HospitalInspections.org

Based on policy review, medical record review, and staff and physician interviews, facility staff failed to supervise and evaluate a patient's care by failing to reassess a patient and follow the chain of command for 1 of 1 patients with a change in condition (Patient #4).

The findings include:

Review of policy titled "Assessment/Reassessment Dimensions", effective 11/2017, revealed "...Patients are re-assessed to evaluate changes in their condition and response(s) to the care, treatment and services rendered.....Patients will receive a focused re-assessment....at least every shift and as warranted by a patient's clinical condition. ..."

Medical record review, on 10/17/2018, revealed Patient #4 arrived to the Emergency Department on 07/11/2018 at 1138 with a complaint of chest pain. Review revealed the pain score on arrival was 10 (on a scale on 0-10, with 10 being the worst pain). At 1200 the pain score had decreased to 1. Review of a physician note at 1233 revealed the pain started several days ago, was intermittent, and when it started it was a "sharp squeezing pain that radiates into arms" and it generally lasted about 20 minutes. The note stated Patient #4 denied pain at the time of the evaluation. At 1304, review revealed Patient #4 was placed into a room on observation. At 1700, a pain score of 0 was noted. Review revealed an order on 07/12/2018 at 0128 for Maalox/Mylanta/Antacid every six hours prn (as needed) for indigestion, which was given at 0145, and at 0146 Reglan (for abdominal symptoms) was administered with no nursing notation of a pain assessment or other symptoms. At 0208, a pain assessment showed a pain score of 9, abdominal pain, and Morphine 15 mg (milligrams) orally was noted as administered. Review revealed a reassessment at 0300 showed a pain score of 7. At 0552, record review revealed a pain score of 9, abdominal pain, and Reglan and Morphine were administered again. Per review of clinical orders, at 0618 an order was given by MD #2 for Fentanyl (for pain) 25 mcg (micrograms) intravenously. At 0646 pain was reassessed and was a score of 10, abdominal pain. At 0715, review revealed Patient #4's abdominal pain remained a 10 and Fentanyl was administered. At 0747, per review of Telemetry Scans, Patient #4 was noted to have a episode of ventricular tachycardia (abnormal fast heart rate). A code STEMI (ST Elevation myocardial infarction [heart attack]) was called, per review, at 0755. At 0759, a pain score of 10 was noted, chest pain, and Morphine 2 mg IV was administered. Patient #4 was subsequently transferred at 0832 to a hospital with interventional cardiology capability. Record review did not reveal nursing notations of abdominal reassessment during the pain episodes, did not reveal any nursing notes of physician notification or details of the change in patient condition and did not reveal a physician physically saw and evaluated Patient #4 during the night time pain episode prior to day shift.

Interview with RN #2, on 10/17/2018 at 0830, revealed the RN cared for Patient #4 during the night of 07/11-12/2018. Interview revealed RN #2 completed a shift assessment between 1900-2100 and did not recall if the patient had pain then. Interview revealed a pain assessment was not noted at the time. Interview revealed when Patient #4 complained of pain during the night it was abdominal pain, not chest pain. Patient #4 was insistent it was abdominal pain and wanted to see a gastroenterologist, RN #2 stated Interview revealed RN #2 asked the hospitalist physician on duty to come see the patient on two occasions. RN #2 stated a messaging system was used to communicate with the physician but it did not connect into the medical record and RN #2 did not document any physician contacts or discussions. Further interview revealed RN #2 did not record any reassessments related to the abdominal pain. Interview revealed if a physician did not come when requested, the RN would ask again and after that would be patient. Interview revealed RN #2 did not call the supervisor and did not initiate the chain of command.

Interview with MD #2, revealed MD #2 came on duty the night of 7/11-12/2018. Interview revealed there was a change in condition for Patient #4 with the abdominal pain. Interview revealed MD #2 reviewed clinical information, and vital signs were stable and testing so far had been normal. Interview revealed physicians received a lot of calls and had to make their own assessments and decisions. Interview revealed the MD did not see Patient #4 that night and did not recall if the nurse requested that the patient be seen.

Interview with MD #4, Medical Director, and MD #5, VP of Medical Affairs, on 10/18/2018 at 1200 revealed a hospitalist was on duty managing the patient's care. Interview revealed the physicians had to prioritize their work. MD #4 stated when there was ongoing pain and a need for fentanyl, and if there was a second nurse request, MD #4 would have expected a physician to try and see the patient. Interview revealed staff members should operationalize the chain of command if a physician is needed and does not come. MD #5 indicated staff members were taught to follow the chain of command. Interview revealed there were opportunities to improve.

NC00142492