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Based on record review and interview the facility failed to ensure the staff providing care to the patient, completed and documented daily wound care assessment. These findings have the potential to cause harm to all patients receiving these procedures at the hospital.

Findings:
A review of the facility's policy titled, "Dressing Change partly stated the following:
It is the policy of UMC Health System to protect a surgical site from contamination by removing soiled dressings, cleansing the wound, and applying a sterile dressing when ordered by a provider or identification of need through nursing assessment.

NOTE: Performed by RN or LVN. A PCA or Nurse Tech may change a minor non-sterile dressing when delegated by the licensed nurse on a patient specific basis.

TEXT: UMC Health System Specifics

- Educate patient prior to dressing change
- Obtain supplies needed for specific dressing change per order or patient need (e.g., soiled dressing).
- Practice good hand hygiene and don PPE or sterile garb per provider orders or per patient infectious precautions.
- Remove old dressing and discard all contaminated articles appropriately.
- Assess wound for size (length, width, and depth), color, odor, drainage color and amount, and surrounding tissue description.
- Remove soiled gloves and repeat hand hygiene.
- Don clean or sterile gloves depending on the technique ordered.
- Apply new dressing as ordered by provider.
- Document assessment findings and dressing change in the patient record. (PCA or Nurse Tech may only document dressing change)."

In an interview, with staff # 5 & staff # 1 after reviewing the patient's record it was acknowledged the wound had progressed to include eschar covering that required new physician orders. It was also confirmed the daily dressing change and skin assessment of the right scapula burn was not documented from 6/30/23 to 7/11/23.