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Based on medical record review, review of the Ambulance Service Report and the Acute Care Transfer Report and interviews, Nursing Staff failed to thoroughly assess Patient Identifier (PI) #1 when the family reported complaints of chest pain on 10/15/14 to include details of PI # 1's pain (location, severity/type, radiation to other locations, and or aggravating and/or alleviating symptoms). This deficient practice affected PI # 1, one of ten medical records reviewed and had the potential to affect all patients served.

Findings Include:

Medical Record Review:

PI # 1 was admitted to HealthSouth Dothan (Hospital # 1) for inpatient rehabilitation on 9/30/14 with diagnoses to include:
1) Stroke.
2) Obesity.
3) Hypertension (HTN).
4) Hyperlipidemia.

A review of the History and Physical Evaluation / Post Admission Physical Evaluation dated 10/1/2014 revealed:

Chief Complaint: Impaired mobility and inability to care for self.

History of Present Illness: A 62 year old who presented to the emergency room with dizziness. Computed tomography (CT) was negative...The patient developed left-sided numbness and tingling. Magnetic Resonance Imaging (MRI) showed a right pontomedullary brainstem infarct...Ongoing left sided weakness.

Past Medical History:

1). Stroke.
2) Chronic Kidney Disease.
3) Type II Diabetes.
4) Hyperlipidemia.
6) Coronary Artery Disease with previous Myocardial Infarction (MI).
7). Morbid Obesity.
8). Obstructive Sleep Apnea.

Physical Examination:
Lungs: Clear to auscultation bilaterally.
Heart: Normal rhythm and rate.
Extremities: Trace edema.
Neurological: Cranial nerves intact. Left sided weakness noted. Visible muscle contracture in left arm, but no movement in left arm. Weakness in the left leg.


Review of Interdisciplinary Temporary Communication Sheet: (Form used by staff to communicate with physician):

10/7/14 05:40: ...Productive cough with blood tinged tissue/sputum.

A review of the Nursing Narrative dated 10/7/14 revealed no documentation the physician was notified directly about PI #1's blood tinged sputum by the Registered Nurse (RN). However, the Daily Nursing Assessment dated 10/7/14 at 01:00 revealed PI # 1 had a productive cough that was described by the RN as "blood tinged."


Interdisciplinary Daily Documentation / Daily Nursing Assessment at 10/14/14 at 00:30 (Documented by LPN, Licensed Practical Nurse / Employee Identifier, EI # 1):

Alert and oriented to person, place and time. Orientation is "consistent to person, place and time."

Edema: Localized. BLE (Bilateral Lower Extremities).

Breath Sounds: Clear (right and left) lung.

"Cough: No." There is no documentation to indicate PI # 1 had any respiratory secretions. Co-Signed by RN (EI # 2) at 00:10.


10/14/14:
HealthSouth Dothan (Hospital # 1):

Nursing Narrative Note documented by LPN / EI # 1, on 10/14/14 at:

20:00: "Family in room with pt. (patient), sitting on BS (bedside)..."

22:00: "Pt's wife @ (at) nursing desk, concerned that pt. has made comments of 'where am I' and 'why is this garbage can moved,' pt. assessed by supervisor, pt. answered questions appropriately, pt. removes CPAP (Continuous Positive Airway Pressure) mask within minutes of it being applied, O2 (Oxygen) sat. (saturation) checked per wife request. 98% at this time."



10/15/14:
Interdisciplinary Daily Documentation / Daily Nursing Assessment at 10/15/14 at 00:30 (Documented by LPN/ EI # 1):

Alert. Oriented to person.

Edema: Generalized.

Breath Sounds: Clear (right and left) lung.
"Cough: No." There is no documentation to indicate PI # 1 had any respiratory secretions. Co-Signed by RN (EI # 2) at 00:10.


Nursing Narrative Note (Documented by LPN - Licensed Practical Nurse/ Employee Identifier # 1) on 10/15/14 at:

0050: "Clonodine PRN (as needed) med. (medication) given for BP (Blood Pressure) 167/101."

0035: "Pt. c/o (complained) chest pain, EKG (electrocardiogram) done, VS (Vital Signs) 181,88, P (Pulse) 69, pt's (patient's) wife wants to send to ER (Emergency Room) to be evaluated." There is no documentation to indicate the nurse assessed PI # 1's chest pain to include (location, severity/type, radiation to other locations, and or aggravating and/or alleviating symptoms).

01:20: "Pt. transported by stretcher via (name of Ambulance Service) to ER."


Review of Acute Care Transfer Report (Hospital # 1), Dated: 10/15/14. Time: 01:00:

How was event discovered? "Family/Visitor Reported."

"Patient (PI # 1) told wife he started having dull left sided chest pain, I (first name of Nursing Supervisor) went in to assess patient. Had to awake patient up to ask him about any pain that he was having. Stated he was having a dull left, side chest pain that just started. Called MD (Medical Doctor) to say wife wanted him transferred to Hospital # 2 for evaluation, was told by ER (Emergency Room) that he was intubated and placed in ICU (Intensive Care Unit)."


