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Based on interview and record review, the facility failed to ensure that a registered nurse evaluated care of a patient at a sufficient level to confirm no changes in condition prior to transfer from a unit, and failed to perform assessments as required by policy once a change in patient condition had been noted for 1 of 10 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 5/14/14 at 2:34 PM. A nurse's note at 3 PM on 5/14/14 read, "Inserted saline lock: 22 gauge in left hand and blood collected." A nurse's note of 5/14/14 at 6:34 PM read, "Admitted to Tele accompanied by tech ...." A nurse's note of 6:35 PM on 5/14/14 read, "Patient left the ED." Thus, the patient had an IV (intravenous) site inserted in her left hand while in the ER and was eventually transfered to a floor unit.

Unit nurse #F wrote on 5/15/14 at 10 AM, "Left hand.... Site appearance - compromised. Removal date 5/15/14." During an interview of the nurse #F at 1:20 PM on 7/15/14, he stated that he had tried to flush the left hand IV site, but it would not flush. At that time, he said he decided to discontinue the site. He stated that there were not any outwardly visible signs of any problems at the site.

A nurse' s note of 5/15/14 at 12 PM indicated patient #1's pain level of "0". This pain assessment was the last entry by the floor nurse prior to a 2:35 PM Nuclear Medicine record entry (below).

Nurse #G in Nuclear Medicine of 5/15/14 at 2:35 PM, wrote in the physician progress note section, "Patient was brought to Nuc Med for a stress test. Upon arrival, Radiology Technologist... found the patient had a large, painful hematoma to left hand. Nurse called to the department to evaluate. Patient... stated to be very painful. Placed warm compress to area patient related little relief. Contacted...(nurse #F) about the patient's hand and he related there was an IV in that area but no hematoma there prior to" going to the radiology department.

In an interview with Nuclear Medicine nurse #G at 1 PM on 8/04/14, he stated that a nuclear technologist called him over to evaluate the patient. He noticed a large hematoma on the back of the patient's hand with some blueish color. It was swollen. The patient said it was painful. He stated that the patient had a regular, short sleeve hospital gown on.

During an interview with nurse #F, at 1:20 PM on 7/15/14, he stated that he first learned of eventual problems from a nurse in imaging, later in the day. Further interview of this nurse was performed on 8/04/14 at 4:21 PM. He stated that there was no problem with the patient at the time of the 12 PM pain assessment of 5/15/14.

Thus, the unit nurse assessed the patient as having no pain at 12 PM. Immediately upon the patient's arrival in Nuclear Medicine at 2:35 PM, nursing staff in that unit noted significant problems with the patient's left hand. In view of these discrepancies having been noted immediately upon arrival, but were unknown to the nurse on the unit from at least 12 PM onward, there is evidence of insufficient monitoring and consistent evaluation of the patient.

Other than the above entries on 5/15/14 at 2:35 PM and an untimed Care Plan entry, there was no evidence of any subsequent specific nursing assessments of the left hand site in which a problem had developed. The next assessment was not until 5/16/14 at 8 PM.

A review of facility policy "Assessment and Reassessment" revealed the following: "Reassessment will be performed every 24 hours, or more frequently as indicated by the patient' s condition. The reassessment is based upon, but not limited to, the following: System status related to the following: System status related to... changes in patient condition." Since there was no evidence of any additional assessments during the above mentioned time interval, nurses were not in compliance with the policy.

During an interview of the Director of Quality on 8/04/14 at approximately 7 PM, she confirmed the findings.

Based on interview and record review, the facility failed to ensure that patient medical record entries regarding intravenous (IV) site assessments were complete, and upper extremity assessments were accurate for 1 of 10 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 5/14/14 at 2:34 PM. A nurse's note at 3 PM on 5/14/14 read, "Inserted saline lock: 22 gauge in left hand and blood collected." A nurse's note of 5/14/14 at 6:34 PM read, "Admitted to Tele accompanied by tech ...."

