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Based on record review, staff interview and policy review it was determined that the registered nurse failed to ensure accurate and timely assessments of the condition for two (#1,#8) of ten sampled patients. This practice does not ensure patients' nursing needs are met or appropriate interventions initiated.


Findings include:


1. The facility policy "Assessment /Reassessment" #PC 004.600, last revised 6/11 requires a shift assessment each shift. The nursing staff works 12 hour shifts. Assessment of the Intravenous (IV) site is included in the shift evaluation.

2. Patient # 1 was admitted to the facility on 5/3/11 with the chief complaint of headache. The history and physical indicated the patient had a history of lupus, diabetes, osteomyelitis and hypertension.

Patient #1 had an original IV line inserted in the left hand at 5:17 p.m. on 5/13/11.
There was no assessment of the IV site for the 7 a.m. - 7 p.m. shift on 5/4/11.

The assessment documented at 8:00 p.m. on 5/4/11 at 8:00 p.m. indicated the IV site was the left forearm. There was no documentation of when the a new IV catheter had been inserted or the reason for discontinuing the old one.

The assessment on 5/6/11 documented the site as the right forearm with the date of insertion as 5/5 instead of 5/4. There was no documentation of assessment of the site.

The assessment documented on 5/7/11 at 11:38 p.m. indicated the site was still the right forearm, but the insertion date was changed to 5/6/11. Again there was no documentation of assessment of the site.

The assessment on 5/8/11 at 8:00 a.m. indicated that the site was red and swollen. A new IV catheter was inserted in the left forearm.

The assessment on 5/8/11 indicated that the site was the right forearm instead of the left. The appearance of the site was not documented.

The assessment on 5/9/11 at 9:30 a.m. documented the site was the right forearm instead of the left and the date of insertion was 5/5/11 instead of 5/8/11.

The assessment on 5/10/11 at 2:56 a.m. documented the correct site and insertion date, but did not document the assessment of the site.

The assessment on 5/10/11 at 9:30 a.m. documented the site was the right forearm instead of the left and indicated the insertion date was 5/5/11 instead of 5/8/11.

The patient was discharged on 5/10/11. Nursing staff documented that the right forearm was swollen, red and purple. Review of the medical record revealed no evidence that the physician was notified of the condition of the right forearm.

The Licensed Practical Nurse who was caring for the patient at the time of the discharge was interviewed on 6/21/11 at approximately 2:30 p.m. She stated that she had notified the physician before the patient was discharged, but did not know if he had actually seen the patient. She stated she did not document that she notified the physician as she does not have time to document everything.

3. Patient #1 was readmitted on 5/14/11 with an infected IV site of the left forearm, requiring surgery.

An IV catheter was inserted into the left hand on 5/14/11 in the ED. The first assessment performed on the nursing unit on 5/14/11 at 9:07 p.m. did not include an IV assessment.

The assessment on 5/15/11 at 8:00 a.m. indicated the site was the left hand and the insertion date was 5/13/11 instead of 5/14/11. There was no documentation of the appearance of the site.

The assessment on 5/15/11 at 10:00 p.m. indicated the insertion date was 5/16/11, which was inaccurate.

On 5/18/11 the IV site was changed to the left antecubital space.

The assessment on 5/19/11 at 9:30 a.m. did not include assessment of the site.

The assessment on 5/20/11 did not include assessment of the site.

The assessment on 5/21/11 did not include assessment of the site. On 5/22/11 the site was changed to the left forearm. The assessment on 5/22/11 at 9:00 p.m. did not include site assessment.

The assessment on 5/23/11 at 11:15 a.m. did not include the site assessment.

The Nursing Director was present during the review of the record on 6/21/11 at approximately 3:00 p.m. She confirmed the findings but could not explain the inaccuracies in documentation. The VP for Quality was also present during the review. She stated the staff documents by exception. However, the policy she provided "Charting Within Defined Parameters", #IM.910.600 last revised 8/09 did not include the assessment of the IV site.

4. Patient #8 was admitted to the facility on 6/17/11 with the diagnoses of dehydration and acute renal failure. The initial IV was started in the left forearm on 6/16/11.

On 6/17/11 there was no shift assessment documented 7 a.m. - 7 p.m. shift.

The assessment on 6/17/11 at 2000 had no documentation of site assessment and indicated the insertion date was 6/17 instead of 6/16.

The assessment on 6/18/11 indicated there was an IV site in the left forearm with an insertion date of 6/17 and one in the left upper arm with an insertion date of 6/16/11. This was the first documentation of an IV site in the upper arm.

The assessment on 6/19/11 at 8:00 a.m. indicated an IV site in the left forearm with an insertion date of 6/17/11 instead of 6/16/11. The left upper arm site was also documented with an insertion date of 6/16/11.

The assessment on 6/19/11 at 9:00 p.m. indicated there was an IV site in the left wrist. There was no documentation of the two other IV sites being discontinued, the conation of the sites at the time discontinued or that a new IV site was initiated.

The staff nurse who was present during the record review on 6/22/11 at approximately 2:30 p.m. substantiated the findings.

5. The physician ordered daily weights for patient #8. Review of the documentation revealed the weight on 6/16, 6/17, 6/18 was documented as 99.7 kilograms (219.8 lbs). On 6/19 the weight was 69.84 kilograms (154 lbs), on 6/20/11 the weight was 73 kilograms, on 6/21 the weight was 73 kilograms (160.9 lbs.) and on 6/22 the weight was 76 kilograms (176.6 lbs). There was no evidence the accuracy or discrepancies of the documented weights had been investigated or addressed.

Based on record review and staff interview, it was determined that the facility did not ensure that medications are administered as ordered by the physician. This practice may result in failure to achieve maximum therapeutic effects.

Findings include:



Patient #8 was admitted to the facility on 6/17/11 with the diagnosis of dehydration and acute renal failure. The physician ordered Flagyl 500 milligrams IV every 8 hours on 6/17/11. Review of the Medication Administration Record revealed the medication was administered 1 1/5 hours late on 6/18/11. The dose was due at 2:00 p.m. and was not administered until 3:33 p.m. Additionally the nurse documented that the medication had been "scanned early, will give at 2200" at 8:15 p.m. on 6/20/11. There was no documentation that the medication was administered at 10:00 p.m., when it was due. These findings were confirmed by the staff nurse present during the record review on 6/22/11 at approximately 2:30 p.m.