**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to prevent development of pressure ulcers for one (#1) three residents reviewed for pressure ulcers of six sample residents. Specifically, the facility failed to prevent avoidable pressure injury and to provide necessary services to promote healing and prevent new injuries from developing. The facility failed to ensure the resident's pressure ulcer had physician orders for monitoring and treatment, and failed to ensure the pressure ulcers were staged correctly for Resident # 1. Due to the facility's failures, Resident #1 developed open areas on her skin, including two stage 2 pressure ulcers. Findings include: I. Professional reference The NPUAP Pressure Injury Stages,The National Pressure Ulcer Advisory Panel, was retrieved on 1/4/22 at http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages read in pertinent part: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (retrieved 11/22/22): Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Individuals with a medical device are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local edema, as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility Policy The Pressure Ulcer/Skin Breakdown -clinical protocol policy, dated 3/14/11, was received on 12/8/22 from the director of nurses (DON). The policy read in pertinent parts, The nursing staff and attending physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition the nurse shall assess and document/report the following: a Vital signs b. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue c. Pain assessment d. Resident's age and sex e. Resident's mobility status f. Current treatments, including support surfaces g. All active diagnoses. The physician and staff will examine the skin of a new admission for ulcerations or indications of a stage I pressure area that has not yet ulcerated at the surface. The physician will help the staff define the type and character of the ulceration. The physician will authorize pertinent orders related to the wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings and application of topical agents. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound. II. Resident #1 A. Resident status Resident #1, over the age of 90, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO) diagnoses included heart failure, rheumatoid arthritis, osteoporosis, chronic pain, and hypertension. The 9/5/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of 15 out of 15. The resident was totally dependent on staff to complete activities of daily living (ADL) including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had no pressure ulcer/injuries, and used a pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. The comprehensive care plan, revised 10/11/22, identified the resident was at risk for developing pressure ulcers and had a history of healed pressure ulcers on her coccyx. The interventions were to assist Resident #1 with peri-care after each incontinent episode, conduct a systematic skin inspection once a week, report any signs of any further skin breakdown (sore, tender, red, or broken areas), encourage the resident to off-load coccyx area when in bed and when sitting in recliner chair, if a pressure ulcer developed, may consult with consultant wound nurse for treatment recommendations. B. Observations and interview On 12/7/22 at 1:15 p.m., the resident was lying on her back in her bed in a semi-reclined position. The bed had a pressure reducing mattress. On 12/8/22 at 2:00 p.m., the resident's weekly skin assessment was observed with licensed practical nurse (LPN) #1. The resident was lying in her bed in a semi-reclining position. The resident had one pillow positioned beneath each hip. LPN #1 proceeded to uncover the resident to observe the resident. The resident had one open area on her lower back and one open area on her left hip. Both open areas were uncovered and a small amount of red blood tinged drainage was visualized on each wound and there was a small amount of dried drainage noted on the bottom sheet. LPN #1 said all the wounds were improved and clarified that was based on her observations from previously assessing the pressure ulcers which was approximately three times a week during November and December 2022. The LPN measured each wound using a clear plastic overlay designed for wound measurements. The wounds were open, not infected with red and pink tissue visualized. After completing the skin assessment, the LPN completed wound care which consisted of washing the pressure wounds with soap and water and after the wounds were dry, she applied hydrocolloid barrier cream. During the skin assessment, the resident said that the pressure wounds were not painful. The resident also stated she could not recall if staff had told her that repositioning can help heal and prevent pressure ulcers. Resident #1 stated she wanted to stay in her bed and can sometimes tolerate repositioning with pillows or a blanket but that she needed help from staff for repositioning. C. Record review The 9/24/22 progress note documented the resident had red and open areas on her right and left buttocks. The areas were massaged, cleansed with soap and water and silicone barrier cream was applied. The resident had three open areas of left buttocks measured 3.5 cm (centimeters) x 4 cm, 1 cm x 1 cm and 1 cm x 1 