HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt. #1) clinical records reviewed for chest pain, the hospital failed to ensure that the physician was notified of new onset and continued symptoms.

Findings include:

1. The hospital's policy titled, "Clinical Documentation Guideline" (revised 9/6/2022), was reviewed and required, "...Focused documentation will be completed as the patient's condition changes. Purpose: To establish a standard process for the communication of essential patient information that accurately reflects patient care, treatment, and services provided... Add or customize interventions as new problems are identified or the patient condition changes... Complete a narrative note in the Data, Action, Response (DAR) format on admission, transfer, discharge, and change in condition... 1. Data: Detail the subjective and objective information related to a patient focused problem/issue. 2. Action: Describe the intervention and actions taken to address the problem or data above. 3. Response: Evaluate the patient's response to the applied interventions. Was the problem resolved, or are future actions/interventions needed?..."

2. The hospital's policy titled, "Rapid Response Team (RRT)" (revised 7/20/2022), was reviewed and required, "...Any of the following guidelines may be used for activating the Rapid Response Team include, but are not limited to: ...Chest Pain... A Rapid Response Team (RRT) will be called for all people (including patients...) requiring medical attention that does not meet Cardiac Arrest criteria... RRT member roles include, but are not limited to: "Charge RN - notify the patient's attending physician and acquire further orders..."

3. The hospital's policy titled, "Chain of Command - Licensed Independent Practitioners (LIP) and Operational Issues" (revised 8/21/2017), was reviewed and required, "...Appropriate documentation in the medical record will reflect objective patient assessment information, notification of the physician and orders received..."

4. The clinical record of Pt. #1 was reviewed on 6/4/2024. Pt. #1 presented to the hospital's Emergency Department (ED) on 2/24/2024, at approximately 10:00 AM, with a chief complaint of shortness of breath and was admitted to the 2 West Telemetry Unit on 2/24/2024 at 11:46 AM, with diagnoses of acute COPD (chronic obstructive pulmonary disease) exacerbation and sinus tachycardia (elevated heart rate/above 100 beats per minute). The initial ED and nursing assessment indicated that Pt. #1 reported no pain upon admission.

- The Attending Physician (MD#1) Progress note on 2/26/24 at 12:25 PM included - "02/26/24 - Feeling better, Denies any pain ..."

- Nursing assessments from 2/24/2024-2/28/2024 were reviewed and indicated that Pt. #1's heart rate remained elevated (between 100-120 beats per minute/bpm range, normal is 60-100) it was noted that other vital signs were with in normal parameter.

-Pt. #1's pain assessment were reviewed from 2/24/24-2/28/24. Pt. #1 did not complain of pain upon admission on 2/24/24 to 2/26/2024. Pt. #1 complained of pain 2/26/2024 at 11:06 PM. The Nursing pain assessment by Nurse (E#2) on 2/26/2024 at 11:06 PM included: "Pain present? - Y, Pain location - Ribs, Pain location modifier - Chest wall ... description - achy ...pain intensity - 4 out of 10, acceptable level of pain - 2 - acceptable level ...aggravating factors - breathing, coughing, movement ..." Another pain assessment by E#2 on 2/27/2024 at 05:10 AM included, "Pain present - Y, Pain location - ribs, pain location modifier - chest wall ...description - achy ...pain intensity - 5 out of 10, acceptable level of pain - 2 - acceptable level ...aggravating factors - breathing, coughing, movement ..." On 2/27/24 at 10:20 PM and 11:00 PM pain assessments were assessed as mild pain of 2-3 respectively. Tylenol (pain medication) was administered when Pt#1 complained of pain and reassessments indicated relief of pain to an acceptable level (2).

- Nursing note (E#2), dated 2/27/24 at 1:06 AM included " ...Has rib pain specially with inspiration/deep breathing and with movement ...Heart rate on 100's, heart rate goes up to 120's when patient is ambulating [walking] to the bathroom ...Will observe for any untoward signs and symptoms." The record lacked documentation that on 2/26/2024 the primary physician was notified or that unsuccessful attempts were made of the new onset and on 2/27/204 continued complaint of mild to moderate chest pain described as :achy" when Pt. #1 would cough. The record lacked documentation that concern was escalated through the proper channels.

