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Based on document review and interview, the facility failed to ensure nursing staff documented patient wound care assessments and treatment as per facility policy/procedure in 2 of 10 medical records (MR) reviewed (patient 1 and 10):

Findings include:

1. Policy/procedure, Wound Care Assessment and Treatment, II-D.1, revised/reviewed 7/18, indicated on page 3: "A treatment order will be obtained upon identification of a pressure-related or non-pressure related wound. The order will include cleansing, the type of topical product, the type of occlusive dressing (if indicated), the frequency of treatment application/dressing change. The treatment order will be transcribed to the Medication Administration Record (MAR) with the date the order is to be indicated. Treatment will be completed in accordance with the providers order and will be documented on the MAR. The provider will be notified immediately if there is evidence of wound regression or signs of infection.

2. Review of patient 1's MR lacked documentation by nursing on the Nursing Reassessment Notes dated 8/1/18 at 0700 and 1900 hours, 8/2/18 at 1000 and 1900 hours, 8/3/18 at 0900 hours of a left hand bruise assessment as had been documented in Nursing Reassessment Note dated 7/31/18 at 2100 hours. Review of Nursing Reassessment Note dated 8/3/18 at 1900 hours, 8/4/18 at 1500 and 1900 hours and 8/5/18 at 0537 and 1900 hours, 8/6/18 at 0700 and 1900, 8/7/18, 8/8/18, and 8/9/18 at 0700 hours, 8/10/18 at 0700 and 1900 hours, 8/11/18 and 8/12/18 lacked consistent documentation of patient wounds including head laceration and knot-forehead/above right eye wound/injury.

3. Review of patient 10's MR lacked documentation by nursing on the Nursing Reassessment Notes dated 11/2/18, 11/3/18, 11/4/18, 11/5/18, 11/6/18, 11/7/18, 11/8/18, 11/9/18, 11/10/18, 11/11/18 and 11/12/18 lacked documentation of consistent wound/skin assessments and treatments. Review of Nursing Reassessment Notes dated 11/13/18 at 0400 hours, 11/14/18 at 0700 and 1900 hours, and 11/15/18 at 0700 hours lacked documentation of wound assessment and treatment/dressing change as documented per physician order dated 11/13/18. Review of patient 10's MR lacked documentation by nursing of bruising and skin tears to body as had been indicated by physician documentation in the discharge summary dated 11/15/18.

4. On 12/5/18 at approximately 1100 hours, medical staff D1 (Nurse Practitioner) was interviewed and confirmed patient 1 and 10's MR lacked documentation of wound assessments and treatments per nursing staff as per facility policy/procedure.