HospitalInspections.org

Based on policy review, record review and interview, it was determined the Governing Body failed to assume responsibility and provide oversight of the hospital's quality of care, patient rights and nursing services.

The findings included:

1. The Governing Body failed to ensure the Chief Executive Officer assumed responsibility and appropriately managed the hospital to ensure staff honored Patient's Rights, and physicians were notified of changes in patients' medical conditions.
Refer to A057.

2. The Governing Body failed to ensure Patient Rights were honored.
Refer to A132.

3. The Governing Body failed to ensure the medical staff was organized and accountable for the medical care provided.
Refer to A347.

4. The Governing Body failed to ensure nursing services provided were appropriately provided in accordance with patient needs.
Refer to A392.

Based on facility policy, record review and interview, it was determined the facility failed to comply with each Patients' Right and honor self-determination for cardiopulmonary resuscitation (CPR). The failure of the facility to provide CPR resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of death.

The findings included:

1. The facility failed to comply with the patient's self-determination for CPR in accordance to the Patient's Rights and facility policy
Refer to A132.

Based on record review and interview, it was determined the Medical Staff failed to have an organized medical staff that was responsible for the quality of medical care provided to patients in the hospital.

The findings included:

1. The Medical Staff failed to be accountable and ensure the quality of medical care provided in the facility.
Refer to A347.

Based on facility policy, record review and interview, it was determined the hospital failed to have an organized nursing service to provide nursing care in accordance with Patients' Rights, perform Cardiopulmonary Resuscitation (CPR) and notify the physician of changes in the patient's condition. The nursing services' failure to perform CPR on patients who were a full CPR status, and notify physicians of significant changes in patient's conditions resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY.

The findings included:

1. Nursing services failed to provide CPR to a patient who was a full CPR in accordance with the facility policy and Patients' Rights.
Refer to A392.

2. Nursing services failed to notify the physician, monitor and provide timely interventions for changes in patient's medical conditions.
Refer to A392.

Based on facility policy, medical record review and interview it was determined the Chief Executive Officer (CEO) failed to be responsible for managing the hospital and ensure staff honored Patients' Rights, and notified the physician of changes in patients' medical condition for 2 of 5 (Patients #1 and 2) sampled patients.

The findings included:

1. Review of the Code E Medical Emergency policy documented, "...initiate the 'Code'...(Medical crises may include, but are not limited to: cardiac arrest, pulmonary crisis)...The Charge Nurse or designee will initiate first aid treatment, including CPR/BLS [Cardiopulmonary Resuscitation/Basic Life Support]..."

2. Medical record review revealed Patient #1 was admitted to the Rehabilitation (Rehab) Hospital on 11/26/12 for rehabilitation services and was a "FULL CODE [cardiopulmonary resuscitation (CPR)]" status.

Review of the 11/26/12 Interdisciplinary Daily Documentation note documented the patient arrived to the facility at 16:10 PM and at 16:30 PM the patient was short of breath, had a low oxygen saturation level of 73.

Review of the 11/26/12, 11/27/12 and 11/28/12 nursing assessment notes documented the patient had a cough that had progressed to a productive cough with yellow sputum. The patient had swallowing and coughing problems that had progressed to the inability of the patient to manage the secretions. There was no documentation the nursing staff notified the physician of the low oxygen level or each time the patient's cough and swallowing problems progressively worsened.

Review of the 11/29/12 nurse's note documented at 0300 AM the patient was unresponsive, no breath sounds or heart sounds. The nurse reported to the charge nurse that the patient had expired.

During an interview on 5/28/13 at 1:35 PM the Chief Nursing Officer (CNO) stated there is no policy or protocol for low oxygen level saturations or physician notification of the low oxygen levels.

During an interview on 5/28/12 at 4:00 PM the CNO stated the staff did not perform CPR on this patient in accordance with the facility policy.

During a telephone interview on 5/30/12 at 6:15 PM LPN #1 stated, "No" CPR was not performed on this patient.

