of services and quality of care, when there was known non-compliance with Patient #1, who was experiencing chest pain of 9 out of 10, and did not receive the proper emergent treatment and should have had labs (Troponin level) done, due to her age and her type of complaint of chest pain resulting in a finding of a condition. The hospital's QAPI Program also failed to take action when there was known non-compliance with Employee D, Physicians' Assistant (PA), who did not document his assessment with Patient #1 on 11/9/2017, did not follow the hospital procedure for chest pain, and did not follow the plan of care for chest pain for Patient #1, which was his scope of practice.


The findings include:


A review of Patient #1's clinical record was conducted. Patient #1 was seen on 11/9/2017 at 12:57 PM in the ED and triaged as emergent for frequent assessment and was placed in the ED hallway bed. Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "My chest is heavy like someone is sitting on me." The patient made complaints the pain would radiate to her back/neck/jaw with a numeric pain scale of 10.


The patient was not documented as being seen by a physician and nursing on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM. No labs were evidenced as being ordered upon admission.


An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation could be found in Patient #1's record of vital signs, nor nursing assessment being conducted from 12:57 - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.


Further review of Patient #1's record revealed no other documentation or care was given to Patient #1 until on 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor was notified by the patient that she was in pain and hadn't receive care. Employee K, then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and abnormal EKG, and required emergency heart catheterization and stent placement.



An interview with Director of the ED, MD on 1/9/2018 at 4:13 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM. He explained any Physician that saw a patient was to document in the patient's record, and no documentation could be found in Patient #1's record. Patient #1 should have been assessed frequently related to her cardiac event.


An interview with Employee D, Physician Assistant (PA) was conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017 and did not follow the hospital procedure for chest pain for Patient #1.


Interview with the Hospital Risk Manager on 1/9/2018 at 2:05 PM, indicated although it was identified on 11/21/17 that hospital procedure for chest pain was not followed, resulting in a delay in care for Patient #1 and it was identified as a concern. They did not complete an Incident/Event report nor monitored to ensure compliance after the event experienced by Patient #1. The Hospital RM confirmed the grievance for Patient #1 was over 45 days and had not been resolved. In addition, the RM confirmed Patient #1 had not been notified of the status of the grievance. She stated, "It was an oversight on our part and I can't find the letter where the patient has been contacted."



An interview with Employee G, Physicians' Assistant (PA) on 1/9/2018 at 5:15 PM, confirmed that before today (1/9/2018), the facility had not discussed with him the delay in care to Patient #1, which she experienced while under his care. He stated, "I was just told today that this patient's care was being reviewed. I see so many patients on a daily basis, there is no way I could remember her care." He also explained that he does not have time to document his assessments.


A review of the facility's grievance report for Patient #1 revealed documentation was not entered to verify the physician was notified, or the patient who made the grievance was contacted. Upon further review of the grievance, the type of event was listed as a communication error instead of the correct event of delay in care. The Risk Manager, on 1/9/2018 at 1:35 PM, explained the grievance for Patient #1 was not entered correctly, was listed as a communication error, and was documented as a delay in care with an Incident Report, which should have been completed. The RM also stated the hospital was to send the patient a letter within 7 days of receiving the grievance, but could not find the documentation that Patient #1 was ever notified of the hospital's acknowledgment of the grievance.


The hospital's investigation failed to identify that the Physicians' Assistant for Patient #1 did not document his assessment.


An interview with Director of the ED, MD, on 1/9/2018 at 6:21 PM revealed the expectation of the PA responsibilities is any PA can see patients and should document on those patients when they are seen. They are to put orders in. He stated, "There has not been an issue with documentation before today, but obviously, it's something we now know we have to look at." He also explained that he will address the delay in care to Patient #1 with the PA immediately.

Based on patient record reviews and staff interviews, the facility failed to treat and document changes in a patient's condition by a physician for Patient #1, out 10 patients records sampled.



The findings include:


A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).



A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10 with the pain going from her back to her chest.



A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "My chest is heavy like someone is sitting on me". The patient made complaints the pain would radiate to her back/neck/jaw, with a numeric pain scale of 10 and is described as "the worst pain ever".



A review of facility orders for Patient #1 revealed Employee G, Physicians' Assistant (PA) assessed the patient and entered orders, but no documentation could be found of the assessment conducted by the employee.



