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Based on policy, procedure, and clinical record reviews and staff interviews, it was determined that the Registered Nurse failed to supervise and evaluate nursing care related to the use of a warming/cooling blanket and skin assessments for 1 (#1) of 4 records reviewed . This practice does not ensure patient goals and safety are maintained.

Findings include:

1. Review of the facility's policy "Bair Hugger (warming blanket)" revised 8/06, indicated that the patient's temperature is to be monitored and recorded every 10 minutes and at discontinuation of the blanket. The review of the operator's manual Medi-Therm III Hyper/Hypothermia Machine, Patient safety section 8.0 on page 14 revealed at least every 20 minutes , or as directed by the physician, to check the patient's temperature and skin condition on the areas of contact with the blanket and to check the blanket's water temperature.

Patient #1's Emergency Room physician orders dated 3/9/10 at 1:38 p.m. instructed that the patient be placed on a warming blanket for hypothermia. Emergency Room (ER) nursing notes revealed at 1:55 p.m. on 3/9/10 the Registered Nurse had placed the patient on a warming blanket. Review of the ER nurses' notes dated 3/10/10 at 2:45 p.m. revealed the patient remained on a "cooling" blanket. Review of ER nursing documentation at 2:51 p.m. noted the skin assessment was within normal limits and intact. The nursing documentation showed the temperature was taken a total of 5 times from the placement of the warming blanket at 1:55 p.m. on 3/9/10 to midnight. The documentation revealed the patient ' s temperature was taken 9 times from 1:00 a.m. to 2:30 p.m. on 3/10/10.
The patient was transferred to the Medical Intensive Care Unit on 3/10/10 at 4:15 p.m. The initial nursing skin assessment revealed a questionable contact dermatitis blister like pattern. A drawing of a body that was included in the nursing notes, was marked with dots to upper back and coccyx area. Review of the nursing documentation dated 3/10/10 at 7:00 p.m., under the skin assessment, revealed an intact blister to right external ankle and blisters to coccyx, buttocks and upper back. The nursing documentation notes that the blisters were patterned like the warming blanket.
The review of the Wound Care Patient Evaluation form dated 3/12/10 revealed pictures were taken of the patient's other wounds but failed to reveal any documentation on the blisters that were documented in the nursing notes. Nursing documentation showed blistering to the upper back and coccyx area from 3/10/10 to 3/18/10. There was no documentation that the physician was aware of the blisters.

Review of nursing documentation dated 3/11/10 at 3:00 a.m. noted the patient was placed back on the warming blanket for a temperature of 95.7. Review of the temperature documentation on 3/11/10 from 7:00 a.m. to 2:00 a.m. and on 3/12/10 showed the temperature was take every four hours. On 3/12/10 the patient's temperature was taken every 4 hours except from 2:00 a.m. to 6:00 a.m. when the temperature was obtained every two hours.
On 3/12/10 at 4:00 a.m. nursing documentation revealed the warming blanket was reapplied for a temperature of 96.5 There was no prior documentation of when the blanket was removed. The nursing documentation revealed at 6:00 a.m. the warming blanket removed.
On 3/12/10 to 3/13/10 from 7:00 a.m. to 6:00 a.m. the patient's temperature was taken every 4 hours. On 3/13/10 to 3/14/10 from 7:00 a.m. to 6:00 a.m. the patient's temperature was recorded at 9:00 a.m., 12:00 p.m., 2:00 p.m., 6:00 p.m., 9:00 p.m. 12:00 a.m., 2:00 a.m. and 6:00 a.m. At 9:00 p.m. on 3/13/10 the patient's temperature was 95.0. There was no documentation of the blanket being on or off during the temperature assessments.

Interview on 3/23/10 at approximately 6:00 p.m. with the Compliance Director and Emergency Room Unit Manager at 3:00 p.m. confirmed the lack of documentation for the physician being notified of the blisters and the lack of the patient's and blanket's temperature being monitored according to the facility's policy and manufacturer recommendation.