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Based on review of hospital documents, medical records, nursing policies and procedures and interviews with hospital staff, the hospital failed to ensure the registered nurse supervised and evaluated patient nursing care. Care/needs cannot be identified without complete baseline and ongoing assessments and evaluations. In three of five patient medical records (Records #1, 2, and 3 of Records #1, 2, 3, 4, and 5) reviewed for nursing assessments and care, the nurse did not perform complete assessments so that care needs could be identified and did not supervise nursing staff to ensure accuracy and completeness of documentation.

Findings:

According to nursing policy and interviews with Staff B, C and D, nursing staff worked twelve-hour shifts and full nursing assessments were performed on each shift.

1. Patient #1 - The patient was admitted on 02/08/2011 and discharged on 02/14/2011.
a. The initial nursing assessment did not document the patient was legally blind and would need help with meals, but instead documented the patient's vision was within normal limits. The fact that the patient was legally blind did not get documented until 02/09/2011. The identification through documentation that the patient needed help with meals/feeding did not occur until 02/11/2011 at the 0730 assessment.
b. The nursing assessment on 02/08/2011 at 2000 noted bruising to the patient's abdomen and left lower extremity. The nursing assessment on 02/09/2011 at 1920 documented the patient had bruises on the left lower extremity. Neither assessment told the exact location of size of the bruises. This bruising was not identified.
c. The nursing assessments on 02/10/2011 at 0745 and 1900 documented a dressing to the patient left upper extremity times two on the forearm area that was clean, dry and intact. The assessments and nursing notes do not identify any occurrence or describe why the patient had dressings to this area. The areas are not mentioned again in the nursing notes or assessments.
d. On 02/12/2011, nursing assessments recorded that a barrier cream/butt paste was applied to the patient's reddened buttocks area. Nursing assessments and notes do not describe the reddened area with size and characteristics.
e. The nursing assessments and notes did not always document the patient's surgical wound for which the patient was admitted.

2. Patient #2 - The patient was admitted on 12/30/2010 and discharged on 01/20/2011.
a. The initial nursing assessment noted the patient had an area of redness to the the sacral area.
b. Nursing notes and assessments did not address this area again until 01/05/2010. The nursing assessment on 01/05/2010 documented the patient's sacral area had a skin disruption. A dressing was applied and the nurse recorded the wound care nurse was to look at the patient the next day (01/06/2011).
c. The wound care nurse did not assess the patient until 01/09/2011.
d. Nursing notes and assessments did not document the patient's skin disruption throughout the stay.

3. Patient #3 - The patient was admitted on 02/18/2011 and discharged on 03/22/2011.
Nursing notes and assessments did not document and describe the patient's colostomy wound or the skin surrounding the colostomy. The patient was admitted with a fistula/ a wound dehiscence with a loop of bowel in the area after a diverting colostomy.

Based on review of hospital documents and meeting minutes and interviews with hospital staff, the hospital failed to track and analyze quality indicators hospital-wide to improve patient care. The Quality program failed to include dietary issues.

Findings:

1. Dietary issues addressed in patient grievances and satisfaction surveys - assistance meal set-ups, wrong diets, cold trays, diet trays with another patient's name - were not addressed in the hospital's Quality Management program.

2. This finding was reviewed and verified with hospital administration on the afternoon of 04/22/2011.