HospitalInspections.org

Based on record review and staff interview, the facility failed to ensure that there was documentation in the medical record of an assessment by a nurse or physician for one of three patients (Patient #1)when the patient complained of chest pain, and blood in stools.

The findings include:

Review of the policy and procedure on 4/28/10 at 1:04 pm revealed that an assessment note (narrative) will be made in the white progress notes prior to calling the physician for any significant medical or psychiatric changes in the individual's condition or for a complaint made by individuals they serve. At minimum, this note will contain vital signs as well as signs and symptoms related to the complaint.

Review of the medical record for Patient #1 on 4/28/10 at 10:56 am revealed that the resident had a history of hypertension, obesity and extensive mental illness. Medical history conducted by the physician on 2/24/10 revealed no history of chest pain, myocardial infarction, anemia or rectal bleeding.

Review of the progress notes dated 4/26/10 at 1:00 PM revealed that the patient complained that on 4/25/10 he/she had chest pain that was non radiating. The staff nurse documented that the physician was notified. The patient also complained that he/she felt that they were having blood in their stools. There were no notes in the progress record to acknowledge the complaint of chest pain; orders for cardiac evaluation or test for stool examination. The nurses' notes contained vital signs. There was no documentation at the time when the resident told the nurse of the chest pain on 4/25/10 whether s/he was having chest pain on 4/26/10 or any other symptomatology like shortness of breath.

Interview with the staff nurse on 4/28/10 at 12:41 PM revealed that Patient #1 did complain of chest pain. The nurse stated that she thought that she had left the physician a note and that usually the physician was paged. At this time, she could not remember if the physician came to the phone to speak with her. The staff nurse stated that she remembered the patient telling her that s/he had chest pain the day before on 4/25/10 but did not have chest pain at the time she (the nurse) documented the patient's complaint on 4/26/10.

The staff nurse stated that the patient had a cold on 4/25/10 and she just took the patient's vital signs. She stated that they usually leave the physician a note and do the patient's vital signs. The staff nurse stated that the physician usually came in the morning and that the patient did not have chest pain at the time she spoke to the patient and that the she (staff nurse) did not notify her supervisor.

Review of the physician's journal revealed that the physician signed off on the note left for him by the staff nurse that the resident complained that there may be blood in his/her stools.

Interview with the physician on 4/28/10 at 1:15 PM, revealed that he heard about the chest pain over the weekend and that he saw the patient on Monday 4/26/10. He stated that his/her vital signs were okay and that there were no further complaints about chest pain. The physician stated that the patient's condition was stable and that he did not write a note right away; that this was his fault. The physician stated that he guessed that he could have written a note. The physician stated that he worked the emergency room, knew of chest pain with different etiologies and that some were mental. There were no orders written for a work up for chest pain or for evaluation of the patient's stool or note in the progress notes to indicate that the patient complained for chest pain/blood in their stool.