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Based on policy review, document review, and staff interviews the Critical Access Hospital (CAH) administration, including the Director of Nursing, failed to ensure that consistent, documented nursing services, that meet the needs of patients, specifically a Certified Nursing Assistants (CNA) failure to report changes in patient condition to the Registered Nurse in charge of the patient's care. Concerns were identified in 1 of 5 closed medical records reviewed (Patient #1). The CAH administration reported an inpatient census of 12 patients.

Failure to ensure that nursing staff consistently provide care to patients, in accordance with the patient's needs and the qualifications of the nursing staff, has the potential to impede the physical recovery of each patient.

Findings included:

1. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #10022.00, dated 11/09, titled Assignment of Patients stated Floyd County Memorial Hospital utilizes a team approach to nursing care. The team consists of registered nurses (RN), licensed practical nurses (LPN), and nursing assistants (CNA).

2. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #2097.00, dated 11/09, titled Admission of a Patient stated in the section tilted All Patients: #4.) The nursing personnel assigned to the patient will perform the admission procedure. Pertinent information concerning the patient or his/her condition will be entered into the Electronic Medical Record.

3. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #2097.00, dated 11/09, titled Admission of a Patient stated in the section tilted Procedure:

a. The RN will conduct the admission interview; assess the patient's physical, mental and emotional status, general condition, health history; assess the patient's present problem, major complaint, and presenting symptoms.
b. The RN is responsible for the initial assessment and for verifying the LPN's findings.
c. The Braden Scale Assessment - Skin Risk is to be completed as part of the admissions interview. Make appropriate consults as indicated to Enterostomal Nurses (skin care specialists) or Dietary.

4. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #2075.00, dated 11/09, titled Documentation in the Narrative Nurses Notes stated in the section tilted Specific information to be included in the Nurses Notes:: #6.) Wounds, ulcers, dressings: Document size, color, drainage, odor, include changes of the wound's appearance and characteristics. Document initial assessment and reassessments of wound using the "Wound Flow Sheet".

5. Review of the first closed medical record for Patient #1 admitted to the medical/surgical unit on 12/18/09 and discharged on 12/23/09 revealed:
a. Nursing staff documented that Patient #1's skin was intact and without discoloration on admission on 12/18/09 to the time of discharge on 12/23/09 at 9:22 AM. Skin assessments are completed and documented once on every shift by nursing staff, per hospital policy.
b. Patient #1's medical record lacked documentation of bruised areas or deformities on Patient #1's left leg when she was admitted to acute care on 12/18/09 to her discharge at 9:22 AM on 12/23/09.

6. Review of the second closed medical record for Patient #1, admitted: 12/23/09 at 4:55 PM to Floyd County Medical Center revealed:
a. Patient #1 returned to the Emergency Room, after staff at the Nursing Home reported the patient was found with multiple, large bruising areas on her left leg, from below the left leg to the left hip area. The Nursing Home staff also reported that the patient's left leg was rotated inward and noticeably shorter than the right leg.

b. Review of the Emergency Room physician's History and Physical dated 12/23/09 at 5:05 PM revealed:
... She (Patient #1) was admitted to this hospital for pneumonia on December 18, 2009. She was placed on intravenous antibiotics, and she has not responded to this. The patient has poor respiratory excursion. The patient was found to have an anemia by the third hospital day and initially it was felt that that was probably secondary to her infectious disorder or gastrointestinal blood loss. Admittedly we elected not to evaluate this. At the time there was no external ecchymosis or bruising noted ... "
Review of her records from her first admission starting with the Emergency Room note does not indicate that there was any external ecchymosis noted or other deformities. Review of all nursing notes indicated that the patient was able to be repositioned with minimal obvious discomfort. There was a note at the time of discharge that a nursing assist noticed some old contusion on the posterior left leg. (This entry was not at the time of discharge but was recorded in the electronic medical record at 3:36 PM). After the patient arrived at the nursing home the nursing staff did call and mention that the leg appeared different to them so we had her return to the hospital where we could x-ray her leg, and she has a nondisplaced distal femur fracture. The bones are markedly osteoporotic.

7. On interview with Staff I, CNA, on 1/5/10 at 2:00 PM, it was reported:
a. "My duties as a CNA involve assisting the nursing staff with caring for patients. I assist with bathing, turning, walking, feeding, measuring intake and output, and anything else the nursing staff tell me to do."
b. "It is my responsibility to report to the nurse, either RN or LPN, any changes I find when I care for a patient."
c. I took care of Patient #1 on 12/22/09 and completed a bed bath on her. This included turning Patient #1 on to her right side and washing the left side of her body, including her legs. There was no bruising on Patient #1 on 12/22/09.
d. On 12/23/09, I was getting Patient #1 ready for transfer to the Nursing Home with the assistance of the staff that was sent by the Nursing Home to accompany the patient. Using the Hoyer Lift (a patient lift that uses a sling to move a patient) we positioned Patient #1 so we could set Patient #1 in her wheelchair. "At that time, I saw a very large bruise on the patient's left leg. It looked like an old bruise."
e. " I assumed it was an old bruise and that someone else had reported it to the nurse." "I did not notify the nurse of the bruise even though I had not noticed the bruise the day before. I am just a CNA not a nurse. I assumed that the nurses knew about the bruise because it looked old."

