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Based on document review and interview, the facility failed to follow their policy/procedure for wound assessment, prevention and documentation for 1 of 10 closed medical records reviewed.

Findings:

1. Policy/procedure QCE-002, Wound Assessment, Prevention and Documentation, revised/reapproved 8/17/16 indicated:
A. page 5: b. Daily documentation of skin and wound inspection completed by an RN will include any of the following, if present: i. skin condition, ii. dressing integrity, iii. description of wound drainage, odor, pain, signs of inflammation or infection
B. page 5: c. Daily documentation will be recorded by the RN as part of the daily nursing assessment.

2. Review of patient 1's medical record (MR) on 12/14/16 at approximately 1400 hours lacked documentation of daily wound assessment for right lower extremity wound on 11/4/16, 11/5/16 and 11/9/16.

3. On 12/14/16 at approximately 1400 hours, staff P8 (Nursing Supervisor) was interviewed and confirmed patient 1's MR lacked daily documentation of wound assessment on 11/4/16, 11/5/16 and 11/9/16. Staff P8 confirmed staff should follow policy for wound assessment, prevention and documentation.