Patient Care Report - Ambulance Service (Transfer via EMS (Emergency Medical Services) from HealthSouth Dothan (Hospital # 1) to the Emergency Department at Hospital # 2:

Date of Service: 10/15/14
Time: Arrived on scene: 01:09.
Transported: 01:32.
Arrived at ED: 01:33.
Patient Name: (PI # 1)

Chief Complaint: SOB (Shortness of Breath).
Other Associated Symptom: Pain
Assessment 01:41: Blood Pressure: 186/82, Pulse: 76 and irregular. Respirations: "30. Labored."
"Airway: Partially obstructed - tongue. Chest expansion - asymmetrical, shallow. Lung Sounds Left = Rhonchi/Wheezing.


Treatment:
01:41- Oxygen 15 LPM (Liters per minute). No oxygen PTA (Prior to arrival). Route: Re-breather mask.

01:41: Cardiac Monitor. A-Fib (Atrial Fibrillation).

Narrative: "...AOS (Arrived on Scene) to find ... (PI # 1) sitting in bed with pain 5/10...Rhonchi noted to right side and snoring on left side...Pt. states complaint of chest pain non-radiating on left side. Cardiac monitor and 12 lead EKG indicate atrial fibrillation...Assisted to stretcher...unable to find IV (intravenous site)...On arrival, pt. (patient) moved to ER room by stretcher and draw sheet lift..."


Review of Medical Record from Emergency Department at Hospital # 2 on 10/15/14. Arrival Time: 01:37:

Nursing Assessment - 01:44: Alert, awake, drowsy. Needs to be aroused using tactile (touch) stimuli, but then will answer questions and follow commands.

Chest pain located in the anterior aspect of left upper chest and left breast area. Pain is described as moderate with radiation to left arm.

Edema, pitting to left midcalf, left ankle, left foot, right midcalf, right ankle and right foot.

Reports shortness of breath. Respiratory effort is labored, shallow. Respiratory pattern is snoring. Sputum is thick, blood streaked. Wife reports chest pain and shortness of breath at rest.

Respiratory - 01:50: NIV/BIPAP (Non-invasive, bi-level positive airway pressure). Respiratory rate 45 bpm (breaths per minute). "Pt. not tolerating (mask) took off to bag pt. and intubate.

02:00: Ventilator Assessment: Actual and Ventilator rate: 18 per minute. Breath sounds: coarse with crackles


Physician Documentation: ED Hospital # 2

02:27 - History of Present Illness: This patient, with a history of hypertension diabetes, myocardial infarction, renal disease, presents as a transfer from Hospital # 1 after complaining of left sided chest pain that woke the patient from sleep. Upon arrival, patient was extremely lethargic would awaken and respond with sternal rub and would quickly fall back to sleep. Patient reports this chest pain feels similar to previous heart attack.

Exam: 02:27:

Constitutional: The patient appears lethargic, in obvious distress.

Cardiovascular: Rate and rhythm regular. Heart sounds distant.

Respiratory: Severe respiratory distress is noted. Labored breathing - severe; grunting moderate, shallow respirations. Tachypnea (abnormally rapid rate of breathing). Decreased breath sounds.

Procedures:
03:00: Intubated...

02:27: Differential Diagnosis: Acute MI (Myocardial Infarction), Congestive Heart Failure...Upon arrival patient began to deteriorate. Saturations were in the 70's. Patient placed on non-rebreather which brought O2 saturation into the 80's...then placed on a BiPAP. Patient continued to deteriorate and the decision was made to intubate and admit to ICU.


Interviews with HealthSouth / Hospital # 1 Staff:

Interview with Attending Physician, Employee Identifier (EI) # 4 on 2/10/15 at 06:15 AM:

According to EI # 4, the patient (PI # 1) could have had flash pulmonary edema when transferred to the acute care hospital on 10/15/14. "I was not on call. It's possible the patient not critically ill when he left HealthSouth (Hospital # 1) and later became increasingly ill." EI # 4 said PI # 1 did not have a CPAP machine at HealthSouth because he was intolerant of CPAP.


Interview with LPN / EI # 1 on 2/10/15 at 11:29:

EI # 1 confirmed assignment to PI # 1 on 10/14/14 and 10/15/14 after review of the Nurses Notes, but employee states unable to remember PI # 1. According to EI # 1, PI # 1's wife reported the patient was confused. "I (EI # 1) thought he was confused...informed supervisor." The Supervisor assessed PI # 1 who answered questions appropriately. EI # 1 was asked to describe the patient's pain because there is no documentation in the nursing note except, "C/o (complained) of chest pain." EI # 1 said, "I should have documented severity and location."


Interview with Nursing Supervisor / EI # 2 on 2/10/15 at 14:35:

According to EI # 2, the patient did not have chest pain at the time of his assessment on the 7:00 PM to 7:00 AM shift on 10/14/14. EI # 1 was asked if he documented the assessment of PI # 1 in the medical record and he said, "The LPN (Licensed Practical Nurse) did. He ( PI # 1) did not have chest pain. PI # 1's wife insisted he had chest pain... He (PI # 1) was not short of breath. Not fighting for air when he left. Another relative was in the room - don't know relationship." EI # 2 verified the transfer order for PI # 1, "Family requests transfer to Hospital # 2 for chest pain evaluation." EI # 2 denied knowledge of pink colored, frothy sputum related to PI # 1.