3. Review of the hospital's Chest Pain Protocol documented, "...Notify MD [physician]...[for complaints of chest pain]"

Medical record review revealed Patient #2 was admitted to the facility on 4/22/13 for rehabilitation services.

The 4/23/13 nurse's note documented at 12:15 AM the patient had chest pain. The physician was not notified of the 12:15 AM chest pain until 3:30 AM, at which time the physician ordered the patient to be sent out to the emergency room (ER). The nursing staff did not call for the ambulance until 4:05 AM and the patient did not leave for the ER until 4:20 AM. The patient expired after being discharged to another hospital ER.

Refer to A129 and A392

Based on facility policy, medical record review and interview it was determined the facility failed to ensure Patient Rights were honored for self-determination to receive Cardiopulmonary Resuscitation (CPR) for 1 of 5 (Patient #1) sampled patients. The facility's failure to provide CPR resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of death.

The findings included:

1. Review of the Code E Medical Emergency policy documented, "...In case of an acute medical crisis, the 'Code E' procedure will be implemented...The first person on the scene of the medical crisis will remain with the patient and initiate the 'Code'...Procedure...(Medical crises may include, but are not limited to: cardiac arrest, pulmonary crisis...)...The Charge Nurse will respond immediately to the area and take charge of the situation until a physician or 911 service arrives...The crash cart will be taken to the area by the Charge Nurse or their designee...The Charge Nurse or designee will initiate first aid treatment, including CPR/BLS [Cardiopulmonary Resuscitation/Basic Life Support]..."

Review of the "Inpatient Preadmission Guidelines/Procedures" policy documented, "... Patient Admissions Forms to be completed...Patient's Rights: This is an agreement between the hospital and the patient stating that we [hospital] agree to abide by their rights..."

2. Medical record review revealed Patient #1 was admitted to the Rehabilitation (Rehab) Hospital on 11/26/12 for rehab services.

Review of the 11/26/12 Preadmission Screening Form (PSF) documented the patient was a "FULL CODE [CPR]" status. The physician signed the PSF document. The PSF documented the patient's anticipated discharge destination was "Home with Services."

Review of the 11/26/12 Interdisciplinary Daily Documentation note documented the patient arrived to the facility at 16:10 PM and at 16:30 PM the patient was short of breath, had a low oxygen saturation level of 73.

Review of the 11/26/12, 11/27/12 and 11/28/12 nursing assessment notes documented the patient had a cough that had progressed to a productive cough with yellow sputum. The patient had swallowing and coughing problems that had progressed to the inability of the patient to manage the secretions. There was no documentation the nursing staff notified the physician of the low oxygen level or each time the patient's cough and swallowing problems progressively worsened.

Review of the 11/29/12 interdisciplinary daily documentation (IDD) notes revealed at 0300 AM the registered nurse/charge nurse (RN/CN) documented, "...Staff [a RN and licensed practical nurse (LPN)] making rounds found - pt unresponsive [without] respirations. No audible Breath sounds or heart sounds..." There was no documentation the RN and LPN stayed with the patient, initiated CPR, and called a CODE. There was no documentation the RN/CN assessed the patient, initiated CPR and called 911.

A RN note dated 12/1/12 at 0740 AM documented, "...LE [late entry] for 11/29/12 0300; while making rounds [LPN name] and myself noted the patient...to be unresponsive; Pt was leaning to the left side of the bed [without] any signs of VS [vital signs]; assessed pt; checked for radial and apical pulse absent, respirations absent, pupils fixed [with] some dilatation...reported to the RN charge nurse that the pt...was expired..."

3. During an interview on 5/28/12 at 4:00 PM the Chief Nursing Officer (CNO) stated the staff did not perform CPR on this patient in accordance with the facility policy.

During a telephone interview on 5/30/12 at 6:15 PM LPN #1 stated she and another nurse made rounds and found the patient on 11/29/12 at 3:00 AM without a pulse or respirations. LPN #1 stated, "No" CPR was not performed on this patient.

