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Based on interview, record review, and review of the facility policy, the facility failed to ensure a Registered Nurse supervised and evaluated the care for one of ten sampled patients (Patient #1). Patient #1 made the decision to leave the hospital against medical advice (AMA); however, there was no evidence the Registered Nurse (RN) provided ongoing assessment and evaluation of the patient for approximately two and one-half hours while the patient waited for transportation to leave the facility.

The findings include:

Review of the facility's Assessment and Reassessment policy (no date) revealed each patient admitted to the facility would receive a head-to-toe assessment by a qualified individual. The policy stated the assessment of the care or treatment required to meet the needs of the patient would be ongoing throughout the patient's hospital stay. The policy further noted the assessment included the collection and analysis of relevant physiological, psychological, and social/environmental data regarding each patient.

Review of the Emergency Room (ER) record revealed Patient #1 presented to the ER on 03/21/12, at 1:53 PM, with complaints of chest pain and was admitted to the Cardiac Telemetry Unit for further evaluation and treatment at 4:51 PM. Review of the initial nursing assessment conducted on 03/21/12, at 5:34 PM, revealed Patient #1 was admitted to the telemetry unit with an intravenous access site, IV Heplock, in place on the patient's left hand and telemetry monitoring was initiated for cardiac monitoring.

A review of the physician's orders dated 03/21/12, at 6:18 PM, revealed the patient had orders for cardiac enzymes to be conducted every six hours and an Electrocardiogram (EKG) to be conducted the following morning on 03/22/12.

Review of the Electrocardiogram (EKG) and laboratory results conducted on 03/21/12 and 03/22/12, revealed Patient #1 had experienced changes in the EKG and had an elevation in troponin levels (elevations may indicate some degree of damage to the heart).

On 03/22/12, at 8:00 AM, the patient's attending physician assessed the patient and noted Patient #1 had a history of Coronary Artery Disease with status post coronary artery bypass grafting and multiple stent placements, Congestive Heart Failure, and Atrial Fibrillation. Patient #1's attending physician recommended cardiology services at the hospital; however, the patient declined and requested to go to another hospital to be treated by a cardiologist that provided treatment to the patient in the past. Ambulance transportation was arranged for Patient #1; however, the patient refused to be transported by ambulance after learning he/she could possibly be responsible for payment. Patient #1 decided to leave the hospital and have family members transport the patient to the desired hospital. Record review revealed the patient signed out Against Medical Advice (AMA) on 03/22/12, at 10:00 PM.

Review of the nursing documentation revealed the Registered Nurse (RN) that worked the 7:00 AM to 7:00 PM shift on 03/22/12, conducted an assessment of Patient #1 on 03/22/12, at 5:40 PM. The nurse assessed Patient #1 to be awake and alert with no complaints of chest pain. The patient was also assessed to have a regular heart rate in normal sinus rhythm per telemetry monitoring and to be receiving oxygen therapy at 2 liters per nasal cannula. Patient #1 was also assessed to have a Heplock IV in place on the left wrist.

At 7:42 PM on 03/22/12, the nursing assistant assessed the patient's vital signs and documented a blood pressure of 107/56, a heart rate of 74 beats per minute, a respiratory rate of 20 breaths a minute, and a temperature of 98.1 degrees Fahrenheit. However, there was no evidence an RN had completed an assessment of Patient #1 from 5:40 PM on 03/22/12, until the patient signed out of the hospital at 10:00 PM on 03/22/12; a timeframe of four hours and twenty minutes.

Interview conducted with Patient #1 on 05/22/12, at 9:30 AM, revealed the patient had decided to leave the hospital AMA after learning he/she could be responsible for payment for the ambulance trip. The patient stated family members were going to take the patient by private car to the desired hospital. Patient #1 stated the family members left to go eat dinner before taking the patient to the other hospital and stated the nurse did not "check on" her/him from around 7:30 PM to 10:00 PM. The patient stated he/she signed the AMA form at 10:00 PM, and left the hospital shortly after.

Interview conducted with RN #1 on 05/24/12, at 11:05 AM, revealed RN #1 was assigned to Patient #1 on 03/22/12, during the 7:00 AM to 7:00 PM shift. RN #1 stated the ambulance service reported to her at "close to change of shift" that the patient had refused to sign the required paperwork for transport to the other hospital. RN #1 stated she discussed this concern with Patient #1 at approximately 6:45 PM, and the patient stated he/she wanted to leave the hospital and have family transport the patient to the other hospital. RN #1 stated she informed the patient of the risks involved with leaving AMA. RN #1 stated she reported to the staff coming on duty for the 7:00 PM to 7:00 AM shift, including RN #2, of Patient #1's request to sign out AMA, and that the AMA form had not been signed. RN #1 further stated when she left the hospital at 8:00 PM the patient was still in the room.

Interview with RN #2 on 05/24/12, at 2:25 PM, revealed she was the charge nurse for the 7:00 PM to 7:00 AM shift and was responsible to "check on" the patients and to assist the other nurses as needed. RN #2 stated she was told during shift report Patient #1 was being transported by private car to another hospital and was to sign out AMA. RN #2 stated she checked on Patient #1 sometime after she received report, but could not recall the time and did not do an assessment of the patient. The RN stated she learned the patient was still at the hospital at 10:00 PM, and had the patient sign the AMA form.

Interview with RN #3 on 05/24/12, at 3:10 PM, revealed he was originally assigned to care for Patient #1 during the 7:00 PM to 7:00 AM shift on 03/22/12. RN #3 stated he was told in shift report the patient was signing out AMA and he believed the patient had already left the hospital. RN #3 stated at approximately 10:00 PM, a nurse aide reported Patient #1 was still at the hospital. RN #3 stated he and RN #2 went to the patient's room and had the patient sign the AMA form. RN #3 stated he did not assess or monitor the patient after he reported to work at 7:00 PM.

Interview conducted with Nurse Aide (NA) #1 on 05/29/12, at 11:47 AM, revealed she had been told the patient was going home by the 7:00 AM to 7:00 PM nurse aides during shift report. NA #1 stated she obtained vital signs on Patient #1 at 7:45 PM, and stated the patient was dressed in street clothes but there were no family members with the patient at that time. The NA stated she saw the patient again at approximately 9:00 PM, and the patient was watching TV. NA #1 stated the patient did not offer any complaints of pain or discomfort when she saw the patient.

Interview with the Vice President of the facility on 05/29/12, at 10:00 AM, revealed the facility could not provide evidence the patient had been monitored or assessed by the RN from 7:30 PM to 10:00 PM on 03/22/12. The Vice President stated communication during the shift report could have been the problem that resulted in the staff's failure to assess Patient #1.

Interview with the Chief Nursing Officer (CNO) on 05/30/12, at 8:55 AM, revealed RNs and nurse aides were to conduct hourly rounds to assess patients. The CNO stated that although the nurse aide was aware the patient remained in the facility the CNO believed the nurse aide thought the RN also was aware the patient remained in the facility. However, according to the CNO, staff assigned to Patient #1's care should have been aware of the patient's status and that the patient remained in the facility.