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Based on review of documentation and interviews with facility staff, the facility failed to completely document nursing notes and other information necessary to monitor the patient's condition.

The findings were:
In the written complaint, the patient's wife was concerned that on 2/26/11 she found her husband's (patient #1) "right arm swollen and puffy, like infiltrated" and stated that the nurse's (staff #2) response was she did not know his condition before. The patient's wife requested that the doctor be contacted. Review of the medical record showed a telephone order from the physician (staff #4) taken by the nurse (staff #2) for a "venous Doppler R arm; increased edema" dated 2/26/11 1500. The Nursing Notes for 2/26/11 at 0842 stated "IV/PICC Type: PICC-double lumen, IV/PICC Site/Size/Condition: Site: Right" and at 1905 "Dr. (staff #4) notified of results of venous Doppler to right arm which showed blood clot present x 2 areas. New order received." The Nursing Notes on 2/26/11 did not contain any assessment of the right arm, condition of PICC (periphally inserted central catheter) site, or notation that physician was contacted. In an interview with the facility chief nursing officer (staff #7) on the afternoon of 9/6/11, she stated that she would have expected the nurse to document an assessment of the patient's right arm and the PICC site. When asked about facility policies on nursing documentation, the she stated there were procedures for how the complete the various screens of the electronic records but no specific policies of what the nurses are to document.