HospitalInspections.org

Based on interview, record and policy review, the facility failed to reassess and evaluate on an ongoing basis and in accordance with accepted standards of nursing practice for changes in the vascular condition of the toes on right foot in 1 (SP#1) out of 3 sample patients (SP).

Findings include:

Review of sample patient (SP) #1 Emergency Provider Report dated 04/04/2020 at 7:34 PM documented patient physical exam of the lower extremities noted as atraumatic, Skin assessment noted as atraumatic, color normal limit, no rash, warm. Patient stabilized and admitted for continuation of care.

Review of SP#1 Photographic Mounting Tool dated 04/11/2020 (no time) documented wound location as right lower extremity comment as blisters.

Review of (sample patient) SP#1 Photographic Mounting Tool dated 04/11/2020 (no time) documented wound location as left lower extremity comment as blister.

Review of SP #1 Hospitalist Progress Notes dated 04/11/2020 documented vascular dorsalis pedal pulses +(plus) 2, no cyanosis noted on extremities.


Interview with Wound Care Coordinator via telephone on 05/05/2020 at 2:26 PM revealed Photographic Mounting Tool is completed when a staff discovers a skin alteration. Stated a blister is an intact wound. Stated the blister identified in the picture dated 04/11/2020 for SP#1 is a skin alteration that would not require a wound care consult because it appears to be vascular. Stated pictures are taken for any skin alteration found on admission, at assessment after admission, every Wednesday and at discharge. Stated an incident report is to be completed for any skin alteration found after admission.
The facility did not provide evidence of nursing reassessments of changes in vascular condition to the right foot from 04/11/2020 to discharge on 04/23/2020 for SP#1.

Review of SP#1 (Readmission) Emergency Provider Report dated 04/23/2020 at 5:11 PM documented the patient presented with chief complaint of right foot swelling and right foot deformity. Patient was discharged earlier in the day and returned for necrotic toes on right foot noted on intake from transferring facility. Patient with necrotic appearing 3rd, 4th and 5th toes with skin loss between toes and serous drainage consistent with wet gangrene. Primary Impression: Gangrene of right foot.


Review of SP#1 Podiatry Consultation Report dated 04/23/2020 documented painful upon palpitation at digits 3, 4, 5 of right foot, mild malodor noted. Necrotic lesion extends to the base of the 3rd, 4th and 5th digits. Localized soft tissue swelling noted at digits 3, 4, and 5 and surrounding tissues at the dorsal aspect of the right foot. Plan: Podiatry recommends emergent amputation of digits 3, 4, and 5 of right digits.


Review of SP#1 Bilateral Legs Arterial Ultrasound dated 04/24/2020 at 4:15 PM documented impression of asymmetric low pulsatility, monophasic waveforms in the right common femoral artery and distally, characteristic for atherosclerotic narrowing. No occlusion is evident.

Interview with Director of Patient Safety on 05/05/2020 at 1:25 PM revealed that there was no evidence of nursing reassessment documentation for changes in the vascular condition to the right foot of SP#1 and the only documentation of SP#1 Photographic Mounting Tool form was dated 04/11/2020.

Review of Hospital Plan for the Provision of Care 2018 documented Telemetry Medical/Surgical (Unit 5) patients are assessed within 8 hours of admission and are reassessed every shift or whenever there is a change in condition, diagnosis, or in response to treatment.