Based on medical record review and interview, it was determined the medical staff failed to be accountable and ensure quality of medical care was provided to 2 of 5 (Patients #1 and 2) sampled patients.

The findings included:

1. Medical record review revealed Patient #1 was admitted to the Rehabilitation (Rehab) Hospital on 11/26/12 for rehab services.

Review of the 11/26/12 Preadmission Screening Form (PSF), conducted by RN #4 documented the patient was a "FULL CODE [Cardiopulmonary resuscitation (CPR)]" status. The physician had signed the PSF on 11/26/12.

Review of the nurse's notes dated 11/26/12 documented the patient arrived to the facility at 16:10 PM. At 16:30 PM the patient was short of breath, had a low oxygen saturation of 73%, and was started on 2 liters of oxygen. The patient's respirations were documented as, "Normal" and "Shallow", "Regular" and "Irregular" and the patient had a cough.

The 11/26/12 Respiratory Therapy (RT) notes documented, "...Monitor aspiration Precautions...", and the patient was, "...dyspneic", respirations were 28 and had a moderate "work of breathing."

Review of the physician's 11/26/12 History and Physical Post-Admission Evaluation dictated at 21:40 PM documented the patient presented for intense inpatient rehab services and plans to return to home with his wife. The Review of Systems documented, "...Negative for cough, sputum production, pneumonia, shortness of breath, or wheezing...Negative for dysphagia...Positive for urinary infection..." Medications included "...Azithromycin [Zithromax] for urinary tract infection...Lasix for edema management..." and Impression on Admission, "...in need of inpatient rehabilitative services to ensure a safe and effective therapy..."

Review of the 11/27/12 nurse's notes documented the patient's respirations were shallow, irregular and a productive cough. The Patient complained of being short of breath and didn't feel like eating anything. At 2000 PM the nurse documented the patient was "very agitated & [and] restless...Restoril 15 mg [milligrams] given..." There was no documentation the physician assessed the patient.

Review of the 11/27/12 Respiratory Therapist (RT) notes documented the patient was in bed and looked "very tired", the therapist was unable to obtain an oxygen saturation level, and the patient's respirations were "still slightly labored..." There was no documentation of a physician assessment of the patient.

The 11/27/12 physician progress note, documented by another physician, documented, "...Pneumonitis- Zithromax x [times] 26 days..."

Review of the 11/28/12 nurse's note documented the patient had shallow respirations and a productive cough with yellow secretions. The nurse documented at 0800 AM the patient was at "...feeding table...tried to cough and was weak and couldn't produce anything...give pt an incentive spirometer...0930 AM...pt coughed up sputum x 3...1300 Pt weak trying to cough..."

Review of the 11/28/12 RT note documented the patient was at the "feeder table" and the Certified Nursing Assistant reported the patient was coughing "a lot while eating & [and] getting chocked [choked]...Bilateral sounds c [with] continuous upper lobe Rhonchi today. Speech notified, Duonebs ordered...Aspiration vs [versus] Congestion. Pt was coughing a lot while in room..."

Review of the 11/28/12 Speech Therapy (ST) note documented the staff were providing maximum assistance with eating secondary to poor tolerance "...requested suctioning [and] review for IV [intravenous] hydration...abnormal breath sounds [after] lunch & supper-unproductive cough & poor throat clearing..."

The 11/28/12 physician daily note documented, "...According to the Speech therapist...he [Patient] is extremely dehydrated and he needs fluids...Lungs...a few rales..."

Review of the 11/29/12 nurse's note documented, "...Staff making rounds found - pt unresponsive s [without] respirations. No audible Breath sounds or heart sounds..." There was no documentation CPR was initiated and full CODE called.

A late entry on 12/1/12 at 0740 AM documented, "...LE [late entry] for 11/29/12 0300 [AM] Pt was leaning to the left side of the bed s [without] any signs of VS [vital signs]; assessed pt; checked for radial and apical pulse absent, respirations absent, pupils fixed c [with] some dilatation...reported to the RN charge nurse that the pt...was expired. RN charge nurse handled the situation..."