A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until on 11/9/2017 at 2:49 PM, when Employee K, (MD), Medical Doctor was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG, which revealed a positive Troponin level and Abnormal EKG and required emergency heart catheterization and stent placement.



A review of the physician's documentation for Patient #1's heart catheterization dated 11/9/2017 at 4:37 PM revealed, "Patient comes in with severe chest pain. Normal EKG and weekly + Troponin. We elected to take her to the cath lab urgently, because of ongoing chest pain. Findings include: "Left ventricular systolic function was normal. Ejection fraction was estimated in the range of 55% to 60 % and stent.



An interview with Employee E, (MD) on 1/9/2018 at 2:51 PM confirmed Patient #1 did not receive the proper care and treatment for almost 2 hours after arriving to the Emergency Room with chest pain per facility operating procedure for a patient arriving with complaints of chest pain. Employee E confirmed Patient #1 should have had Troponin level done due to her age and her type of complaint of chest pain and stated, "I don't know why it wasn't done. That's an anomaly." The Employee was asked if the hospital had a certain time frame where the Troponin level should be drawn and he said a patient should be seen and treated by the physician within 10 minutes from arrival. "



An interview with Employee D, Physicians' Assistant (PA), conducted on 1/9/2018 at 5:30 PM confirmed he did not document his assessment with Patient #1 on 11/9/2017, and did not follow the hospital procedure for chest pain for Patient #1. He stated, "I don't know why I didn't run the test, unless she complained of something different when I saw her." Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain of 9/10 out of 10 and did not receive the proper emergent treatment.



A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (#3312809), effective date 10/1/1987 last revised date of 4/7/2017 reads, "Relieve pain, anxiety, and provide close observation until serious cardiac or pulmonary involvement is ruled out".

The RN or Paramedic will provide monitoring and care appropriate for the patient with chest pain until serious cardiac or pulmonary involvement is ruled out. Patients presenting with chest pain or angina equivalent symptoms will be treated as emergent. Symptoms include: Chest pain; pressure; tightness; fullness; shortness of breath without obvious primary upper respiratory symptoms; dizziness; syncope; palpitations; epigastric pain, particularly in women, and drug overdose. Any of the above symptoms with or without arm pain or numbness and tingling, nausea/or vomiting and upper back pain. Critical requirements for safety are listed as EKG; Rapid assessment of patients' signs and symptoms, to rule out impending Myocardial infarction, or other cardiac or pulmonary crisis. Oxygen therapy, medications for relief of pain, Cardiac monitoring. Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: Record vital signs as indicated and after administration of medications, Monitor EKG and patient condition.



A review of the Hospital Standards of Care reads: "Implement Emergency Department Chest Pain guideline orders,
EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.


A review of the Hospital Emergency Department order set for chest pain revealed when a patient complains of chest pain, the following is to be completed: "Patient is to have nothing by mouth, obtain blood pressures; continuous pulse oximetry; cardiac monitoring; EKG; Saline Lock; Oxygen administration; blood draw for Troponin level; complete chemistry; chemistry 8; complete blood count with differential, and chest x-ray.

Based on observations, record reviews and staff interviews, the hospital failed to plan and ensure nursing care was provided for each patient, as evidenced by the hospital's failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled ( A385).

The facility failed to have organized nursing services that provide 24-hour nursing services, evidenced by the failure of a Registered Nurse to assess a patient in the Emergency Room with chest pain (A396).


The hospital also failed to have completed patient records, which include all practitioners' orders, nursing notes, and vital signs for Patient #1, out of 10 records sampled.


The cumulative effect of these systemic problems resulted in the facility's inability to provide nursing services by a registered nurse as required by the Condition of Participation (CoP) for Nursing Services.

Based on patient record reviews, and staff interviews, the hospital failed to plan and ensure nursing care was provided for each patient, as evidenced by the hospital's failure to monitor and assess a patient that came into the Emergency Department for chest pain for 1 out of 10 patient records sampled. (Patient #1)


The findings include:


A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).


A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10 with the pain going from her back to her chest.


A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "Heavy, like someone is sitting on me." The patient made complaints her pain was a numeric pain scale of 10 and described it as the "worst pain ever."



A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs or assessments for Patient #1 from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.



A review of the Hospital Standards of Care reads: "Implement Emergency Department chest pain guideline orders,
EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications."


An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation could be found in Patient #1's record of vitals signs, nor nursing assessment being conducted from 12:57PM - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.



