HospitalInspections.org

Based on record review, interviews and observation the facility failed to ensure that 1 (P5) of 10 (P2 -P11) received an appropriate, comprehensive assessment, including diagnostic testing, by a Medical Doctor (MD) and subsequent proper care and treatment in accordance with accepted standards of practice. This deficient practice is likely to result in patients not receiving proper and necessary care and places patients at increased risk for poor health outcomes and potential physical harm.

The Findings are:

A. Record review of patient P1's (Complainant) email complaint sent to NM DOH, dated 12/28/20 at 4:06 pm reveals: "On the morning of November 13, 2020 my dad (P5- Target patient) woke up with chest discomfort. Dad described the pain as "acid reflux, heartburn." And further states that he (P5) was diagnosed with H-Pylori and was given two oral antibiotics (AB's). States that she (P1) called [name of facility] and spoke with a nurse (name unknown) asking about her dad's visit. P1's email states "I asked if they [name of facility] got a troponin, imaging or ECG (all cardiac labs or tests) they said no. I said my dad is 68 years old and is a cancer patient and complaining of heartburn. You did not do a cardiac work up on him to make sure he is not having a heart attack. He (the nurse on phone) said no, we did not, we just got a CBC and CMP." P1's email further reveals that she took P5 to the ED
(Emergency Department) of another hospital in the area on 11/14/2020 (the next day) where P5 was diagnosed with a myocardial infarction- STEMI. And that P5 was immediately transferred to another hospital specializing in cardiac care for a stent placement. Email further reads "I am horrified with the care he (P5) was provided at (name of facility)."

B. Record review of patient (pt.) P5's visit to the facility's Urgent Care (UC) clinic dated 11/13/20 at 8:13 am reveals the nursing triage states "68 y/o male here with c/o 'heartburn' since last night". This is also relisted on the MD's (S4) assessment. The MD's assessment (MDA) further reveals a significant medical history (hx.) with highlights including: Obesity; Malignant tumor of colon; on chemotherapy for 6 months. "Subjective: This is a 68 yo male with a history of colon cancer, h pylori pyloric ulcer (a stomach ulcer) who has had 'heart burn' since last night." The MD assessment note (MDA) also documented, "(Pt. stated) 'Tried to vomit, felt like it' but didn't vomit anything." The pt. was nauseous, but unable to vomit. The MDA continues, "Not feeling sob, no chest pain. Able to go for a walk this morning. Never happened before." MDA further states, "Abd (abdomen): Soft, non-tender, non-distended, no epigastric (upper abdominal area) pain." P5's vital signs (v/s) were within normal limits (wnl) except for significantly elevated blood pressure (b/p) of "161/92" (> 140/90 is wnl), and the pt. has no documented history of high blood pressure. A CMP, CBC w/ differential labs (blood testing) were ordered. No other labs or diagnostic tests were ordered by the MD. The MD's "Plan: Treating patient for h pylori triple therapy clarithromycin, amoxicillin, omeprazole [Antibiotic and Proton Pump Inhibitor (PPI) medications used for treating stomach ulcers], this will likely help patient with current acute reflux symptoms ..."
Not documented in the visit assessment are: Any documentation of a recheck of the pts. v/s due to elevated blood pressure. No documentation of the severity or quality of the pts. pain. Any questioning of pts. cardiac hx. or family cardiac hx. Any further questioning regarding what "Never happened before".

