HospitalInspections.org

Based on interview, record review and a review of facility documentation, the facility failed to ensure that a registered nurse (RN) evaluated the nursing care for each patient through the performance of thorough assessments in accordance with policy for 1 of 20 sampled patients (#1).

Findings:

A review of the medical record of patient #1 was performed. The patient was admitted to the Emergency Room (ER) on 7/28/17 at 7:46 PM. A request for admission was made at 9:09 PM on 7/28/17. The patient was on the Cardiovascular Intensive Care Unit from 8/01/17 through 8/07/17.

A Nurse Practitioner note of 8/03/17 at 10:28 AM read, "Extremities: decreased range of motion, left foot cyanosis, ischemic changes." This was the first mention in the record of any discrepancy regarding the patient's toes. A physician note of 8/03/17 at 11:57 AM read, "New left toe discoloration noted this morning, possible janeway lesions as well. Left distal 1-3 toes are cold, and blue....Plan.... would appreciate recommendations of left lower extremity discoloration, likely attributable to septic emboli." "Janeway lesions are one of the stigmata of infectious endocarditis. They are irregular, erythematous, flat, painless macules on the palms, soles, thenar and hypothenar eminences of the hands, tips of the fingers, and plantar surfaces of the toes; they rarely present as a diffuse rash, and are very rare in clinical practice." (nih.gov).

The patient was on the Cardiovascular Step Down Unit as of 8/07/17.

The record revealed that nurses had assessed the patient during each shift from 8/03/17 through 8/08/17 for edema and peripheral pulses. During this time period, they did not document any abnormalities with respect to the patient's toes despite the mention of a significant abnormality by the Nurse Practitioner and physician on 8/03/17.

A nurse's note of 8/09/17 at 7:38 AM read, "Noted slight bruising in both heels....left toes are blackish." Despite medical practitioners aware of a discrepancy with the patient's left foot as of 8/03/17, which, per the 8/09/17 nurse's note indicated had worsened, there was no evidence in the record that nursing had tracked the status of the toes from 8/03/17 through 8/08/17.

A review of facility policy "Nursing Documentation" read, "Documentation will indicate that the patient met the defined parameters or documentation will describe variations from the defined parameters....Reassessment is also undertaken whenever a change in patient condition is identified." The lack of any nursing documentation from 8/03/17 through 8/08/17 regarding an outwardly visible decline in the status of the patient's toes, as first noted by medical practitioners on 8/03/17, indicated a lack of compliance with this policy which required documentation on variations from defined parameters. There was no evidence that thorough assessments that included the toes were performed by nurses from 8/03/17 through 8/08/17.

During an interview of the Risk Manager and Vice President of Quality on 10/17/17 at approximately 3 PM, they confirmed the findings.