A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (#3312809), effective date 10/1/1987 last revised date of 4/7/2017 reads: "Procedures: place patient on oxygen therapy, draw blood for lab studies and point of care testing, carry out orders by physician as soon as possible. Required documentation: record vital signs as indicated and after administration of medications, monitor EKG and patient's condition.



An interview with Employee E on 1/9/2018 at 2:40 PM, confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.

Based on record reviews and interviews with staff, the hospital failed to have completed patient records which include all practitioners' orders, nursing notes, and vital signs for 1 (#1) out of 10 records sampled.



The findings include:



A closed record review for Patient #1 revealed the patient arrived at Memorial Hospital Jacksonville Emergency Department on 11/9/2017 at 12:57 PM via Emergency Medical System (EMS).


A review of the EMS Run Sheet dated 11/9/2017 revealed Patient #1 had complaints of chest pain, of 9 out of 10, with the pain going from her back to her chest.


A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "My chest is heavy like someone is sitting on me." The patient made complaints the pain would radiate to her back/neck/jaw, with a numeric pain scale of 10 and is described as "the worst pain ever".



A review of facility orders for Patient #1 revealed Employee G, Physicians' Assistant (PA), assessed the patient and entered orders, but no documentation could be found of the assessment conducted by the employee.



A review of Patient #1's record revealed no other documentation or care was given to Patient #1 until 11/9/2017 at 2:49 PM, when Employee K, (MD) Medical Doctor, was notified by the patient that she was in pain and hadn't received care. Employee K then ordered stat labs to be drawn and a repeat EKG which revealed a positive Troponin level and abnormal EKG, which required emergency heart catheterization and stent placement.



An interview with Employee D, Physicians' Assistant (PA) was conducted on 1/9/2018 at 5:30 PM, who confirmed he did not document his assessment with Patient #1 on 11/9/2017, did not follow hospital procedure for chest pain for Patient #1. He stated, "I don't know why I didn't run the test unless she complained of something different when I saw her." Employee D confirmed the Nursing Assessment and EMS Run Sheet both revealed the patient was experiencing chest pain, of 9 out of 10, and did not receive the proper emergency treatment.



An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed Employee D, PA should have filled out a Medical Screening Exam when he assessed Patient #1, which was not found in the patient record.



An interview with Employee E, MD on 1/9/2018 at 4:13 PM, confirmed any Physician that saw a patient was to document in the patient's record and no documentation was found in Patient #1's record that was assessed by Employee D.



A review of Nursing Triage Assessment performed by Employee H, Registered Nurse (RN) on 11/9/2017 at 12:57 PM revealed Patient #1 had chest pain x 2-3 days, with nausea and vomiting, shortness of breath (SOB), and also complained of neck, back/head/jaw pain x 2 days. The patient pointed to the middle of her chest and stated, "Heavy, like someone is sitting on me". The patient made complaints her pain was a numeric pain scale of 10 and described it as "the worst pain ever."


A review of Patient #1's Vitals Signs Data Sheet revealed no nursing documentation was recorded for vital signs or assessments for Patient #1 from 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.



A review of the Hospital Standards of Care reads: "Implement Emergency Department chest pain guideline orders,
EKG to be done within 10 minutes; Record rhythm identification and mount monitor strip every 30 minutes x 2, then every hour and as needed (PRN). Vital signs are to be taken every 30 minutes x 2, then PRN and vital signs are to be taken every 30 minutes to 1 hour after giving any Intramuscular (IM) or Intravenous (IV) pain medications.



An interview with Employee F, RN, on 1/9/2018 at 4:07 PM confirmed no documentation was found in Patient #1's record of vitals signs, nor Nursing Assessment being conducted from 12:57PM - 4:58 PM on 11/9/2017 for Patient #1, and it should have been done every 30 minutes, according to Emergency Operating Procedures.



A review of the facility's Policy and Procedures for Chest Pain (Care of a Patient with) (#3312809), effective date 10/1/1987 last revised date of 4/7/2017 reads: "Required documentation: record vital signs as indicated and after administration of medications; Monitor EKG and patients' condition.



An interview with Employee E, on 1/9/2018 at 2:40 PM confirmed he reviewed the record for Patient #1 and she was never placed on oxygen, nor had documentation of any care from the nursing staff from time of entry on 11/9/2017 at 12:57 PM until 11/9/2017 at 4:58 PM.