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Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a registered nurse (RN) evaluated the care for one (1) of ten (10) sampled patients (Patient #1). On 03/27/19, nursing staff photographed a wound to Patient #1's coccyx; however, nursing staff failed to document the appearance/measurements of the wound on 03/27/19 and 03/28/19.

The findings include:

Review of facility's policy titled "Wound Assessments and Measurements," undated, revealed the purpose of the policy was to "promote healing by communicating the current status of open wounds" and "to provide accurate documentation of open wound measurements that reflects current patient status." Further review of the policy revealed wound measurements would be completed upon admission, when indicated by a change in appearance, weekly, and upon discharge.

Review of Patient #1's medical record revealed the facility admitted the patient on 03/14/19 with diagnoses including Chronic Respiratory Failure, Alzheimer's Disease, Anxiety, Bipolar Disorder, Chronic Obstructive Pulmonary Disease (COPD), Dementia, and Diabetes.

Review of "Photographic Documentation" for Patient #1 dated 03/27/19 revealed "placed mepilex [dressing] to coccyx - stage I, blister, and skin tear." Review of the medical record revealed no further documentation regarding the wound until 03/29/19.

Interview with Registered Nurse (RN) #1 on 05/01/19 at 8:48 AM revealed she assessed Patient #1 on 03/27/19 and discovered the areas to the patient's coccyx. The nurse stated she photographed the areas and placed the photographs in the patient's chart, but failed to further document the wounds in the electronic medical record.

Interviews with RN #2 on 04/29/19 at 3:40 PM and RN #3 on 04/30/19 at 8:42 AM revealed they provided care for Patient #1 on 03/28/19 but did not document the appearance of the patent's wounds in the patient's medical record.

Interview with the Community Chief Nursing Officer (CCNO) on 04/30/19 at 4:30 PM revealed nursing staff were required to complete and document an assessment on each patient at least once per shift. Further interview revealed she would have expected nursing staff to document the appearance of Patient #1's wounds in the medical record.