During a telephone interview on 5/30/13 at 4:30 PM the patient's physician (and facility Medical Director) was interviewed regarding the patient's progressive Respiratory issues, appropriateness and aggressiveness of his treatment. The physician stated, "I saw him [Patient #1] the night he came into the facility. He had swallowing difficulty on admission and that's why I asked for a speech consult to look at him. I saw the swallowing problem, but didn't write it down." The physician stated, "No" he was not notified of the 73% oxygen saturation level on admission. The physician was interviewed regarding the inconsistency of the History and Physical to the documentation in the medical record and if he was aware of the patient's cough, that progressed to a productive cough with yellow sputum. The physician stated, "I started him on breathing treatments on 11/28/12. I relied on the Speech Therapist to inform me of swallowing problems. Doesn't look like he was here long enough to be aggressive with his treatment. I didn't want to label him with swallowing problems if it isn't needed."

2. Medical record review revealed Patient #2 was admitted to the Rehab hospital on 4/22/13.

Review of the PSF documented the "Anticipated Admit Date" to be 4/22/13. The patient had an acute care hospital stay on 2/23/13 for a Neurological condition that included a Cerebral Vascular Accident (CVA). The patient "...was seen by...cardiologist and cleared for intense PT/OT [Physical Therapy/Occupational Therapy] program...Spouse states patient snores terribly, feels like he might have sleep apnea but has never been diagnosed..." and was to be discharged home with home services.

Review of the 4/22/13 nurse's note documented the patient arrived to the facility on 4/22/13 at 1030 AM, had "expressive aphasia", used an "IPAD" to help with his communication. The patient had a history of Myocardial infarct (heart attack), Cardiac Disease, Impaired memory and a pulse of "48."

The physician's 4/22/13 History and Physical Post Admission Evaluation documented the patient was "...Negative for heart disease...Negative for chest pain..."

The 4/22/13 physician admission orders included Aspirin 81 milligrams daily, Chest Pain Protocol and a Low Cholesterol Diet.

The 4/23/13 Interdisciplinary Daily documentation (IDD) note revealed at "...0015 Observed pt [patient] standing in doorway of room. Call light not on. Unable to express verbally - was rubbing chest and repeating 'Oh man, Oh man' nods 'yes' when asked if chest hurt...restlessness noted-pt rocking back and forth rubbing chest. Manual bp [blood pressure]...130/80 P [pulse] -71, pulse ox [oxygen saturation] 98% RA [room air]...chest pain protocol initiated. Nitro SL [sublingual] X 1 administered. Mylanta protocol initiated & administered...O2 [oxygen]/2l bnc [ 2 liters a minute by nasal cannula]...will continue to monitor for CP [chest pain]..." There was no documentation the physician was notified of the patient's condition.

"0100...unable to express needs...will continue to monitor..."

"0200 Pt up and down. BP 96/73 unable to express needs verbally...will continue to monitor CP..." There was no documentation the physician was notified of the patient's low BP and condition.

"0315 Observed pt on hands & knees in doorway....unable to articulate any pain. Yes/No answers inconsistent at this time...very pale...skin cold & clammy...80/60 [blood pressure], P-76...Pt answers 'yes' and 'no' when asked if having pain" There was no documentation the physician was notified of the patient's condition.

"0330...Pt color looks better, no longer clammy, skin is cool to touch. Physician notified order received to send to ER..."

"0400 Report called to...ER..."

"0405 Ambulance called..."

"0420 Ambulance arrived..."

The 4/24/13 Progress note documented the patient was transferred to the local hospital Emergency Room for complaints of Chest Pain and expired.

