**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide one of three residents (#5) out of 21 sample residents, with timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury that resulted in the development of a stage 4 coccyx wound with osteomyelitis. Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). And, on 6/6/24, x-rays revealed the presence of osteomyelitis, inflammation of the bone due to infection, requiring an extended course of antibiotic treatment. Interviews, observations, and record review revealed the facility failed to provide timely and necessary treatment and services to prevent the development of the resident's pressure injury and then, failed to provide the treatment and services necessary to manage the pressure injury and promote healing. Specifically: -Record review and interviews revealed the facility failed to timely provide Resident #5 with devices for pressure relief. Record review revealed a physician's order for an air mattress was not initiated until 2/21/24, approximately two and a half months after the pressure injury had developed and the order was not implemented until 3/10/24, 20 days later. Even then, the air mattress provided had been previously used and the facility was unable to provide documentation on how old the mattress was and how much use it had received, as well as provide an instruction manual on its proper use and settings. Further, an interview with Resident #5 revealed he was not repositioned routinely at night time unless he asked staff to do so. His care plan failed to include a directive for staff to assist the resident in turning and repositioning to offload pressure until 2/21/24, over a month after his pressure injury was assessed as a stage 4. -Record review revealed weekly skin assessments were not completed to ensure Resident #5's pressure injury was regularly monitored; physician orders for dressing changes were not followed and dressing changes were not performed in a manner to prevent infection. -Interviews, record review, and observations revealed the facility failed to ensure the nutritional support ordered on 2/21/24 (double protein) was consistently offered to Resident #5. Per the WCP, interviewed on 7/24/24 at 9:56 a.m., Resident #5's pressure injury was avoidable; he saw no other clinical issues that would contribute to the pressure injury. Findings include: I. Professional references A. Classification of pressure injuries According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA: 2019, retrieved from https://www.internationalguideline.com/guideline on 7/30/24, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Support surfaces 1. According to Joerns Healthcare PRO [NAME] Plus product details, retrieved online from https://www.joerns.com/product/p-r-o-matt-plus/ on 8/5/24, The P.R.O. [NAME] Plus is a non-powered mattress replacement system featuring our Pressure Redistribution Optimization (P.R.O.) Technology. With the addition of an optional control unit, the mattress provides powered immersion or alternating pressure therapy, allowing facilities to use one mattress for both pressure injury prevention and treatment. The P.R.O.Matt® Plus system is designed for a minimum service life of five (5) years, subject to the use and maintenance procedures stated in this manual. The P.R.O. [NAME] Plus is a reactive surface that allows the provision of optimal interface pressures through controlled air cell inflation for at-risk patients in the prevention and treatment of Stage 1 and 2 pressure injuries, and treatment of uncomplicated Stage 3 and 4 pressure injuries in patients with multiple turning surfaces. For Stage 3 and/or Stage 4 treatment, care staff should be able to position the patient off of the pressure wound in at least 2 positions. 2. According to Avacare Medical the How Long Can a Air Mattress Last, retrieved on 7/29/24 from: https://www.avacaremedical.com/blog/how-long-can-a-air-mattress-last.html#:~:text=Air%20mattresses%20can%20endure%20for,sharp%20items%20to%20prevent%20punctures, Air mattresses can assist with medical issues like pressure reduction or better blood circulation. Air mattresses can endure for two to eight years when properly maintained and used occasionally. When the air mattress isn ' t in use, thoroughly deflate it and put it in a carry bag to extend its lifespan. Keep the air mattress in a cool, dry area free of sharp items to prevent punctures. [NAME] ' t over inflate the air mattress; avoid sitting on the edge of an inflated air bed to avoid seams ripping and bulging. II. Facility policy A. The Prevention of Pressure Injuries policy and procedure, revised April 2020, was received from regional nurse consultant (RNC) #1 on 7/24/24 at 10:17 a.m. It read in pertinent part: [P]purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure injury risk factors, repeat the risk assessment weekly and upon any changes in condition. Reposition all residents with or without risk of pressure injuries or an individualized