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Based on interview and record review it was determined the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for 1 of 5 sampled patients (Patient 5). Findings include:

According to admission records Patient 5 had been admitted to the hospital on 1/27/12 for treatment of a "right distal femur fracture." The initial physician assessment described the patient as "very pleasant elderly ... in excellent general health, upbeat and oriented." A surgical repair was performed and the patient was transferred to a nursing unit for post-surgical care. Post-operative care was to include "physical therapy for mobility, transfers and strengthening."

Hospital "Flowsheet" records indicated that Patient 5's care was routine and uneventful until 1/29/12. On 1/29/12 at 4:28 pm Employee 3 charted that Patient 5 had "spilled hot tea and burned [him/herself]." According to the record, Employee 3 reported that information to Patient 5's supervising nurse for that shift, Employee 8.

Review of Patient 5's record of 1/29/12 determined that the information regarding Patient 5's burn had not been noted by Employee 8. There was no documented record that Employee 8 responded to the incident, completed an assessment of the burn area or evaluated the nursing care of the patient. There was also no documented evidence that Employee 8 completed an incident report or initiated contacted with the physician for treatment orders.

Hospital "Flowsheets" of 1/30/12 reflected that at 7:05 am the "night shift nurse" Employee 4, charted that "per patient during the day of 1/29 was drinking hot tea when it spilled on [him/her] and scalded [his/her] skin....per assessment pt has burns on right forearm, right hip, and right buttock..."

On 1/30/12 at 9:34 am the supervising nurse for day shift, Employee 6, completed a skin assessment for Patient 5. That assessment identified that the patient had a "blister burn on right buttock, forearm and hip....blister burn, pink, fragile and tender." There was no evidence that Employee 4 or Employee 6 initiated contact with the physician for treatment orders.

Patient 5 was discharged from the hospital to his/her home with Home Health Agency (HHA) services on 1/31/12. The discharge information provided to the HHA failed to include any information regarding the patient's burns. The burns were not identified in the records provided to the HHA. The referral information and physician orders failed to provide a treatment plan for the burns.

In interview on 5/10/12 at 11:15 am the CNO and Risk Manager indicated that Patient 5's medical record did not accurately document the occurrence of this event or the presence of the burns. They also acknowledged that information regarding the burns had not been communicated with the HHA. Nursing staff failed to supervise and evaluate the nursing care of Patient 5 as required.