C. Record review of an email sent out to the facility's clinical staff dated January 7, 2021 at 12:01 am from Staff member S8 (MD, Director of Emergency Services (DES)) has a Subject line: "Magic words and EKGs":
"Hey guys, A reminder to everyone screening patients in OPD (Outpatient Disciplines, or servics) that the following phrases are magic: 'my chest hurts', 'my stomach hurts right here [pointing to under the ribs in the middle]', 'it's not pain, it's pressure', 'I think I have heart burn', 'I've been really freaked out and my chest has been hurting.'
Why magic? They all need EKG's, automatically at the time of screening. I've had a few patients recently that have had 'chest pain' as a chief complaint but haven't had an EKG done...Or they have a story, the patient who says 'it's my heartburn.' (Which is a diagnosis, BTW, not a chief complaint.) ...It's tempting to come up with a diagnosis yourself (anxiety, GERD, etc) or to accept the patient's self-diagnosis (heart burn, stress) but REMEMBER: we cannot miss a heart attack. If the pt has pain between the upper belly/lower ribs and the neck, do an EKG. And, as Dr. (name) pointed out, hand it directly to a provider (MD, NP, PA)."
"Thanks! (S8 Name)".

D. The facility's "Myocardial Infarction/Chest Pain Protocol (MICPP)", not dated or numbered, supports the "use of the PQRST mnemonic: P- Provoking. What provokes the pain? Q- Quality. What is the quality of the pain? R- Radiating. Does it radiate to any other area? S- Severity. How severe is the pain, on a scale of one to ten with ten being the worst? T- Time. When did the pain start? ...Has it ever occurred before?"
The only MICPP sign or symptom that is documented in the MD's assessment of P5 during their visit on 11/13/20 is "Time".

E. The facility's "Patient Chief Complaint (PCC)" guidelines, not dated or numbered, lists 8 pages of chief complaints with descriptions and guidelines for treatment. None of the following complaints: Epigastric, GERD, Heartburn or Indigestion, are listed anywhere on this PCC list. These four complaints can be indicators of a potential cardiac problem, including a possible heart attack.

F. On 2/17/21 at 11:55 am during phone interview, P1 (Complainant) stated that she was very unhappy with the care that her father (patient P5) received at (facility's name) Urgent Care (UC) clinic (on 11/13/2020). She said that P5 was seen by Dr. (name- S4) who is a Family Practice trained MD (Medical Doctor), not an ED (Emergency Dept.) doctor. P1 felt that P5 got a terrible "work-up" (medical assessment, testing and diagnosis). That P5 has a significant medical history (hx.), including being 68 y.o., obese and has a hx. Cancer and Barrett's Esophagus (BA- a chronic acid reflux condition, irritating the esophagus/throat). P1 was upset that a cardiac work-up was not done. Stated that her father (P5) complained to MD of severe burning and severe heartburn. Also that P5 told MD that he had "never experienced that (type of pain) in my life." P1 was also upset that her father was not offered meds (medications), such as a GI (Gastrointestinal- pertaining to the stomach and intestines) cocktail (A combination of medications for relieving GI upset, Acid reflux) or stomach medications (such as Protonix). P1 stated that she spoke with Dr. (name- S1, Medical Director) regarding this incident a few days later. P1 stated that S1 said: He was sorry. We will talk with Dr. (name- S4). But that S1 did not offer to make any changes or remedies. P1 did not file a complaint with the facility, but did file a complaint with "JCAHO (Joint Commission- A hospital accreditation organization)." P1 was not with P5 during this alleged incident at the facility. P1 also stated that she is a Nurse Practitioner (NP) working in the ED at another hospital in the area.

G. On 2/18/21 at 2:35 pm during interview, I asked S1's (Medical Director- M Dir.) professional opinion (regarding P5's visit to the facility's Urgent Care clinic on 11/13/20 and the assessment and care that P5 received), S1 stated "Yes, I would have gotten Troponins, Lipase and an EKG (all are cardiac labs and tests)." S1 further stated "Dr. (name- S4, MD who saw P5 on 11/13/20) is a new doctor here, but a good doctor." S1 also stated that he remembered this case and remembered speaking with P5's daughter (P1) and that he apologized and asked if P1 wanted to do anything else (about the incident). S1 stated that P1 did not want to file a formal grievance with the facility. But that P1 seemed to want to pursue it (the incident) further, possibly a lawsuit or complaint.

