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Based on clinical record review, policy review and interview, it was determined a Registered Nurse (RN) failed to supervise and evaluate the nursing care in that 7 (#2-#8) of 10 (#1-#10) patient's clinical records reviewed did not contain a detailed RN assessment describing the patient's wounds each shift. Failing to provide a detailed RN assessment of the patient's wounds did not allow for notification of the physician or wound care nurse to make timely changes in the patient's wound care plan and interventions. The failed practice had the likelihood to affect all patients with wounds or at risk for wounds. The findings follow:

A. Review of the facility's policy titled, "Assessment of Patients," with an effective date of September 2020, showed, "An RN assessment at least once a shift or more often if indicated, patient body systems and pain status as indicated by patient's condition, plan of care, and/or unit standards. An RN/Care Coordinator will complete at a minimum a 'Basic Nursing Physical Exam' including pain assessment for each patient each shift. Basic physical examination will be guided by the norms suggested below. Population specific or unit specific assessment guidelines and standards of care supersede this baseline criterion. The patient's condition will dictate any assessment needs."

B. The findings of A were confirmed in an interview with the Quality Facilitator on 12/10/21 at 4:00 PM. The Quality Facility confirmed a detailed documentation of the patient's wound should be documented each nursing shift (7 AM to 7 PM and 7 PM to 7 AM shifts).

C. Review of Patient #2's clinical record showed the following:
1) Wound Care Progress Note dated 10/27/21 at 2:23 PM showed the patient had wounds on their right toes, right cheek, left elbow, right ear, left ear, back, and sacrum.
2) Review of the RN assessments from 12/01/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/01/21 (AM and PM shifts), 12/02/21 (AM and PM shifts), 12/03/12 (PM shift), 12/04/21 (AM and PM shifts), 12/05/21 (PM shift), 12/06/21 (AM and PM shifts), 12/07/21 (PM shift) and 12/08/21 (AM and PM shifts).

D. The findings of C were confirmed in an interview with the Director of Nursing on 12/14/21 at 8:30 AM.

E. Review of Patient #3's clinical record showed the following:
1) Wound Care Progress Note dated 10/18/21 at 10:12 AM showed the patient had wounds on their coccyx, mouth and left knee.
2) Review of the RN assessments from 12/05/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/05/21 (AM and PM shifts), 12/06/21 (AM and PM shifts), 12/07/21 (AM and PM shifts) and 12/08/21 (AM and PM shifts).

F. The findings of E were confirmed in an interview with the Director of Nursing on 12/14/21 at 1:20 PM.

G. Review of Patient #4's clinical record showed the following:
1) Wound Care Progress Note dated 11/18/21 at 2:05 PM showed the patient had wounds on their right ear and left ear.
2) Review of the RN assessments from 12/05/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/05/21 (AM and PM shifts), 12/06/21 (AM and PM shifts), 12/07/21 (AM and PM shifts) and 12/08/21 (AM and PM shifts).

H. The findings of G were confirmed in an interview with the Director of Nursing on 12/10/21 at 1:15 PM.

I. Review of Patient #5's clinical record showed the following:
1) Wound Care Progress Note dated 11/18/21 at 1:48 PM showed the patient had wounds on their right heel, sacrum, left lower abdomen and right hip.
2) Review of the RN assessments from 12/05/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/05/21 (AM shift), 12/06/21 (PM shift), 12/07/21 (PM shift) and 12/08/21 (PM shift).

J. The findings of I was confirmed in an interview with the Director of Nursing on 12/10/21 at 3:40 PM.

K. Review of Patient #6's clinical record showed the following:
1) Wound Care Progress Note dated 11/19/21 at 10:07 AM showed the patient had wounds on their right ischium, left ischium and sacrum.
2) Review of the RN assessments from 12/06/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/06/21 (AM and PM shifts), 12/07/21 (AM and PM shifts) and 12/08/21 (AM and PM shifts).

L. The findings of K were confirmed in an interview with the Director of Nursing on 12/14/21 at 10:35 AM.

M. Review of Patient #7's clinical record showed the following:
1) Wound Care Progress Note dated 11/11/21 at 11:44 AM showed the patient had wounds on their buttock/scrotum.
2) Review of the RN assessments from 12/05/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/05/21 (AM and PM shifts), 12/06/21 (AM and PM shifts), 12/07/21 (PM shift) and 12/08/21 (AM and PM shifts).