During an interview on 5/28/13 at 4:00 PM, the patient's physician (and facility Medical Director) was questioned regarding the inconsistency between the patient's cardiac history and the physician's progress note that documented the patient had no cardiac disease or chest pain. The physician stated, "There must have been something I picked up on with his assessment, but didn't write it down. I don't know...He was aphasic and difficult to understand." The physician stated, "No, I don't always put the reason for the chest protocol in the notes"

Based on facility policy, medical record review and interview, it was determined the nursing services failed to perform Cardiopulmonary Resuscitation (CPR) on a patient who was a full CPR, and notify physicians of significant changes in patients' medical condition for 2 of 5 (Patients #1 and 2) sampled patients. The nursing services' failure to perform CPR on a patient who was was a full CPR, and notify physician of changes in patients' medical condition resulted in a SERIOUS and IMMEDIATE THREAT to the health and safety of all patients and placed them in IMMEDIATE JEOPARDY and risk of death.

The findings included:

1. Review of the Code E Medical Emergency policy documented, "...In case of an acute medical crisis, the 'Code E' procedure will be implemented...The first person on the scene of the medical crisis will remain with the patient and initiate the 'Code'...Procedure...(Medical crises may include, but are not limited to: cardiac arrest, pulmonary crisis...)...The Charge Nurse will respond immediately to the area and take charge of the situation until a physician or 911 service arrives...The crash cart will be taken to the area by the Charge Nurse or their designee...The Charge Nurse or designee will initiate first aid treatment, including CPR/BLS [Cardiopulmonary Resuscitation/Basic Life Support]..."

Review of the "Inpatient Preadmission Guidelines/Procedures" policy documented, "...The Rehab [Rehabilitation] Liaison evaluates the patient...the admissions team and medical director [determine] the appropriate level of rehab services...would be most beneficial for the patient..."

The facility Chest Pain Protocol documented, "...O2 @ 2L/min [oxygen at 2 liters per minute]...Nitroglycerin one tab sublingual every 5 minutes x [times] 3 doses (not to exceed 3 tabs in 15 minutes)...ASA [Aspirin] 325 mg [milligrams] po [by mouth] x 1 dose...Notify MD [physician]..."

Medical record review revealed Patient #1 was admitted to the Rehab Hospital on 11/26/12 for rehab services.

Review of the 11/26/12 Preadmission Screening Form (PSF), conducted by RN #4 revealed the patient was a "FULL CODE [CPR]" status. The PSF was signed by the admitting physician on 11/26/12. The PSF documented, "...problems with SOB [short of breath] with exertion...O2 at 2L BNC [by nasal cannula] QHS [every night] and PRN [as needed]..." The patient had diagnoses of Anemia, Osteoarthritis, Gastroesophageal Reflux, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Hyperlipidemia, Cardiac Bypass surgery and Peripheral Vascular Disease. The patient's anticipated discharge destination was "Home with Services."

The 11/26/12 "Physician's Orders" included an order for "...Chest pain protocol..."

Review of the 11/26/12 admission interdisciplinary daily documentation (IDD) assessment revealed the patient arrived to the facility at 16:10 PM. At 16:30 PM Licensed Practical Nurse (LPN) #2 documented the patient was short of breath, had a low oxygen saturation of 73% and was started on 2 liters of oxygen per nasal cannula. On the IDD pulmonary assessment section documented the patient as having "Normal" and "Shallow", "Regular" and "Irregular" breathing pattern and "Yes" the patient had a cough.

Review of the 11/27/12 IDD assessment revealed the patient had shallow and irregular pulmonary depth/pattern and a productive cough. At 1800 PM an IDD nurse's note documented the patient complained of being short of breath and didn't feel like eating anything. There was no documentation the physician was notified of the patient's condition.

On 11/27/12 at 1815 the Respiratory Therapist (RT) documented the patient was in bed and looked "very tired" this evening, was unable to obtain an oxygen saturation and the patient's respirations "still slightly labored..." There was no documentation the physician was notified of the patient's condition.

On 11/27/12 at 2000 the IDD nurse's note documented the patient was "very agitated & [and] restless...Restoril 15 mg [milligrams] given..." This IDD was signed off by the RN at 2030 PM as "...based upon patient status, the plan requires no modifications..." There was no documentation the physician was notified of the patient's condition.