8. On interview with Staff J, RN, on 1/5/10 at 2:30 PM, it was reported:
a. I took care of Patient #1 on 12/22 and 12/23/09. Patient #1, because of her condition, required that staff turn her every two hours. I was able to complete my daily skin assessments easily when we turned her. I did not note any kind of bruising or skin problems on 12/22/09. If I had seen concerns, I would have reported to my supervisor, the Doctor, and the ET nurses.

b. On 12/23/09, I was assigned to take care of Patient #1. "I did not do a head to toe skin assessment of Patient #1 on this day."

c. The nursing assistants (CNA) was responsible for getting Patient #1 ready for discharge by transferring Patient #1 into her wheelchair. I was not in Patient #1's room when staff put Patient #1 in the wheelchair. "No one in that room ever reported to me that there were bruises on Patient #1's legs or that there were any concerns or changes in her condition."

d. "Later in the afternoon, Staff I did report to Staff F and myself that she noticed a large (10 inches long by 10 inches wide) bruising area on Patient #1's left leg. The bruise was reported to be from behind Patient #1's left knee to her left hip area." Staff I stated that she "thought I already knew about the bruise as it looked old.

e. On 12/23/09 at 3:36 PM, Staff L documented in Patient #1's medical record that Staff I reports seeing a contused area approximately 10 inches on the posterior left leg of Patient #1. And that the bruising resembled an old contusion. Staff L reports that the bruising was not seen by Staff L and that Staff L only documented what Staff I reported to her.

9. On interview with the Nurse Manager of the Medical/Surgical Unit on 1/4/10 at 1:15 PM and on 1/5/10 at 10:00 AM, stated:
a. It is my expectation that, due to CNA training, that any change in a patients condition or anything out of the ordinary would be reported and that the RN/LPN would make an assessment of the situation.

b. Staff I and Staff L did not follow Floyd County Memorial Hospital policy/procedures for the proper reporting, assessment, and documentation of a patients condition. It is my expectation that all nursing staff will follow all policies and procedures.

Based on policy review, document review, and staff interviews the Critical Access Hospital (CAH) administration, including the Director of Nursing, failed to ensure that a Registered Nurse supervised and evaluated the nursing care provided for every patient. Specifically a Registered Nurses' failure to assess a patient's condition that resulted in the discharge of a patient with undiagnosed severe contusions (bruising) and left leg fracture. Concerns were identified in 1 of 5 closed medical records reviewed (Patient #1). The CAH administration reported an inpatient census of 12 patients.

Failure to ensure that a Registered Nurse supervises and evaluates the care provided to each patient by all patient care staff has the potential to impede the physical recovery of each patient.

Findings included:

1. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #10022.00, dated 11/09, titled Assignment of Patients stated Floyd County Memorial Hospital utilizes a team approach to nursing care. The team consists of Registered Nurses (RN), Licensed Practical Nurses (LPN), and Nursing Assistants (CNA).

2. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #2097.00, dated 11/09, titled Admission of a Patient stated in the section tilted All Patients: #4.) The nursing personnel assigned to the patient will perform the admission procedure. Pertinent information concerning the patient or his/her condition will be entered into the Electronic Medical Record.

3. Review of Floyd County Memorial Hospital, Nursing Services policy and procedure #2097.00, dated 11/09, titled Admission of a Patient stated in the section tilted Procedure:

a. The RN will conduct the admission interview; assess the patient's physical, mental and emotional status, general condition, health history; assess the patient's present problem, major complaint, and presenting symptoms.
b. The RN is responsible for the initial assessment and for verifying the LPN's findings.

4. Review of the first closed medical record for Patient #1 admitted to the medical/surgical unit on 12/18/09 and discharged on 12/23/09 revealed:
a. Nursing staff documented that Patient #1's skin was intact and without discoloration on admission on 12/18/09 to the time of discharge on 12/23/09 at 9:22 AM. Skin assessments are completed and documented once on every shift by nursing staff (RN and/or LPN), per hospital policy.
b. Patient #1's medical record lacked documentation of bruised areas or deformities on Patient #1's left leg when she was admitted to acute care on 12/18/09 through her discharge at 9:22 AM on 12/23/09.