cm. Two red areas, and one open on the right hip measured 3.5 cm x 3.5 cm. -A description of the open areas was not included in the progress note. A review of the record revealed there was not a notification to the physician regarding the development of the open areas on the resident's skin. On 9/30/22 the monthly MDS assessment indicated the resident had four stage 1 pressure ulcers. Interventions in place on 9/30/22 included; pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. A change in condition MDS was completed on 10/5/22.The assessment showed the resident had one stage 1 pressure ulcer and two stage 2 pressure ulcers. The resident's ADL status was unchanged. -The record failed to show the primary care physician was notified regarding the regarding the staging and open areas on the resident's skin. (Cross-reference F580). -The record review revealed there were no physician orders were obtained for application of ointments/medications, or pressure ulcer preventive or healing interventions. The 10/6/22 skin check marked completed, was blank. On 10/11/22 the physician completed a 60-day summary. The summary indicated the skin had no rashes, and that no new issues were present for evaluation. The 10/13/22 skin check indicated the resident had breaks in her skin on the left coccyx area and had resolving redness and irritation on the right back. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 10/26/22 1:54 p.m. progress note indicated the resident had new open areas on her skin. The open areas listed were: right side of back measured 4 cm x 4 cm, two on the coccyx measured 1.2 cm x 2 cm, 2 cm x 2 cm, and left side of back 1 cm circular. The nurse documented the areas were cleansed with soap and water and silicone barrier cream was applied. -A review of the resident's progress notes revealed documentation did not include wound descriptions, a notification to the physician regarding the skin check findings of the open area, and treatment orders were not located in the medical record. The 10/27/22 skin check marked completed, was blank. On 11/1/22, the resident's care plan was updated and included, the resident was at risk for skin breakdown and pressure ulcers related to the desire to lay on the back and not off-load. Interventions included, use pillows or blankets to assist resident with positioning, assist with toileting, hygiene, and repositioning, the resident declined an air mattress and/or air-overlay mattress topper, Resident declined to be repositioned or to off-load bony prominences and that resident and medical power of attorney were aware of the high risk for skin breakdown status, and the resident requested to lay in bed at all times. The 11/10/22 skin check indicated the Resident had two areas of redness and irritation: the coccyx and left hip. The left hip area was classified as a stage 1 decubitus ulcer and a description of the ulcer was not included. -A review of the resident's record revealed there was not a notification to the physician regarding the skin check findings of the open areas and redness. The 11/5/22 MDS assessment indicated the resident had 2 stage 2 pressure ulcers, treatments in place were pressure relieving device for bed, turning/repositioning program, interventions to manage skin problems, application of ointment/medications. The 11/24/22 skin check indicated the resident had open areas on her right back and coccyx and noted the coccyx had a decubitus ulcer but did not include a description or measurement of the ulcer. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 12/2/22 skin check indicated the resident had open areas on her coccyx and her left hip area. The coccyx was classified as a decubitus. A description, measurements, and staging were not included in the documentation. -A review of the resident's record revealed there was not a notification to the provider regarding the staging and open areas on the resident's skin. The 12/3/22 MDS assessment indicated the resident had 2 stage pressure ulcers. Treatments in place were; pressure relieving device for bed, turning/repositioning program, application of ointment/medications. The 12/5/22 physician progress note revealed an evaluation of the resident's skin was not included. The physician documented the nurses reported on 10/11/22 and 12/5/22 the resident was stable. The 12/8/22 skin check indicated the resident had breaks in her skin: coccyx area 1 cm x 1.5 cm, stage 2 left hip 1 cm x 1 cm, and left hip 2 cm x 2 cm, each stage 2. -A description of the pressure wounds was not included. On 12/8/22, after the start of the survey, the physician was contacted by the nurse regarding the pressure ulcers. The documentation indicated the physician was notified the resident had two pressure ulcers; one on the left hip, stage 2, and on the coccyx, and stated it was almost a stage 1 pressure ulcer. The physician then ordered to cleanse the area with normal saline, hydroguard, and off-loading. On 12/14/22 a mobile wound nurse completed an evaluation of the pressure ulcers. The coccyx wound measured 1.00 cm x 1.50 cm x < 0.2 cm and was classified as a stage 2 pressure ulcer. The left hip wound #1 measured 2 cm x 2 cm x <0.2 cm and was classified as a stage 2 pressure ulcer and left hip wound #2 measured 1 cm x 1 cm x <0.2 cm and was classified as a stage 2 pressure ulcer. The three wounds had 100 % red, dermal base and had well defined edges. The wound nurse recommended treatment for the three wounds included: clean the wound per physician order and apply hydrocolloid dressing and to change the dressing every other day or as needed. On 12/14/22 the physician orders were updated and included, cleanse the pressure ulcer areas with normal saline, apply hydroguard, cover with a silicone hydrocolloid dressing to promote autolytic debridement, and change the dressing every other day or as needed. An order was also obtained to measure the wound on the resident's coccyx and left hip weekly with skin measurements. D. Staff interview LPN #1 was interviewed on 12/8/22 following the skin assessment and treatment at 2:00 p.m. She said the current treatment for the pressure ulcers was to clean the areas with soap and water and then a thin layer of hydrocolloid barrier cream was applied. The LPN was unable to refer to physician orders for wound care and stated the current product used was one they have used for a long time. LPN #1 said the nurse would select the product and treatment that was appropriate for the condition and resident comfort and was based on the nurse's experience. The LPN said when a new problem was identified during the skin assessment the process was to notify the family and physician. If new orders are obtained after physician notification, the order and notes are downloaded from one system and then entered into the resident's electronic health record. The director of nurses (DON) was interviewed 12/8/22 at 3:00 p.m. The DON said nursing staff and the attending physician assess and document the risks for developing pressure ulcers. The care plan was to include the resident's risk for skin breakdown and pertinent approaches were put into place. The DON said when a pressure ulcer developed a full assessment, which included location, stage, measurement, and description of tissue should be included in the assessment. She said the resident had a weekly skin assessment completed. The DON said the resident was at high risk for developing pressure ulcers. The DON stated once a concern for a skin condition was identified the nurse would select a treatment product in stock, taking into consideration the resident's status, such as activity level, fluid status, diet ordered, or condition of circulation. The DON stated the application of hydraguard barrier cream to open pressure ulcer was current practice and the current treatment for the resident did not include application of protective or preventive dressings. The DON confirmed there was no physician order for the treatment which was provided to the resident's wounds. She said when the wound was open and or bleeding the wound should have a dressing on it. The DON stated the physician should be contacted to help define the type of wound and to help determine treatments, considering the resident's condition and other diagnoses. The DON stated by including the physician, the physician can then authorize the nursing staff to treat and manage skin conditions. The DON stated the purpose of completing a weekly skin assessment is to assess the current status of the resident's skin and to determine whether or not current treatments are effective. When the current treatments were not effective, the nurse completing the assessment should contact the physician, provide the assessment information, and then changes to care could be considered. Registered nurse (RN) #1 was interviewed on 12/21/22 at 11:00 a.m. RN #1 said that she had a conversation with the resident on the importance of being repositioned frequently and not lying in the same position. She said that after she explained the importance to the resident she understood and was more cooperative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to inform the physician and the resident's legal representative of changes in condition with two (#1 and #2) out of three residents out of six sample residents. Specifically, the facility failed to: -Notify the physician for Resident #2 and Resident #1 when their was a change in condition; and, -Notify the resident representative of a change in condition for Resident #2. Findings include: I. Facility policy and procedure The Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated 3/14/11, was provided by the director of nursing (DON) on 12/7/22 at 2:00 p.m. The policy read in pertinent part, under cause identification, 1. The Physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin. 2. The Physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing. The director of nursing (DON) was interviewed on 12/22/22 at 12:00 p.m. The DON said the facility did not have a specific policy on notification to the physician or the resident's legal representative. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted to the facility on [DATE]. According to the May 2022 computerized physician orders (CPO) diagnoses included; vascular dementia, diabetes mellitus with diabetic nephropathy, restless leg syndrome, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, cellulitis (skin infection) of right toe, and other skin changes. The 5/6/22 minimum data set (MDS) assessment showed cognitive skills for daily decision making as severely impaired-never/rarely made decisions. He was totally dependent on the assistance of one staff member to physically assist with dressing and bathing. No Braden scale completed on MDS assessment. The MDS assessment showed the resident did not have any pressure ulcers. The MDS assessment showed that other skin problems or lesions were abrasions, bruises. The MDS assessment showed that skin treatments were a pressure relieving device(s) for chair, pressure relieving device(s) for bed, and a turning/repositioning program. The MDS assessment showed that foot problems and care were limited to nails and calluses being trimmed during the last 90 days. B. Representative interview The legal representative of Resident #2 was interviewed on 12/13/22 at 4:42 p.m She said she was contacted by facility on morning of 5/28/22 and was informed that Resident #2 was heading to the emergency room because of an infection in the toes. She said the nursing facility had not provided her with any information prior to this in regards to concerns with the feet of Resident #2. C. Record review The nursing facility face sheet listed wife of Resident #2 as primary decision maker. The progress note dated 5/2/22 read in pertinent part, Resident has red and scabbed areas to top of both great toes, both long toes and both of the 3rd toes. Resident's shoes are rubbing on the toes. The 5/5/22 weekly skin check revealed scabbed great toes, long toes bilateral feet and redness noted to toes bilat feet. Foot problems and care revealed that nails/calluses were trimmed during the last 90 days on weekly skin assessment. The progress note dated 5/26/22 documented in pertinent part, When skin assessment done this am noted larger black scabbed area on right great toe with redness of great toe itself. Area is not warm to touch but does appear to cause discomfort when touched due to resident pulls foot away when foot dried this morning with shower. When checking last skin check noted there was scabbed areas on great toe. Area of black scab measures 2.5 cm (centimeter) by 1.5cm and is irregular. The emergency department (ED) progress note on 5/28/22 read, Gangrene right great toe. Large scab present to the right great toe. Left toe abrasion. ED notes continued to read course of action was to transport Resident #2 to a different hospital so that toe could be amputated due to gangrene. -The resident's medical record failed to show the physician was notified of the changes of condition in the resident's skin prior to the resident's transfer to the emergency department on 5/28/22. In addition, Resident #2's representative was not notified of the condition of his skin prior to him being transferred to hospital. C. Interviews Certified nursing aide (CNA) #2 was interviewed on 12/8/22 at 2:00 p.m CNA #2 said that she was familiar with Resident #2 and often provided care with activities of daily (ADL). She said the resident's toes were red and this was reported to the charge nurse. She was unable to provide specific dates. The director of nursing (DON) interviewed on 12/21/22 at 1:00 p.m The DON reviewed the resident's medical record and confirmed the resident had a significant change to his left foot. She said the physician and legal representative should be notified when there was a change of condition. III. Resident #1 A. Resident status Resident #1, over the age of 90, was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO) diagnoses included heart failure, rheumatoid arthritis osteoporosis, chronic pain, and hypertension. The 9/5/22 minimum data set (MDS) assessment revealed the resident's brief interview for mental status (BIMS) with a score of 15 out of 15. The resident was totally dependent on staff to complete activities of daily living (ADL) including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had no pressure ulcer/injuries, and used a pressure relieving device for bed, turning/repositioning program, application of ointments/medications, and other preventive or protective skin care. B. Change of condition The resident experienced a change of condition in her skin with the start of 9/24/22 with an open area to her right and left buttocks (Cross-reference F686 pressure injury). On 10/13/22 she had a pressure injury on her left coccyx and resolved redness and irritation on the right side of her back. On 10/26/22 the resident had a new open area o n her right side of back, two areas on her coccyx and the left side of her back. On 11/10/22 the resident had a left hip area classified as a stage 1 pressure injury. -The resident's medical record failed to show evidence the primary care physician was notified of the changes in the skin check findings of the open area, and treatment provided since 9/24/22. C. Staff interview Licensed practical nurse (LPN) #1 was interviewed on 12/8/22 at 2:00 p.m. The LPN stated when a new problem was identified during the skin assessment the process was to notify the family and physician. She said a note would be documented in the progress notes to indicate both the family and the physician were notified. The director of nurses (DON) was interviewed 12/8/22 at 3:00 p.m. The DON said the physician should always be notified timely when a change of condition occurs with a resident. She reviewed Resident #1's record and could not find any evidence that the physician was notified. She said in the past a text message was utilized to the physician's phone. -However, she was unable to show evidence that a text message was used.