Nurse #F's note on 5/14/14 at 10:49 PM read, "IV site intact with no signs of infections or infiltration noted when checked during rounds and prn (as needed)." Thus, an IV site assessment was performed during the 7 PM - 7 AM shift, which indicated that there were no problems with the left hand site.

Nurse #F's note on 5/15/14 at 10 AM read, "Left hand.... Site appearance - compromised. Removal date 5/15/14." It is unknown from this note as written the degree of compromise which existed at the IV site.

Regarding the term "compromised", this was a selection from the medical record computer drop down menu. The drop down had three options which the nurse could choose from: (1) "Patent /no redness /no overt signs of infiltration"; (2) "Compromised" and (3) "Not present at time of assessment." Regarding the first option of the preceding, it listed three compromised situations which the nurse had available to assert were not present, in totality. These were "positive" choices regarding potential forms of site compromise. Under this drop down menu arrangement, if the IV site had a problem or compromise such as not being patent (could not be flushed), as asserted in an interview below with nurse #F as being the case, the only available option on the computer was the second one, "compromised". However, selection of this second option with no additional input had the effect of indirectly asserting the possibilities of the site having at least one or more of the following compromised situations, inversely drawn from the "positive" options listed in the first drop down choice: being non-patent; red and/or infiltrated. There was no way to determine which, if any of the compromises mentioned in a positive manner in the first option, were being referenced with the choice of "compromised".

Regarding additional input to clarify what was meant by "compromised", there was no entry in an available comment section regarding the assessment. Thus, since the record did not make a distinction as to what exactly was compromised, when at least three possible options for compromise were available as a choice from a positive (no site problem) perspective, the nursing entry was inaccurate and incomplete.

During an interview with nurse #F, who authored this 10 AM note at 1:20 PM on 7/15/14, he stated that he had tried to flush the site, but it would not flush. Thus, the site was not patent, one of at least three compromised situations mentioned as possibilities for not being present as stated in the first option of the drop down menu. However, this was not specified in the record so that the other two options could be eliminated at least through a process of elimination.

During an interview of the Risk Manager on 5/17/14 at approximately 5:30 PM, she confirmed the findings.

Further review of the record was performed. Nurse #G;s note from the Nuclear Medicine department on 5/15/14 at 2:35 PM, was written in the physician progress note section and read, "Patient was brought to Nuc Med for a stress test. Upon arrival, Radiology Technologist...found the patient had a large, painful hematoma to left hand. Nurse called to the department to evaluate. Patient... stated to be very painful." Thus, there was document of a change with the patient's distal, left upper extremity (hand).

Nurse #I's note on 5/15/14 at 8:30 PM read, "Edema: upper extremity - absent bilateral. ... Extremity color: upper extremity - normal bilateral.... Extremity strength: Hands - strong bilaterally. Arms - strong bilaterally." This entry is in clear conflict with prior and subsequent nursing and physician documentation, as the patient's left hand was visibly compromised.

A physician note of 5/16/14 at 10 AM read, "IV infiltration. (L) hand swollen. Tender. Pain up medial arm."

A physical therapy note of 5/16/14 at 2:30 PM read, "(L) hand swelling /pain.... (L) hand elevated on pillow."

Regarding any nurse's notes on 5/16/14 on the 7 AM - 7 PM shift, this shift was covered by nurse #J. A review nurse #J's notes revealed the following at 8 AM on 5/16/14: "Edema: upper extremity - absent bilateral.... Extremity color: upper extremity - normal bilateral.... Extremity strength: Hands - strong bilaterally. Arms - strong bilaterally." This entry is in clear conflict with prior and subsequent nursing documentation.

During a telephone interview with nurse #J on 8/04/14 at 5:53 PM, she stated that she recalled the patient. She stated that the patient had pointed out to her that her hand was swollen and that the patient believed it came from an IV she had there previously. She observed that it was swollen and bruised. This information conflicts with what was documented with respect to the overall status of the upper extremities, specifically the left side.

During an interview of the Director of Quality on 8/04/14 at approximately 7 PM, she confirmed the findings.