schedule, as determined by the interdisciplinary care team. Choose a frequency for repositioning based on the resident ' s risk factors and current clinical practice guidelines. Provide support devices and assistance as needed Select appropriate support surfaces based on the residents' risk factors in accordance with current clinical practice. B. The Supportive Surfaces Guidelines Policy was provided by RNC #1 on 7/25/24 at 11:30 a.m. The policy read in pertinent part: [T]he purpose of this procedure is to provide guidelines for the assessment of appropriate pressure-reducing and relieving devices for residents at risk of skin breakdown. Redistributing supportive surfaces are to promote comfort for all bed or chair-bound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. Supportive surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface, such as a foam, gel, static air alternating air, or air loss mattress when lying in bed. For resident(s) who recline and are dependent on staff for repositioning, change their position at least every two hours III. Resident #5 A. Resident status on admission Resident #5, age younger than 65, cognitively intact, with a diagnosis of paraplegia per his 6/11/14 minimum data set (MDS) assessment, was admitted to the facility on [DATE]. A skin assessment completed on admission [DATE]) revealed Resident #5's skin was intact. In an interview on 7/24/24 at 11:30 a.m., registered nurse (RN) #1 and RNC #1 confirmed the resident's admission assessment documented the resident entered the facility with his skin intact. B. Resident status following admission - development, and worsening of a pressure injury on the resident's coccyx. On 11/10/23, a comprehensive skin assessment revealed Resident #5 had redness to his coccyx, and on 11/28/23, 14 days after admission, a wound physician's note revealed an unstageable pressure injury of the resident's coccyx. The onset of the coccyx wound on 11/28/24 was confirmed by RN #1 in an interview on 7/24/24 at 11:30 p.m. On 1/2/24, a wound physician's progress note identified the pressure injury as a stage 4 wound (full-thickness tissue loss with exposed bone, tendon, or muscle). On 6/4/24, an x-ray of the coccyx was ordered to rule out osteomyelitis, which was confirmed on 6/6/24. According to 6/12/24 skin/wound progress notes, on 6/11/24, the wound physician recommended a six-week course of antibiotics to treat the infection. On 7/24/24 at 9:56 a.m. the WCP was interviewed. He said Resident #5 had an avoidable facility-acquired pressure injury to his coccyx. The WCP said Resident #5 had no other clinical issues that could contribute to the wounds. The WCP was unaware of any changes in Resident #5 daily routines that could have contributed to the development or worsening of the pressure injury. The WCP said he noticed the wound was not healing so he suspected osteomyelitis and had an x-ray taken to confirm this diagnosis. The WCP said osteomyelitis requires a long-term use of antibiotics and residents need antibiotics moving forward for a minimum of six weeks. The WCP said Resident #5's wound had become stagnant so he cultured the wound. The WCP said the wound culture provided insight into the infection in the wound and what antibiotics would be successful in the treatment of the resident's osteomyelitis. The WCP said Resident #5 antibiotics had to be changed to medication that could kill the organisms. The WCP said any opening on the skin exposes the body to the environment which can lead to the colonization of bacteria leading to infection. The WCP said providing good wound care to an open area was important to prevent infections and many types of dressings can be used for healing so it was important to be done correctly. On 7/16/24, a coccyx wound culture was collected by the WCP. On 7/18/24, an order was written for placement of a peripherally inserted central catheter (PICC- used to administer intravenous medication) and, on 7/19/24, Cefepime (antibiotic) 2 grams and Vancomycin (antibiotic) 1500 mg IV (intravenous) was ordered for osteomyelitis. C. Facility failures 1. Record review and interviews revealed the facility failed to implement pressure-reducing measures to provide pressure relief and promote healing. a. Delay in initiating an air mattress and failure to ensure the air mattress was properly functioning to be effective. Record review: Record review revealed an order for an air mattress was not initiated until 2/21/24, seven and a half weeks after the coccyx wound was identified as unstageable. The resident's 11/7/24 comprehensive care plan further revealed an air mattress was not placed until 3/10/24, 20 days after the 2/21/24 order. Interviews and observations: Resident #5, interviewed on 7/24/24 at 4:36 p.m., said his current mattress was broken. Resident #5 said that the one he had before was worse. Resident #5 said that the laundry director told him this was the best mattress she could find. The resident was observed lying in his bed on an air