N. The findings of M were confirmed in an interview with the Director of Nursing on 12/14/21 at 11:10 AM.

O. Review of Patient #8's clinical record showed the following:
1) Wound Care Progress Note dated 11/12/21 at 9:14 AM showed the patient had wounds on their left ear, coccyx and left buttock.
2) Review of the RN assessments from 12/05/21 to 12/08/21 showed there was no evidence of a detailed RN assessment of the wounds on 12/05/21 (AM shift), 12/06/21 (AM and PM shifts), 12/07/21 (AM and PM shifts) and 12/08/21 (AM shift).

P. The findings of O were confirmed in an interview with the Director of Nursing on 12/14/21 at 12:35 PM.
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Based on clinical record review and interview, it was determined the facility failed to ensure 6 (#1, #2, #4, #6, #8 and #9) of 10 (#1-#10) patients reviewed were turned every two hours per physician's orders. Failure to turn the patients every two hours placed the patients at risk of skin breakdown. The failed practice had the likelihood to affect all patients at risk for skin breakdown. Finding follow:

A. Review of Patient #1's clinical showed the following:
1) Physician Order dated 10/20/21 at 9:38 AM showed to turn the patient now then every two hours.
2) Physician Order dated 10/27/21 at 5:17 AM showed to turn the patient every two hours.
3) Wound Care Progress Note dated 10/21/21 at 10:33 AM showed recommended intervention of reposition patient at least every two hours.
4) Nursing documentation from 12/05/21 at 7:AM to 12/09/21 at 6:00 AM showed Patient #1 was not turned as follows:
a) On 12/05/21, Patient #1 was turned at 2:30 PM. There was no evidence Patient #1 was turned until 12/05/21 at 7:09 PM.
b) On 12/06/21, Patient #1 was turned at 5:14 AM. There was no evidence Patient #1 was turned until 12/06/21 at 8:45 AM.
c) On 12/07/21, Patient #1 was turned at 5:14 AM. There was no evidence Patient #1 was turned until 12/07/21 at 10:30 AM.
d) On 12/08/21, Patient #1 was turned at 5:00 AM. There was no evidence Patient #1 was turned until 12/08/21 at 9:14 AM.
e) On 12/08/21, Patient #1 was turned at 12:50 PM. There was no evidence Patient #1 was turned until 12/08/21 at 4:00 PM.
f) On 12/08/21, Patient #1 was turned at 7:15 PM. There was no evidence Patient #1 was turned until 12/09/21 at 12:30 AM.
g) On 12/09/21, Patient #1 was turned at 2:00 AM. There was no evidence Patient #1 was turned until 12/09/21 at 5:14 AM.

B. The findings of A were confirmed in an interview with the Director of Nursing on 12/14/21 at 9:50 AM.

C. Review of #2's clinical record showed the following:
1) Physician Order dated 10/27/21 at 7:20 PM showed to turn the patient every two hours.
2) Wound Care Progress Note dated 10/27/21 at 2:23 PM showed to reposition the patient at least every two hours.
3) Nursing documentation from 10/30/21 at 6:00 AM to 11/27 /21 at 7:00 PM showed Patient #2 was not turned as follows:
a) On 10/30/21, Patient #2 was turned at 6:00 AM. There was no evidence Patient #2 was turned until 11/30/21 at 5:00 PM.
b) On 10/31/21, Patient #2 was turned at 2:06 AM. There was no evidence Patient #2 was turned until 10/31/21 at 10:04 AM.
c) On 11/08/21, Patient #2 was turned at 5:00 AM. There was no evidence Patient #2 was turned until 11/08/21 at 6:00 PM.
d) On 11/21/21, Patient #2 was turned at 8:00 AM. There was no evidence Patient #2 was turned until 11/21/21 at 1:35 PM.
e) On 11/27/21, Patient #2 was turned at 12:00 PM. There was no evidence Patient #2 was turned until 11/27/21 at 4:00 PM.

D. The findings of C were confirmed in an interview with the Director of Nursing on 12/14/21 at 8:30 AM.

E. Review of Patient #4's clinical record showed the following:
1) Physician Order dated 11/18/21 at 4:28 PM showed to turn the patient every two hours.
2) Wound Care Progress Note dated 11/18/21 at 2:05 PM showed to reposition the patient at least every two hours.
3) Nursing documentation from 11/27/21 at 7:00 AM to 12/08/21 7:00 AM showed Patient #4 was not turned as follows:
a) On 11/27/21, Patient #4 was turned at 3:38 PM. There was no evidence Patient #4 was turned until 11/27/21 at 7:44 PM.
b) On 11/29/21, Patient #4 was turned at 7:38 AM. There was no evidence Patient #4 was turned until 11/29/21 at 11:00 AM.
c) On 11/30/21, Patient #4 was turned at 5:00 AM. There was no evidence Patient #4 was turned until 11/30/21 at 7:44 PM.
d) On 12/06/21, Patient #4 was turned at 5:15 AM. There was no evidence Patient #4 was turned until 12/06/21 at 7:44 PM.
e) On 12/07/21, Patient #4 was turned at 6:00 AM. There was no evidence Patient #4 was turned until 12/06/21 at 6:00 PM.
f) On 12/07/21, Patient #4 was turned at 8:13 PM. There was no evidence Patient #4 was turned until 12/08/21 at 12:15 AM.

