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Based on record review and interview the facility nursing staff failed to evaluate and accurately record their evaluation of 2 (#2 and #5) of 8 (#1 through #8) patients whose medical record was reviewed.

This deficient practice had the likelihood to effect all patients of the facility.


Findings included.


On 4/1/2019 in the conference room the medical record (MR) for patients #1 through #8 were electronically reviewed with the assistance of the Infection Control nurse, staff #4. The findings were as follows:
Patient (Pt) #2:

Pt #2 came to the Emergency Department (ED) after suffering a fall in her home where her Right (rt) knee was injured. During the fall she reported she fell against a piece of furniture in her bedroom. Pt #2 took Coumadin 2.5 mg of Coumadin every other day and Coumadin 5 mg every alternate day. The physician documented bruising along pt #2's body where she fell against the bedroom furniture.

The Registered Nurse (RN) documented in the assessment of pt #2's skin "WNL" (within normal limits). The RN, failed to record the bruising that would have been visible had the RN evaluated pt #2's skin.

Pt #5:

Pt #5 came to the ED after a fall at home where she suffered a fractured wrist. The Physician documented pt #5 had a visibly deformed rt. wrist. (with mild discoloration and edema)

The RN documented Skin WNL.

Had the RN evaluated pt #5, the deformed rt. wrist with mild discoloration and edema would have been visible.