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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 four of four (Records #1, 2, 3 and 4) patient records reviewed, the nurse did not perform complete skin assessments after the initial assessment so that care needs and precautions could be identified.

Findings:

1. The unit's initial nursing assessment had a section that prompted nurses to look for bruises, rashes and other identifying marks. The initial assessment form also contained an additional drawing form entitled, Initial Intake Body Marks. These were not present on subsequent assessments.

2. Records #1, 2 ,3, and 4 noted skin marks on admission assessments. Record #2 only recorded scar and tattoos present, but the others noted skin impairments.

3. Subsequent assessments the Records #1, 2, 3, and 4 only noted skin assessments as "intact" and "no breakdown". Any disruptions/skin impairments documented were only in the nursing narrative notes. The discharge notes did not contain a skin assessment of the patient at the time of discharge with any notation on skin impairments.

4. Patient #1 - On the admission assessment on 10/11/2011, the nurse documented the patient had a three centimeter round area that "has reddened discoloration." Subsequent nursing assessments did not include this finding or detail progression. Nursing narrative notes had a notation on 10/25/2011 that the nurse observed dried blood at the patient's nostril and observed the patient "picking" her nose and the patient was redirected and reminded to not do this. An order was obtained for Bacitracin to the patient's nares twice a day. Nursing notes did not contain further documentation on the patient's nostril or whether the intervention was effective.

5. Patient #3 - On the admission assessment on 08/11/2011, the nurse documented the patient had a bruise to the top of the right foot and redness to posterior thighs bilaterally. Subsequent nursing assessments did not include these findings or detail progression. Nursing narrative notes on 08/29/2011, documented the patient had a "mashed and discolored" right great toe. The notes did not document how or when this occurred. The patient was seen by medical staff and an order for antibiotics was obtained. Nursing assessments did not contain documentation of this skin problem or progression of the skin impairment. The patient is a diabetic.

6. These findings were reviewed with Staff B, C, D and E at the time of chart reviews and again with administrative staff at the exit conference on the afternoon of 12/20/2011.