- On 2/28/2024 at 10:10 AM, a Rapid Response Team (RRT) was initiated due to chest pain rated at a 5 described as sharp, supraventricular tachycardia (erratic fast heartbeat) and tachypneic (rapid shallow breathing). MD #1 was informed, labs, EKG, and a Cardiologist consult was ordered. The Cardiologist evaluated Pt. #1 and medication was ordered: Cardizem to treat the tachycardia, Aspirin and Nitroglycerin for chest pain management.

On the evening of 2/28/24 a second RRT was initiated, followed by a Code Blue (cardiac arrest) on 2/28/2024 at 10:35 PM. Pt. #1's was transferred to intensive care unit (ICU). Pt. #1 was intubated and resuscitative measures performed. The family was made aware of Pt. #1 condition and decided to remove intubation and stop medications. Pt. #1 expired on 2/29/2024 at 12:02 AM due to probable acute myocardial infarction (heart attack).

5. A telephone interview was conducted with the Hospitalist (MD#1) on 6/5/2024, at approximately 9:18 AM. MD#1 stated that Pt. #1 presented with symptoms of COPD exacerbation and the initial cardiac work-up in the ED was not significant for cardiac issues. MD#1 stated that MD#1 was not made aware that Pt. #1 was reporting any chest pain at all during the admission up until the rapid response on 2/28/2024. MD#1 stated that MD#1 would expect the nurses to notify MD#1 of a new onset of chest pain. MD#1 stated that MD#1 comes to see MD#1's patient's at least once a day and when MD#1 is not here, the nurses can call MD#1 or send a message through the Hospital's messaging system.

6. An interview was conducted with the Registered Nurse (E#1) on 6/5/2024, at approximately 11:00 AM. E#1 stated that if a patient starts reporting new chest pain, they (staff) would call a rapid response and in that process the attending physician would be notified. E#1 stated that E#1 was working as the Charge Nurse the day of Pt. #1's rapid response. E#1 stated they tried to get a hold of MD#1 regarding the patient's change in condition and it took about 45 minutes before MD#1 responded. E#1 stated that nurses should document in the medical record that notification of the physician was attempted or completed and what instructions/orders were given if any. E#1 stated that documentation should include how many attempts were made if unable to reach the physician. E#1 stated that this notification could either be entered as an intervention or a DAR note.

7. An interview with the Director of Nursing (E#12) was conducted on 6/5/2024, at approximately 12:43 PM. E#12 stated that nurses are required to perform system assessments at least every shift and vitals at certain intervals depending on the unit and orders. E#12 stated that if the nurse's assessment indicates a change in patient's condition or new onset of symptoms, it should be documented in the clinical record. E#12 stated that if it was just a minor complaint, the nurse might call the doctor to let him know, if it's a major concern like chest pain, a rapid response would be called, and the physician would be notified during that process anyway. E#12 stated that either way the nurse would write a note or put an intervention in the record that the physician was notified.

8. On 6/5/24 at approximately 2:00 PM, the Interim Manager of the Telemetry Unit (E #6) was interviewed. E #6 stated that after Pt. #1's RRT on 2/28/24, E #6 reviewed Pt. #1 clinical record and assisted with the investigation. It was not identified that there were issues of not being able to notify MD #1 of Pt. #1's new onset and continued chest pain. The results of the investigation were the nurses concerns that Pt. #1 didn't have a cardiologist and how to initiate the escalation process.

9. A telephone interview was conducted with the RN (E#2) on 6/6/2024, at approximately 9:37 AM. E#2 stated that if any patient will come in with chest pain or reports chest pain later, E#2 will immediately call for a RRT Activation. E#2 stated they will call the primary physician for orders and maybe consult cardiology. E#2 stated that if no RRT is called, E#2 will still notify the primary physician. E#2 stated that if physicians do not respond to pages, E#2 will inform the supervisor. E#2 stated that if E#2 did not agree with a physician order E#2 will suggest and document the encounter. E#2 stated that if there were any issues, E#2 manager would discuss (huddle) with them right away but cannot recall any recently or any in regard to Pt. #1.