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Based on review of policies and procedures and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse (RN) assessed, planned, supervised and reassessed/evaluated the nursing needs and care for each patient. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In three (Records #1, 2, and 4) of three patient records reviewed of patients being discharged to nursing homes and who required continuity of care, the nurse did not follow the hospital's policies and procedures for assessment and discharge to other non-acute care facilities; perform complete assessments so that care needs could be identified; and the supervising nursing staff did not supervise to ensure policies were followed and nursing assessments were checked for accuracy and completeness of documentation.

Findings:

1. Staff D and E told the surveyors on the afternoon of 04/10/11 that full nursing assessments were completed at least every shift. They stated that nursing staff should document and describe all wounds/skin disruptions (including bruising and rashes) in each nursing assessment. The drop-down boxes in the computerized medical record reviewed did not list these conditions as options. Staff E stated the nurse would have to "free text" this information in order to get it added to the medical record.

2. The registered nurse did not perform complete nursing assessments for 4 of 5 patient records reviewed so that patient needs could be identified and continued upon discharge/transfer of care to another facility. Patient records #1, 2 and 4 did not contain complete nursing assessments for each shift and describe the patient's condition at the time of discharge.
a. Patient #1- admitted on 01/20/2012 and discharged on 01/27/2012. On 01/23/2012 at 1310, the wound care nurse recorded a consult on the patient for "wound on left foot". The note recorded the patient had "old dry cracked skin on feet" with a plan for treatment with Aquaphor. The complete location is not documented. Wound care staff did not document any other notes. Nursing assessment notes do not reflect this assessment. The documentation of skin on 01/20/2012 at 1415 and 1715 records "dry; wound(s) and skin warm, dry and intact. Mucous membranes pink, moist and intact. Color appropriate for Race." Documentation starting on 01/20/2012 at 2330 only recorded "dry;wound(s) and exceptions to WDL", with no explanations were documented. Nursing notes do not reflect a complete assessment and description of the patient's skin condition. The discharge note by the nurse documented the facility was called, but no detail of what was provided is listed. The patient's condition at the time of discharge is not recorded.

b. Patient #2 - admitted on 01/11/2012 and discharge on 01/25/2012. The initial nursing assessment documented the patient's skin was within normal limits. On 01/16/2012 at 2009, the nurse recorded the patient skin was within normal limits. On 0123/2012 at 0830 the nurse documented the patient had an open wound on his buttocks, but no description with measurements was documented.

c. Patient #4 - admitted on 03/22/2012 and discharged on 04/03/2012. The initial nursing assessment documented the patient had a wound/incision to the right superior chest that was black, full thickness from incision for pacemaker. On 03/29/2012 at 1247, the wound nurse documented the patient had an open wound/friction sheer to the coccyx. The medical record does not contain any other documentation of skin disruptions or assessments by wound care staff. The patient was placed on daily dressing change for the coccyx wound. Nursing notes did not reflect the dressing was changed on 04/02/2012. The notes do not describe the wound or healing progression at the time of dressing changes or if it is resolved at the time of discharge. Nursing assessments do not consistently document the presence or absence/resolution of either skin disruption. The patient's condition, including skin condition at the time of discharge is not documented. The nursing discharge summary did not describe or refer to either skin disruption.

3. The written policy entitled, Discharge of a Patient, documented, "Report is called to the receiving facility by the nurse responsible for the care of the patient prior to discharge". The policy lists items included in the report, "pertinent clinical information, special psychosocial needs, status regarding Advances Directives, progress toward identified goals, time and mode of transport, and laboratory values.

4. Review of medical records for Patients #1, 2, and 4 did not demonstrate the patient's condition was assessed at the time the patient was discharged. Nursing notes did not record the patient's condition at the time of discharge or if any paperwork accompanied the patient. The medical records for these patients did not describe, when/if the facility was contacted, what information was provided.
a. Patient #1 - The nursing notes did not record what information was reported to the receiving facility or what documents were sent with the patient. The nursing notes did not document the patient's condition at the time of discharge.

b. Patient #2 - The last recorded assessment for the patient was 01/24/2012 at 2215. The patient was not discharged until 1513 on 01/25/2012. The nurse documented she called to give report, but was put on hold. The record did not document whether report was given to the receiving facility or what information was provided so that nursing care could be planned and/or continued. The nursing notes did not document the patient's condition at the time of discharge. On 0123/2012 at 0830, the nurse documented the patient had an open wound on his buttocks, but no description with measurements was documented. The nursing notes did not reflect if this information was relayed to the nursing home staff. The discharge instruction listed medication to be applied "to affected area 2 times a day", but the document does not record where the "affected" areas were.
c. Patient #4 - Although the case manager called on 04/02/2012 at 1417, and obtained admission acceptance, the documentation did not record what information was exchanged about the patient, his condition, or his required treatment needs. The nursing notes did not document the the nurse contacted the receiving facility and the required information provided, along with the patient's condition/assessment of needs. The nursing notes did not document the patient's condition at the time of discharge.

5. The supervising nursing staff did not supervise to ensure policies were followed and nursing assessments were checked for accuracy and completeness of documentation. See above findings for examples. The above findings were reviewed with Staff D and E at the time of medical record review on 04/10/2012 and again with Staff A, B, D and E during the the exit conference on the afternoon of 04/10/2012. The hospital was given an opportunity to provide additional data. None was provided.