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A. Based on document review and interview, it was determined that for 3 of 10 (Pt #1, 6, and 9) Emergency Department (ED) records reviewed, the Hospital failed to ensure all patients presenting to the Hospital receive a complete nursing assessment to include skin.

Findings include:

1. Hospital policy subject and title, "Emergency and Trauma Services, Nursing Documentation Standards," (Effective date 11/01/09) required, "III Procedure: 2...The primary nurse is accountable for the provision of nursing care...B. This assessment will encompass an evaluation of the following physiologic systems:7. Skin Integrity."

2. Pt #1 was a 56 year old female that presented to the Hospital's ED by Chicago Fire Department Emergency Medical Service (EMS) with a chief complaint of crisis. Pt #1 was triaged at 11:48 AM as a level 2 (emergent) on a 1 - 5. Pt #1's initial nursing assessment at 11:50 AM failed to include assessment of Pt #1's skin integrity as required.

3. The clinical record of Pt #6 was reviewed on 6/12/14 at approximately 11:00 AM. Pt $+#6 was a 41 year old female that presented to the Hospital's ED on 6//4/14 with a complaint of Nausea/Vomiting. Pt #6 was triaged as a level 2 (emergent) on a 1 - 5 level. Pt #6's initial nursing assessment dated 6/4/14 at 12:46 PM lacked an assessment of Pt #6's skin integrity as required.

4. The clinical record of Pt #9 was reviewed on 6/12/14 at approximately 11:00 AM. Pt #9 was a 71 year old female that presented to the Hospital's ED on 5/19/14 wit chief complaint of dehydration. Pt #9 was triaged as a level 3 (urgent) on a 1 - 5 level. Pt #9's initial nursing assessment on 5/19/14 at 9:29 7 PM failed to include an assessment of Pt #9's skin integrity as required.

5. The findings were verified by the Manager of Emergency Services during interviews on 6/12/14 at approximately 11:00 AM and 6/13/14 at approximately 9:15 AM. During the interview, the Manager stated that the patients' should have had their skin assessed as required.

B. Based on document review and interview, it was determined that for 1 of 1 (Pt #1) clinical record reviewed with a diagnosis of drug abuse, the Hospital failed to ensure reasons for incomplete tests were documented.

Findings include:

1. Hospital policy subject and title, "Emergency and Trauma Services, Nursing Documentation Standards," (Effective date 11/01/09) required, "III. Procedure: E. Miscellaneous: 1. Any non-pharmacological treatment/interventions rendered in the ED..."

2. Pt #1 was a 56 year old female that presented to the Hospital's ED by Chicago Fire Department Emergency Medical Service (EMS) with a chief complaint of crisis. Pt #1's clinical record contained a physician's order dated 4/28/14 at 11:56 AM that required a urine drug screen. On 4/29/14 at 8:20 PM the order was canceled. Pt #1's clinical record lacked documentation as to the reason the test had not been completed.

3. The Manager of Accreditation, Clinical Compliance and Policy Management stated during an interview on 6/13/14 at approximately 12:00 PM that the cliniocal record lacked documentation of why the patient's urine drug screen was not collected.