H. On 2/19/21 at 11:00 am during interview in the Emergency Department (ED), S5 (Medical Doctor- MD) stated that he had been working at the facility for about 3 ½ years and that his medical degree was as a "Family Practice" MD. Also, that prior to coming to this facility he had worked for about 10 years in Pennsylvania "doing full spectrum (of areas of working as an MD), except for the ER (Emergency Room)." Stated that he received general training for the ED when he arrived at the facility and that "we always have other MD's (to consult with)". S5 stated that for complaints of (c/o) GERD (Gastro esophageal reflux disease- can cause indigestion and heartburn sensations), left shoulder pain, nausea, shortness of breath, "I always get cardiac enzymes (a cardiac lab test) and an EKG ...I've learned to play it safe."

I. On 2/19/21 at 10:10 am during interview, S1 (Medical Director) stated that the email (see "Record Review C.") from S8 (MD, Dir. of Emergency Services) was sent out, in response to the outcome of P5's Urgent care clinic visit on 11/13/20. He also stated that ER training is part of Residency (MD's clinical rotations after completing medical school) training. S1 stated that the facility also uses OPPE's (Ongoing Professional Practice Evaluations) and that "when an (new) MD arrives, we assess their training and comfort level (with the ER). We do extra training as the individual needs." S1 also verbalized that the facility does ongoing ER specific trainings about "3 or 4 times a month." These were given as some of the reasons why there are not specific protocols some situations or signs and symptoms (s/s) for "GERD or Heartburn" (no written facility protocols for either of these conditions).

J. Record review on 2-25-21 of the Cleveland Clinic's website (https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction)
revealed that "Symptoms of a heart attack include: Chest pain or discomfort in the center of the chest...burning...It is sometimes mistakenly thought to be indigestion or heartburn...or choking feeling (may feel like "heartburn"). Nausea or vomiting." [This is not a comprehensive list from their website].

The website (https://my.clevelandclinic.org/health/diseases/16818-heart-attack-myocardial-infarction#diagnosis-and-tests) further revealed the following tests for diagnosing a heart attack: "Many tests may be ordered to determine if you have experienced a heart attack. These include: 12-lead ECG (a diagnostic heart test); Blood Studies (lab tests specific to the heart); Echocardiogram (a diagnostic heart test); and Cardiac catheterization (a diagnostic heart test).

K. Record review on 2-25-21 of Web MD's website (https://www.webmd.com/heart-disease/guide/heart-disease-heart-attacks#2-6) revealed that:
"Symptoms of a heart attack include:
· Discomfort, pressure, heaviness, tightness, squeezing, or pain in your chest or arm or below your breastbone
· Discomfort that goes into your back, jaw, throat, or arm
· Fullness, indigestion, or a choking feeling (it may feel like heartburn)
· Sweating, upset stomach, vomiting, or dizziness
· Severe weakness, anxiety, fatigue, or shortness of breath
· Fast or uneven heartbeat"

This website suggests the following diagnostic tests:
"Tests to diagnose a heart attack
Your doctor may order tests including:
· EKG. An EKG (also known as an electrocardiogram or ECG) can tell how much your heart muscle has been damaged and where. It can also monitor your heart rate and rhythm.
· Blood tests. Different levels of cardiac enzymes in your blood can indicate heart muscle damage. These enzymes are usually inside the cells of your heart. When those cells are injured, their contents -- including the enzymes -- spill into your bloodstream. By measuring the levels of these enzymes, your doctor can find out the size of the heart attack and when it started. Tests can also measure troponin levels. Troponins are proteins inside heart cells that are released when the cells are damaged by the lack of blood supply to your heart.
· Echocardiography. This imaging test can be used during and after a heart attack to learn how your heart is pumping and what areas aren't pumping the way they should. The "echo" can also tell whether any parts of your heart (valves, septum, etc.) have been injured in the heart attack.
· Cardiac catheterization. You might need cardiac catheterization, also called cardiac cath, during the first hours of a heart attack if medications aren't helping the ischemia or symptoms. The cardiac cath can give an image of the blocked artery and help your doctor decide on a treatment."