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Based on medical record review, staff interview, and review of policy and procedures it was determined the Registered Nurse failed to ensure each patient was assessed, intervention provided and evaluation completed related to skin care for two (#7, #8) of ten patients sampled.

Findings include:

Review of the facility policy, "Initial Patient Assessment and Reassessment" #NS.000-03, last revised 8/2013, stated (4)(a) the patient assessment is to include content regarding, (vi) skin integrity.

1. Review of the medical record for patient #7 revealed the patient was admitted on 12/2/2014. Review of the ER (Emergency Room) nursing documentation revealed at 6:19 p.m. the patient had a medicated patch to the coccyx area. The family member stated the patient had an ulcer on the coccyx area.

On 12/3/2014 at 1:44 a.m. the patient was admitted to the medical/surgical unit. The RN (Registered Nurse) performed an admission assessment on 12/3/2014 at 6:00 a.m. The RN did not note if the patient's skin was intact.

On 12/3/2014 at 8:00 a.m. the day shift RN reassessed the patient and noted the patient's skin to be intact and the patient needed total assistance for repositioning. On 12/3/2014 at 9:00 p.m. the night shift RN reassessed the patient and noted the patient's skin to be intact. There was no documentation the patient had been repositioned or was there evidence the patient's coccyx was assessed.

On 12/4/2014 the day shift nurse reassessed the patient at 11:00 a.m. The nurse noted the patient's skin was not intact. Review of the documentation revealed no evidence what part of the patient's skin was not intact. On 12/4/2014 at 2:00 p.m. the RN assessed the patient's coccyx and described it as pink, tender, 20% yellow slough, and a foam dressing was applied.

Review of the medical record revealed from 12/3/2014 at 1:44 a.m. through 12/4/14 at 7:00 p.m. there was no evidence the RN repositioned the patient at least every two hours due to the patient requiring total assistance for repositioning. Review of the medical record revealed from 12/3/2014 at 1:44 a.m. through 12/4/2014 at 2:00 p.m. the patient's coccyx dressing was not removed from the wound and no care was provided by the RN.

2. Review of the medical record for patient #8, a current patient, revealed the patient was identified with a pressure ulcer. Review of the record revealed the patient's ulcer was not assessed by an RN for three days.

Interview with the risk manager and manager of education on 4/29/2015 at 4:30 p.m. confirmed the above findings.

Based on policy and procedure review, personnel file review and staff interview it was determined the facility failed to provide adequate supervision and evaluation of the clinical activities of agency nursing personnel and follow policy and procedure related to Verification of Agency Nurse Qualifications for two (#C and #E) of five personnel files reviewed.

Findings include:

Review of the policy and procedure titled "Verification of Agency Nurse Qualifications" last revised on 8/2013, stated on page 2, (6) off-site agency staff are to attend in-services on new products, chart forms, policies and procedures when provided during scheduled times. Off -site agency staff will be encouraged to attend continuing education programs sponsored and as required by the hospital. Number (7) all off site agency nursing staff will be evaluated upon their initial assignment by house supervisor or unit manager/charge nurse as assigned. Number (8) Individuals receiving acceptable evaluations of satisfactory or above in all categories will be reevaluated on a periodic bases. Number (10) All off-site agency nursing staff must follow and comply with the hospital's established policies and procedures or they will not be allowed to work.

1. The personnel file for Nurse #C did not contain performance re-evaluation by the facility after initial evaluation on 12/10/2013. It did not contain the evidence of the nurse completing annual continuing education the facility's nursing staff was required to complete.

2. The personnel file for Nurse #E did not contain performance re-evaluation by the facility after initial evaluation on 3/26/2013. It did not contain the evidence of the nurse completing annual continuing education the facility's nursing staff was required to complete.

The findings were confirmed with the Education Specialist on 4/29/15 at approximately 4:10 p.m. related to re-evaluation of performance and annual continuing education of agency nurses.