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Based on clinical record review, policy and procedure review and interview it was determined a RN (Registered Nurse) failed to supervise the care of one (#7) of one (#7) wound care patient in that there were not wound assessments for five (night shift on 02/03/17, night shift on 02/05/17, day and night shift on 02/06/17 and day shift on 02/07/17) of 15 (01/30/17 through 02/07/17) shifts. Failure to document the wound appearance did not give other providers the physical information necessary to make decisions regarding care and treatment. The failed practice affected Patient #7 on 02/08/17. Findings follow:

A. Review of Patient #7's clinical record revealed a nursing note authored by the Wound Care Nurse at 1115 on 01/31/17 that revealed the following wounds:
Ulcer 1 right heel - unstageable, moist with black eschar, unable to visualize wound base, ulcer base is yellow with slough present, peri-wound are is intact. Light or minimal amount of yellow drainage noted, no odor...
Ulcer 3 sacrum - unstageable, moist, unable to visualize wound base, ulcer base is yellow with slough present, peri-wound area is intact...
Ulcer 4 Left Ischium - Stage III, ulcer base is yellow, ulcer base is pink with slough present, peri-wound area intact, no odor, no drainage...
Ulcer 5 left heel - unstageable, black eschar present, unable to visualize wound base, peri-wound area is intact, light or minimal amount of drainage, seroganguineous, no odor...
Wound 2 left fifth toe - missing toenail, wound base is moist, wound base pink, peri-wound are intact, peri-wound area dry.
Wound 3 left anterior foot - ruptured blister, wound base is moist, wound base pink, peri-wound area is intact, peri-wound area is dry, peri-wound area is erythemic...
Wound 4 left lower anterior leg - ruptured blister, wound base moist, wound base pink, peri-wound area is intact, peri-wound area is dry, peri-wound area is erythemic...
Wound 5 perineum - perineum/yeast like rash, no open areas, peri-wound area is intact, peri-wound area is moist, peri-wound area is erythemic...

B. Review of the nursing notes revealed the following:
02/03/17 7 PM (Ante Meridian) shift, no wound assessment.
02/05/17 7 PM shift, no wound assessment.
02/06/17 7 AM (Ante Meridian) shift, no wound assessment.
02/06/17 7 PM shift, no assessment of Ulcers 1,3, 4 or 5, or Wounds 3 and 5.
02/07/17 AM shift, no assessment of Ulcers 3, 4 and 5 or Wounds 3, 4 and 5.

C. Review of the policy and procedure titled "Electronic Nursing Documentation" received from the Regulatory Specialist at 1040 on 02/07/17 revealed the following under DOCUMENTATION GUIDELINES: under Type of Documentation - Physical Assessment of System, Who - RN, Where - Daily Flowsheet, What - Systems Assessment, Time Frame - Each shift within 4 hours, Head to Toe Assessment Start of all shifts and:...

D. During an interview with the Assistant Vice President of Patient Care Services and the Clinical Educator at 1405 on 02/08/17 both stated the head to toe nursing assessment includes all wounds.

E. The findings of A, B and C were verified during an interview with the Regulatory Specialist at 1230 on 02/08/17.