Review of the 11/28/12 IDD assessment revealed the patient had shallow respirations and a productive cough with yellow secretions. The IDD narrative note (IDDNN) documented at 0800 AM the patient was at "...feeding table...tried to cough and was weak and couldn't produce anything...give pt an incentive spirometer...0930 AM...pt coughed up sputum x 3...1300 Pt weak trying to cough..." There was no documentation the physician was notified of the patient's condition until 1:00 PM.

The 11/28/12 RT noted documented at 1215 PM the patient was up at the "feeder table" and going back to their room. The Certified Nursing Assistant stated the patient was coughing "a lot while eating & getting chocked [choked]..." The RT note continued to document, "Bilateral sounds c [with] continuous upper lobe Rhonchi today. Speech notified, Duonebs ordered...Aspiration vs [versus] Congestion. Pt [patient] was coughing a lot while in room..."

The 11/29/12 RN charge nurse (CN) note documented, "...0200 Pt laying in bed. [No complaints of] pain or distress noted. IV [Intravenous] (R) [right] forearm infusing LR @ 75 cc/hr..." At 0300 AM the RN documented, "...Staff [a RN and LPN] making rounds found - pt unresponsive s [without] respirations. No audible Breath sounds or heart sounds..." There was no documentation the RN and LPN stayed with the patient, initiated CPR and called a CODE (a response team to perform CPR), or the RN/CN performed an assessment of the patient, initiated CPR and called a CODE.

A late entry nurse's note on 12/1/12 at 0740 AM documented, "...LE [late entry] for 11/29/12 0300; while making rounds [LPN name] and myself noted the patient...to be unresponsive; Pt was leaning to the left side of the bed s [without] any signs of VS [vital signs]; assessed pt; checked for radial and apical pulse absent, respirations absent, pupils fixed c [with] some dilatation...reported to the RN charge nurse that the pt...was expired. RN charge nurse handled the situation..."

During an interview on 5/28/13 at 1:35 PM the Chief Nursing Officer (CNO) was unable to find documentation the physician was notified of the low oxygen saturation level of 73% and cough on 11/26/12. The CNO stated the nurses most likely just used the "Chest Pain" protocol to apply the oxygen. There was no documentation the staff informed the physician of the patient's cough that progressed to a productive cough with yellow secretions.

During an interview on 5/28/13 at 1:35 PM the CNO stated there was no policy or protocol for low oxygen level saturations or physician notification of the low oxygen levels.

During an interview on 5/28/12 at 4:00 PM the CNO stated the staff did not perform CPR on this patient in accordance with the facility policy and Patient Rights.

During a telephone interview on 5/30/13 at 4:30 PM the patient's physician and facility Medical Director stated, "No" he was not notified of the 73% oxygen saturation level on admission. The physician stated he relied on the staff to inform him of the coughing or swallowing problems.

During a telephone interview on 5/30/12 at 6:15 PM LPN #1 stated she and another nurse made rounds and found this patient on 11/29/12 at 3:00 AM without a pulse or respirations. LPN #1 stated, "No" CPR was not performed on this patient.

During a telephone interview on 5/31/13 at 10:00 AM, regarding the 11/26/12 note, LPN #2 stated the patient was having some shortness of breath and his oxygen saturation was 73%. LPN #2 stated the charge nurse instructed her to start the oxygen. LPN #2 stated regarding the 11/27/12 note the patient was agitated and trying to get out of bed.

2. Medical record review revealed Patient #2 was admitted to the Rehab hospital on 4/22/13 and was on a Low Cholesterol Diet.

Review of the PSF conducted by the Emergency Medical Technician - Paramedic (EMT-P) on 4/12/13, prior to the patient being admitted to the facility, revealed the patient had an acute care hospital stay on 2/23/13 for a Neurological condition that included a CVA. The patient "...has exceptional potential to overcome right sided weakness...was seen by...cardiologist and cleared for intense PT/OT program...Spouse states patient snores terribly, feels like he might have sleep apnea but has never been diagnosed...drags right foot from time to time..." The patient was to be discharged home with home services.