Based on interview and record review, the facility failed to ensure that a registered nurse evaluated care of a patient at a sufficient level to confirm no changes in condition prior to transfer from a unit, and failed to perform assessments as required by policy once a change in patient condition had been noted for 1 of 10 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 5/14/14 at 2:34 PM. A nurse's note at 3 PM on 5/14/14 read, "Inserted saline lock: 22 gauge in left hand and blood collected." A nurse's note of 5/14/14 at 6:34 PM read, "Admitted to Tele accompanied by tech ...." A nurse's note of 6:35 PM on 5/14/14 read, "Patient left the ED." Thus, the patient had an IV (intravenous) site inserted in her left hand while in the ER and was eventually transfered to a floor unit.

Unit nurse #F wrote on 5/15/14 at 10 AM, "Left hand.... Site appearance - compromised. Removal date 5/15/14." During an interview of the nurse #F at 1:20 PM on 7/15/14, he stated that he had tried to flush the left hand IV site, but it would not flush. At that time, he said he decided to discontinue the site. He stated that there were not any outwardly visible signs of any problems at the site.

A nurse' s note of 5/15/14 at 12 PM indicated patient #1's pain level of "0". This pain assessment was the last entry by the floor nurse prior to a 2:35 PM Nuclear Medicine record entry (below).

Nurse #G in Nuclear Medicine of 5/15/14 at 2:35 PM, wrote in the physician progress note section, "Patient was brought to Nuc Med for a stress test. Upon arrival, Radiology Technologist... found the patient had a large, painful hematoma to left hand. Nurse called to the department to evaluate. Patient... stated to be very painful. Placed warm compress to area patient related little relief. Contacted...(nurse #F) about the patient's hand and he related there was an IV in that area but no hematoma there prior to" going to the radiology department.

In an interview with Nuclear Medicine nurse #G at 1 PM on 8/04/14, he stated that a nuclear technologist called him over to evaluate the patient. He noticed a large hematoma on the back of the patient's hand with some blueish color. It was swollen. The patient said it was painful. He stated that the patient had a regular, short sleeve hospital gown on.

During an interview with nurse #F, at 1:20 PM on 7/15/14, he stated that he first learned of eventual problems from a nurse in imaging, later in the day. Further interview of this nurse was performed on 8/04/14 at 4:21 PM. He stated that there was no problem with the patient at the time of the 12 PM pain assessment of 5/15/14.

Thus, the unit nurse assessed the patient as having no pain at 12 PM. Immediately upon the patient's arrival in Nuclear Medicine at 2:35 PM, nursing staff in that unit noted significant problems with the patient's left hand. In view of these discrepancies having been noted immediately upon arrival, but were unknown to the nurse on the unit from at least 12 PM onward, there is evidence of insufficient monitoring and consistent evaluation of the patient.

Other than the above entries on 5/15/14 at 2:35 PM and an untimed Care Plan entry, there was no evidence of any subsequent specific nursing assessments of the left hand site in which a problem had developed. The next assessment was not until 5/16/14 at 8 PM.

A review of facility policy "Assessment and Reassessment" revealed the following: "Reassessment will be performed every 24 hours, or more frequently as indicated by the patient' s condition. The reassessment is based upon, but not limited to, the following: System status related to the following: System status related to... changes in patient condition." Since there was no evidence of any additional assessments during the above mentioned time interval, nurses were not in compliance with the policy.

During an interview of the Director of Quality on 8/04/14 at approximately 7 PM, she confirmed the findings.

Based on interview and record review, the facility failed to ensure that patient medical record entries regarding intravenous (IV) site assessments were complete, and upper extremity assessments were accurate for 1 of 10 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 5/14/14 at 2:34 PM. A nurse's note at 3 PM on 5/14/14 read, "Inserted saline lock: 22 gauge in left hand and blood collected." A nurse's note of 5/14/14 at 6:34 PM read, "Admitted to Tele accompanied by tech ...."