F. The findings of E were confirmed in an interview with the Director of Nursing on 12/10/21 at 1:15 PM.

G. Review of Patient #6's clinical record showed the following:
1) Physician Order dated 11/19/21 at 3:07 PM showed to turn the patient every two hours.
2) Wound Care Progress Note dated 11/19/21 at 10:07 AM showed to reposition the patient at least every two hours.
3) Nursing documentation from 12/04/21 at 7:00 AM to 12/08/21 at 7:00 AM showed Patient #6 was not turned as follows:
a) On 12/05/21, Patient #6 was turned at 3:00 AM. There was no evidence Patient #6 was turned until 12/05/21 at 6:45 AM.
b) On 12/05/21, Patient #6 was turned at 11:16 PM. There was no evidence Patient #6 was turned until 12/06/21 at 3:25 AM.
c) On 12/06/21, Patient #6 was turned at 10:25 PM. There was no evidence Patient #6 was turned until 12/07/21 at 3:15 AM.
d) On 12/07/21, Patient #6 was turned at 7:31 PM. There was no evidence Patient #6 was turned until 12/07/21 at 11:00 PM.
e) On 12/07/21, Patient #6 was turned at 11:00 PM. There was no evidence Patient #6 was turned until 12/08/21 at 3:52 AM.

H. The findings of G were confirmed in an interview with the Director of Nursing on 12/14/21 at 10:35 AM.

I. Review of Patient #8's clinical record showed the following:
1) Physician Order dated 11/12/21 at 1:28 PM showed to turn the patient every two hours.
2) Wound Care Progress Note dated 11/12/21 at 9:14 AM showed to reposition the patient at least every two hours.
3) Nursing documentation from 12/05/21 at 7:00 AM to 12/09/21 at 7:00 AM showed Patient #8 was not turned as follows:
a) On 12/05/21, Patient #8 was turned at 6:54 PM. There was no evidence Patient #8 was turned until 12/05/21 at 10:08 PM.
b) On 12/06/21, Patient #8 was turned at 3:14 AM. There was no evidence Patient #8 was turned until 12/06/21 at 7:00 AM.
c) On 12/07/21, Patient #8 was turned at 3:00 AM. There was no evidence Patient #8 was turned until 12/07/21 at 7:04 AM.
d) On 12/08/21, Patient #8 was turned at 3:00 AM. There was no evidence Patient #8 was turned until 12/08/21 at 9:27 AM.
e) On 12/08/21, Patient #8 was turned at 11:27 AM. There was no evidence Patient #8 was turned until 12/08/21 at 3:27 PM.

J. The findings of I were confirmed in an interview with the Director of Nursing on 12/14/21 at 12:45 PM.

K. Review of Patient #9's clinical record showed the following:
1) Physician Order dated 11/18/21 at 5:27 PM showed to turn the patient every two hours.
2) Wound Care Progress Note dated 11/15/21 at 2:26 PM showed to reposition the patient at least every two hours.
3) Nursing documentation from 12/04/21 at 7:00 AM to 12/09/21 at 7:00 PM showed Patient #9 was not turned as follows:
a) On 12/05/21, Patient #9 was turned at 5:00 AM. There was no evidence Patient #9 was turned until 9:10 AM.
b) On 12/08/21, Patient #9 was turned at 3:00 AM. There was no evidence Patient #9 was turned until 6:39 AM.
c) On 12/08/21, Patient #9 was turned at 3:10 PM. There was no evidence Patient #9 was turned until 8:09 PM.
d) On 12/08/21, Patient #9 was turned at 8:09 PM. There was no evidence Patient #9 was turned until 11:10 PM.
e) On 12/08/21, Patient #9 was turned at 11:10 PM. There was no evidence Patient #9 was turned until 12/09/21 at 3:09 AM.

L. The findings of K were confirmed in an interview with the Quality Manager/Infection Prevention on 12/14/21 at 1:05 PM.
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