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Based on review of 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 one of five patient medical records (Records #1) 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:

Record #1 - Patient admission from 12/27/2010 - 02/25/2011. The patient was a paraplegic with lack of sensation of the lower body.
1. On 01/11/2011, the wound care specialist took a picture of Patient #1's sacral area showing a skin disruption/denuded area. The chart contained an order on 01/11/2011 at 1422 for a topical to be applied twice a day and after peri-care to open wounds on gluteus and sacrum; apply a "butt paste" to closed area on gluteus and sacrum twice a day and after pericare; and to turn the patient every two (2) hours.
a. The nursing notes for 01/11/2011 and prior did not reflect the patient had any skin problems for this body area.
b. The first nursing entry concerning skin problems on the sacral area was on the evening nursing assessment for 01/12/2011. The nurse documented "blister on sacral area" and at 2200 that the patient's sacral area was cleaned and wound care was performed. Under the skin area of assessment.
c. Nursing staff often wrote to see the wound care sheets. However, other than the picture taken on 01/11/2011 (mentioned above), the first documentation on these sheets of skin problem in the sacral area was 01/13/2011.

2. On 02/21/2011, the wound care specialist took a picture of Patient #1's left heel. He noted the patient had a reddened area on the left upper heel. Nursing notes or wound care sheets do not document a problem in this area.

3. Nursing notes did not reflect the patient was turned every two hours or that nursing staff had trouble with patient cooperation on turning and keeping pressure off pressure points and skin disruption areas. Example: On 12/28/2010, the flowchart and nursing notes do not document the patient was turned/repositioned every two hours from 0900 to 1900; 01/10/2011, the flowchart and nursing notes do not document the patient was turned/repositioned every two hours from 1200 to 0600; on 01/29/2011, the repositioning section of the flowsheet was blank and nursing notes did not document patient was turned or that there was a problem with turning the patient.