The 4/22/13 IDD narrative note documented the patient arrived to the facility on 4/22/13 at 1030 AM, had "expressive aphasia" used an "IPAD" to help him communicate.

The 4/22/13 "Interdisciplinary Assessment" form documented the patient had a history of "...MI [Myocardial Infarct]...CAD [Coronary Artery Disease]...impaired memory..." and a pulse of "48."

The 4/22/13 IDD completed by an RN at 6:20 PM documented the patient had expressive aphasia and the patient was on a "Regular" diet.

The 4/23/13 IDD narrative note revealed at "...0015 Observed pt standing in doorway of room. Call light not on. Unable to express verbally - was rubbing chest and repeating 'Oh man, Oh man' nods 'yes' when asked if chest hurt...restlessness noted-pt rocking back and forth rubbing chest. Manual bp [blood pressure]...130/80 P [pulse]-71, pulse ox [oxygen] 98% RA [room air]...chest pain protocol initiated. Nitro SL [sublingual] X [time] 1 administered. Mylanta protocol initiated & administered...O2/2 l [liters] bnc [bi-nasal cannula]...will continue to monitor for CP [chest pain]..." There was no documentation the physician was notified of the patient's condition.

"0100...unable to express needs...will continue to monitor..."

"0200 Pt up and down. BP [blood pressure] 96/73 unable to express needs verbally...will continue to monitor CP..." There was no documentation the physician was notified of the patient's low BP or medical condition.

"0315 Observed pt on hands & knees in doorway....unable to articulate any pain. Yes/No answers inconsistent at this time...very pale...skin cold & clammy...80/60 [blood pressure], P-76...Pt answers 'yes' and 'no' when asked if having pain" There was no documentation the physician was notified of the patient's low BP or medical condition.

"0330...Pt color looks better, no longer clammy, skin is cool to touch. Physician notified order received to send to ER..."

"0400 Report called to...ER..."

"0405 Ambulance called..."

"0420 Ambulance arrived..."

During an interview on 5/28/13 at 4:00 PM, the patient's physician and facility Medical Director was asked if he was notified of the 12:15 AM chest pain on 4/23/13. The physician stated, "I don't think so." The physician also stated the patient "...was aphasic and difficult to understand. I would have wanted him on over to the hospital [ER]"

During a telephone interview on 5/30/13 at 6:45 PM RN #3 was questioned regarding the care of Patient #2. RN #3 stated "No" the physician was not notified when the patient initially complained of chest pain on 4/23/13 at 0015 AM. RN #3 stated during the time the patient began having chest pain at 0015 and the time the physician was notified at 0330 AM, "...He [patient] got up several times and would go back to bed. He did not appear to be in distress..." RN #3 stated "I called the MD [physician] when he [patient] came to the door on his hands and knees [at 0313 AM]. He would say things that didn't make sense like "Poppie, Poppie." RN #3 was asked if the patient was assessed for the complaints of chest pain at 0015 AM, such as listening to heart sounds, EKG or findings to reveal they were monitoring the patient for the chest pain from the 0015 AM incident until the patient left per ambulance at 0420 AM. RN #3 stated, "I don't think I listened to him at that time [0015 AM]. I did assess him at 0330 [AM], after the doctor said to send him out. When we send a patient to the ER, we have to do a full assessment." RN #3 stated "No Ma'am" they do not have the capability to obtain an electrocardiogram (EKG).

During a telephone interview on 5/31/13 at 10:05 AM LPN #3 was interviewed regarding the patient complaining of chest pain and the administration of Nitroglycerin for the chest pain. LPN #3 stated, "I administered the nitroglycerin to [patient's name]. I took him [was assigned to the patient's care] at 11:00 PM and it was my first experience with him...he had expressive aphasia...At 1:00 AM, I rubbed his arm and chest and he nodded his head No. He was going back and forth from the lobby and room. His pain appeared better with no distress"