HospitalInspections.org

Based on record review and interview, the facility failed to maintain patient's well-being by failing to report signs and symptoms normally associated with a heart attack to the physician for 1 (Patient #1) of 1 patients. This deficient practice caused actual harm to the patient who subsequently had a cardiac arrest and was transported to a local hospital where he expired. The findings are:

A. The complaint reported an injury of unknown origin. According to the complaint Patient #1 asked to go to the restroom and the staff assisted him to the commode. As Staff Member #4, a CNA (Certified Nursing Assistant) was assisting him back into his wheelchair, the patient slumped over Staff Member #4 and she lowered him to the floor. Patient was unresponsive to verbal commands and sternal chest rubs. Patient #1 became pulseless and cardiopulmonary resuscitation (CPR) was initiated. Emergency medical services (EMS) arrived and transported Patient #1 to a local hospital. Patient #1 expired at the hospital.

B. Record review of the facility's medical record revealed Patient #1 was admitted to the facility on 02/11/16 for Physical and Occupational Therapy and died in another hospital on 02/14/16.

C. On 03/30/16 at 12:40 pm during interview, the Director of Nursing (DON) stated on 02/13/16 the Staff Member #4 told her that Patient #1 was having a seizure and when she went and checked on Patient #1 he was not having a seizure. The DON stated Patient #1 did say that "he felt weird." When the DON was asked if she reported this incident to the physician she stated, "No, the patient did not have a history of seizures and the patient did not mention he had a seizure."

D. On 03/30/16 at 2:00 pm during interview, Staff Member #4 stated that on 02/13/16 she reported to the DON that Patient #1 was nauseated after breakfast, refused lunch due to left shoulder pain with numbness to his hands, and had a seizure while showering. (Per WebMD, among the eleven heart symptoms never to ignore are nausea, prioritized as symptom #2, and pain that spreads to the arm, prioritized as symptom #3.) Staff Member #4 stated that when the nurse arrived the patient was no longer having a seizure and Patient #1 stated, "I don't know where I went but I feel like I am going to die." Staff Member #4 stated that Patient #1 also stated, "If I was at home I would be calling 911." Staff Member #4 stated that the DON was present during both of Patient #1's statements. Staff Member #4 reported that the DON responded, "We can't just send people out [to the emergency room], we have to call the physician."

E. Record review of facility's policy titled "Recognizing and Responding to deterioration in a Patient's condition" dated 03/2015 revealed the following:
1."Purpose: To improve patient outcomes by using a standardized process for detecting and acting upon early signs of deterioration in patients. This will in part, be achieved through the implementation of the National Early Warning Score (NEWS) system.
2. A NEWS is to be calculated:
Upon admission.
Each time a regular set of vital signs is obtained at 6 AM and 6 PM.
Any time a clinical staff member (any department) has cause for concern about the condition of a patient.
Any time a family member expresses concern about the condition of the patient a reassessment should be done.
3. Clinical response to the NEWS should be recorded on the chart. This will provide a continuous record of actions taken in response to variations in the NEWS and act as a prompt for escalating care if necessary."

F. Record review of Patient #1's medical record indicated there was no documentation of reported signs and symptoms from Patient #1 for the day of the event. There was neither documentation that a "NEWS" was completed nor any notes that the physician was notified of changes in Patient #1's condition.