Nurse #F's note on 5/14/14 at 10:49 PM read, "IV site intact with no signs of infections or infiltration noted when checked during rounds and prn (as needed)." Thus, an IV site assessment was performed during the 7 PM - 7 AM shift, which indicated that there were no problems with the left hand site.

Nurse #F's note on 5/15/14 at 10 AM read, "Left hand.... Site appearance - compromised. Removal date 5/15/14." It is unknown from this note as written the degree of compromise which existed at the IV site.

Regarding the term "compromised", this was a selection from the medical record computer drop down menu. The drop down had three options which the nurse could choose from: (1) "Patent /no redness /no overt signs of infiltration"; (2) "Compromised" and (3) "Not present at time of assessment." Regarding the first option of the preceding, it listed three compromised situations which the nurse had available to assert were not present, in totality. These were "positive" choices regarding potential forms of site compromise. Under this drop down menu arrangement, if the IV site had a problem or compromise such as not being patent (could not be flushed), as asserted in an interview below with nurse #F as being the case, the only available option on the computer was the second one, "compromised". However, selection of this second option with no additional input had the effect of indirectly asserting the possibilities of the site having at least one or more of the following compromised situations, inversely drawn from the "positive" options listed in the first drop down choice: being non-patent; red and/or infiltrated. There was no way to determine which, if any of the compromises mentioned in a positive manner in the first option, were being referenced with the choice of "compromised".

Regarding additional input to clarify what was meant by "compromised", there was no entry in an available comment section regarding the assessment. Thus, since the record did not make a distinction as to what exactly was compromised, when at least three possible options for compromise were available as a choice from a positive (no site problem) perspective, the nursing entry was inaccurate and incomplete.

During an interview with nurse #F, who authored this 10 AM note at 1:20 PM on 7/15/14, he stated that he had tried to flush the site, but it would not flush. Thus, the site was not patent, one of at least three compromised situations mentioned as possibilities for not being present as stated in the first option of the drop down menu. However, this was not specified in the record so that the other two options could be eliminated at least through a process of elimination.

During an interview of the Risk Manager on 5/17/14 at approximately 5:30 PM, she confirmed the findings.

Further review of the record was performed. Nurse #G;s note from the Nuclear Medicine department on 5/15/14 at 2:35 PM, was written in the physician progress note section and read, "Patient was brought to Nuc Med for a stress test. Upon arrival, Radiology Technologist...found the patient had a large, painful hematoma to left hand. Nurse called to the department to evaluate. Patient... stated to be very painful." Thus, there was document of a change with the patient's distal, left upper extremity (hand).

Nurse #I's note on 5/15/14 at 8:30 PM read, "Edema: upper extremity - absent bilateral. ... Extremity color: upper extremity - normal bilateral.... Extremity strength: Hands - strong bilaterally. Arms - strong bilaterally." This entry is in clear conflict with prior and subsequent nursing and physician documentation, as the patient's left hand was visibly compromised.

A physician note of 5/16/14 at 10 AM read, "IV infiltration. (L) hand swollen. Tender. Pain up medial arm."

A physical therapy note of 5/16/14 at 2:30 PM read, "(L) hand swelling /pain.... (L) hand elevated on pillow."

Regarding any nurse's notes on 5/16/14 on the 7 AM - 7 PM shift, this shift was covered by nurse #J. A review nurse #J's notes revealed the following at 8 AM on 5/16/14: "Edema: upper extremity - absent bilateral.... Extremity color: upper extremity - normal bilateral.... Extremity strength: Hands - strong bilaterally. Arms - strong bilaterally." This entry is in clear conflict with prior and subsequent nursing documentation.

During a telephone interview with nurse #J on 8/04/14 at 5:53 PM, she stated that she recalled the patient. She stated that the patient had pointed out to her that her hand was swollen and that the patient believed it came from an IV she had there previously. She observed that it was swollen and bruised. This information conflicts with what was documented with respect to the overall status of the upper extremities, specifically the left side.

During an interview of the Director of Quality on 8/04/14 at approximately 7 PM, she confirmed the findings.