6. Review of the second closed medical record for Patient #1, admitted: 12/23/09 at 4:55 PM to Floyd County Medical Center revealed:
a. Patient #1 returned to the Emergency Room, after staff at the Nursing Home reported the patient was found with multiple, large bruising areas on her left leg, from below the left leg to the left hip area. The Nursing Home staff also reported that the patient's left leg was rotated inward and noticeably shorter than the right leg.

b. Review of the Emergency Room physician's History and Physical dated 12/23/09 at 5:05 PM revealed:
... She (Patient #1) was admitted to this hospital for pneumonia on December 18, 2009. She was placed on intravenous antibiotics, and she has not responded to this. The patient has poor respiratory excursion. The patient was found to have an anemia by the third hospital day and initially it was felt that that was probably secondary to her infectious disorder or gastrointestinal blood loss. Admittedly we elected not to evaluate this. At the time there was no external ecchymosis or bruising noted ... "
Review of her records from her first admission starting with the Emergency Room note does not indicate that there was any external ecchymosis noted or other deformities. Review of all nursing notes indicated that the patient was able to be repositioned with minimal obvious discomfort. There was a note at the time of discharge that a nursing assist noticed some old contusion on the posterior left leg. (This entry was not at the time of discharge but was recorded in the electronic medical record at 3:36 PM). After the patient arrived at the nursing home the nursing staff did call and mention that the leg appeared different to them so we had her return to the hospital where we could x-ray her leg, and she has a nondisplaced distal femur fracture. The bones are markedly osteoporotic.

7. On interview with Staff I, CNA, on 1/5/10 at 2:00 PM, it was reported:
a. My duties as a CNA involve assisting the nursing staff with caring for patients. I assist with bathing, turning, walking, feeding, measuring intake and output, and anything else the nursing staff tell me to do."
b. "It is my responsibility to report to the nurse, either RN or LPN, any changes I find when I care for a patient.
c. I took care of Patient #1 on 12/22/09 and completed a bed bath on her. This included turning Patient #1 on to her right side and washing the left side of her body, including her legs. There was no bruising on Patient #1 on 12/22/09.
d. On 12/23/09, I was getting Patient #1 ready for transfer to the Nursing Home with the assistance of staff that was sent by the Nursing Home to accompany the patient. Using the Hoyer Lift (a patient lift that uses a sling to move a patient) we positioned Patient #1 so we could set Patient #1 in her wheelchair. "At that time, I saw a very large bruise on the patient's left leg. It looked like an old bruise."
e. " I assumed it was an old bruise and that someone else had reported it to the nurse. I did not notify the nurse of the bruise even though I had not noticed the bruise the day before. I am just a CNA not a nurse. I assumed that the nurses knew about the bruise because it looked old."

8. On interview with Staff J, RN, on 1/5/10 at 2:30 PM, it was reported:
a. I took care of Patient #1 on 12/22 and 12/23/09. Patient #1, because of her condition, required that staff turn her every two hours. I was able to complete my daily skin assessments easily when we turned her. I did not note any kind of bruising or skin problems on 12/22/09. If I had seen concerns, I would have reported to my supervisor, the Doctor, and the ET nurses.

b. On 12/23/09, I was assigned to take care of Patient #1. "I did not do a head to toe skin assessment of Patient #1 on this day." I was responsible for the care of Patient #1 on the day of discharge. It is hospital policy that a head to toe skin assessment is done on every patient at discharge.

c. The nursing assistant (CNA) was responsible for getting Patient #1 ready for discharge by transferring Patient #1 into her wheelchair. I was not in Patient #1's room when staff put Patient #1 in the wheelchair. "No one in that room ever reported to me that there were bruises on Patient #1's legs or that there were any concerns or changes in her condition."

d. "Later in the afternoon, Staff I did report to Staff F and myself that she noticed a large (10 inches long by 10 inches wide) bruising area on Patient #1's left leg. The bruise was reported to be from behind Patient #1's left knee to her left hip area." Staff I stated that she "thought I already knew about the bruise as it looked old.

e. On 12/23/09 at 3:36 PM, Staff L documented in Patient #1's medical record that Staff I reports seeing a contused area approximately 10 inches on the posterior left leg of Patient #1. And that the bruising resembled an old contusion. Staff L reports that the bruising was not seen by Staff L and that Staff L only documented what Staff I reported to her.

9. On interview with the Nurse Manager of the Medical/Surgical Unit on 1/4/10 at 1:15 PM and on 1/5/10 at 10:00 AM, stated:
a. It is my expectation that, due to CNA training, that any change in a patients condition or anything out of the ordinary would be reported and that the RN/LPN would make an assessment of the situation.

b. The Registered Nurse is ultimately responsible for the care of every patient. It is the RN's responsibility to supervise and evaluate the care provided by all patient care staff.

c. Staff L did not follow Floyd County Memorial Hospital policy/procedures for the proper reporting, assessment, and documentation of a patients condition. It is my expectation that all nursing staff will follow all policies and procedures.