HospitalInspections.org

Based on review of Hospital policy, clinical records, staff interview, and personnel file review, it was determined, that for 1 of 10 clinical records reviewed (Pt. #1), the Hospital failed to ensure nursing staff took appropriate action when a patient's condition changed.

Findings include:

1. Hospital policy titled, "Nursing Documentation," effective 9/09, required, "... Nursing documentation is required... Change in condition/status... In the ICU [Intensive Care Unit]... system reassessments are performed and documented at a minimum of every 4 hours, based on... identified problems..."

2. Pt. #1's clinical record included that Pt. #1 was a 60 year old female, admitted to the Hospital on 2/26/12, with a diagnoses of Fever and Esophageal Cancer.

A physician's progress note on 3/4/12 at 3:19 PM, included, " ... She is concerned about her left arm swelling. She denies any pain in the arm ... Left upper extremity has 3++ pitting edema ..." A consultation note dated 3/6/12, included, " ... the patient developed pain and swelling of the left upper extremity and an ultrasound dated 3/4/12, showed DVT [Deep Venous Thrombosis] involving the left internal jugular vein ... Impression ... Deep venous thrombosis involving left upper extremity..."

3. The first nursing documentation of Pt. #1's left arm swelling was on 3rd floor (Medical/Oncology/Renal Unit) flow sheets on 3/4/12 at 3:29 AM. Pt. #1 transferred from ICU to the 3rd floor in the evening on 3/3/12.

4. On 7/24/12 at 9:20 AM, an interview was conducted with the Manager of the ICU. The Manager stated that she had investigated Pt. #1's family complaint regarding lack of action related to Pt. #1's left arm swelling. The Manager stated that an RN (E #2) took care of Pt. #1 on 3/3/13 and was approached by the family regarding left arm swelling. E #2 thought the swelling was slight and that the blood pressure cuff was the cause. E #2 removed the blood pressure cuff and elevated Pt. #1's arm on a pillow. Pt. #1 had been on DVT prophylactic Lovenox prior to the swelling.

5. The Intensive Care Unit (ICU) flow sheets and notes did not include assessment of left arm swelling or any actions taken related to edema. A physician was not notified.

6. The Manager stated that she spoke with E #2 about the incident. However, E #2's personnel file was reviewed and there was no counseling or educational documentation related to the Manager's speaking to E #2 regarding Pt. #1's incident.