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Based on the review of medical records and staff and physician interviews, it was determined that the facility's staff failed to report a change in the patient's condition for 1 of 2 (#1) sampled medical records.

Findings were:

Review of 1 of 2 (#1) medical records revealed that a registered nurse (RN) completed the initial nursing assessment and noted that the patient was admitted to the facility with a bedsore on his/her lower back, a cast on the left lower extremities, and a bruise on the right hip. Nurses' notes revealed the patient was assessed every 12 hours. Nurses' notes also revealed that from hospital day #1 through hospital day #12 the patient's left lower extremity was cool to touch 10 of 12 days. On hospital day #12, the day of discharge, nurses' notes revealed the patient's left toes were black with a blister noted on the big toe. The record lacked documented evidence that the physician, other staff, or receiving hospital were notified of the change in the condition of the patient's left foot.

During interview #3 on 7/13/11 at 1:00 p.m. in the Quality Manager's office, the nurse (employee file #1) stated he/she was the nurse who had cared for and discharged the patient. The nurse stated he/she had assessed the patient and documented that the patient's left toes were black and that there was a blister on the patient's big toe. The nurse explained the physician had seen the patient every day and that he/she thought the physician was aware of the condition of the patient's foot. The nurse stated he/she had not notified the physician or anyone else about the condition of the patient's foot. The nurse stated he/she normally reviewed the previous assessments in the record and the initial patient assessment to determine if there had been a change in the patient's condition. The nurse stated he/she could not remember whether he/she had reviewed patient #1's previous nursing assessments. The nurse also stated that he/she should have consulted with the physician prior to discharge regarding the condition and color of the patient's toes.

During interview #2 on 7/13/11 at 12:30 p.m. in the conference room, the physician (credential file #2) that discharged the patient stated that he/she had seen the patient the day of discharge but was not aware of and had not been notified that there had been a change in the condition of the patient's foot.

Based on the review of medical records and staff and physician interviews, it was determined that the facility's staff failed to report a change in the patient's condition for 1 of 2 (#1) sampled medical records.

Findings were:

Review of 1 of 2 (#1) medical records revealed that a registered nurse (RN) completed the initial nursing assessment and noted that the patient was admitted to the facility with a bedsore on his/her lower back, a cast on the left lower extremities, and a bruise on the right hip. Nurses' notes revealed the patient was assessed every 12 hours. Nurses' notes also revealed that from hospital day #1 through hospital day #12 the patient's left lower extremity was cool to touch 10 of 12 days. On hospital day #12, the day of discharge, nurses' notes revealed the patient's left toes were black with a blister noted on the big toe. The record lacked documented evidence that the physician, other staff, or receiving hospital were notified of the change in the condition of the patient's left foot.

During interview #3 on 7/13/11 at 1:00 p.m. in the Quality Manager's office, the nurse (employee file #1) stated he/she was the nurse who had cared for and discharged the patient. The nurse stated he/she had assessed the patient and documented that the patient's left toes were black and that there was a blister on the patient's big toe. The nurse explained the physician had seen the patient every day and that he/she thought the physician was aware of the condition of the patient's foot. The nurse stated he/she had not notified the physician or anyone else about the condition of the patient's foot. The nurse stated he/she normally reviewed the previous assessments in the record and the initial patient assessment to determine if there had been a change in the patient's condition. The nurse stated he/she could not remember whether he/she had reviewed patient #1's previous nursing assessments. The nurse also stated that he/she should have consulted with the physician prior to discharge regarding the condition and color of the patient's toes.

During interview #2 on 7/13/11 at 12:30 p.m. in the conference room, the physician (credential file #2) that discharged the patient stated that he/she had seen the patient the day of discharge but was not aware of and had not been notified that there had been a change in the condition of the patient's foot.