mattress with a fitted sheet over the mattress. CNA #1 was interviewed on 7/24/24 at 4:31 p.m. CNA #1 said she checked the resident's air mattress when she did her morning rounds. She said she pushes on the mattress to ensure it is inflated and feels firm to touch. Regional nurse consultant (RNC) #1 and the DON were interviewed on 7/24/24 at 4:00 p.m. The RNC #1 said the facility did not have a system to track equipment repairs needed. The RNC said the only documentation to show when the air mattress currently on the resident's bed was ordered was 2/21/24. RNC #1 was interviewed again on 7/25/24 at 10:33 a.m. RNC #1 said the facility was unable to obtain the operator ' s manufacturer manual for the low-loss air mattress currently placed on Resident #5 ' s bed because the mattress was so old that it was no longer being manufactured or sold by any vendors. RNC #1 was unable to verify the age of the mattress or previous usage of the mattress. She said for that reason, the mattress will be replaced today in the afternoon when the resident gets out of bed. Licensed practical nurse (LPN) #3 was interviewed beginning on 7/29/24 at 9:42 a.m. She said air mattresses were not to have fitted sheets on them as it could restrict the function of the air mattress airflow. The resident's replacement air mattress, a P.R.O [NAME] Plus, was reviewed with LPN #3 for proper function and settings. The air mattress was set at #3 mode therapy and no cycle time. LPN #3 said the air mattress was not set to the right settings based on the physician's order and she needed to get the order clarified to match the settings available on the air mattress pump. The laundry director (LD) was interviewed on 7/29/24 at 10:33 a.m. The LD said she was responsible for managing and placing air mattresses on residents' beds once ordered. -The LD said she was responsible for making sure the mattresses were functioning properly. The LD said she did not monitor the function or integrity of the actual mattress; rather, she only referenced monitoring the pump and its function. When a mattress was not able to hold air and was not making the normal whooshing sounds she said she replaced the mattress pump but did not change out the actual mattress. The LD said the facility had several backup pumps in stock. Malfunction pumps were discarded. -The LD said the facility had recently purchased a couple of new pressure-relieving air mattresses but most of the air mattresses in stock were older and had been acquired by the previous facility owners. Some of the air mattresses were used more than others and they no longer tracked the age or length of time a mattress was used by one of the residents in the facility. -The LD said the facility did not have the manufacturer's manuals for the air mattresses and they did not know the exact age of the mattresses in stock. The LD said she did not know how old the mattress that Resident #5 had been using was or how much time it had been in use by other residents before it was placed on his bed. -The LD said the resident had been complaining about the mattress that was on his bed, saying that it was uncomfortable and was causing him a great deal of discomfort. The LD said she changed out his mattress on 7/28/24 (during the survey) with a new mattress that was approximately a month or two old. -The LD said the lifespan of a pressure-relieving air mattress was dependent upon how long it was in use. She was not sure but thought that an air mattress under continuous use was only effective for pressure relief for a year or two. The NHA confirmed the facility did not have a tracking system to determine how long the older pressure-relieving air mattress had been in use. The NHA said Resident #5 ' s mattress was changed to a newer mattress (on 7/28/24) when the facility was unable to verify the age or usage of the mattress on the resident's bed. b. Failure to timely and consistently implement turning and positioning of the resident. A review of the resident's 11/7/23 comprehensive care plan revealed a directive for staff to assist the resident in turning and repositioning as indicated/tolerated was not initiated until 1/3/24, about a month after the resident's wound was identified and after the wound physician's progress note identified the pressure injury as a stage 4 pressure injury, CNA #1, interviewed on 7/24/24 at 4:31 p.m., said Resident #5 was dependent on staff for positioning due to his medical condition. She said the resident did not refuse care when offered. Resident #5 was interviewed on 7/24/24 at 4:36 p.m. and said that the last time he got up in his wheelchair was last week for 2 to 6 hours. He said he gets up when he wants to. He said the CNAs come in to reposition him when he asks or if he needs to go to the bathroom. Resident #5 said at night, they do not come in and reposition him unless he asks them to. 2. Record review, observations, and interview revealed weekly skin assessments were not completed to ensure Resident #5's pressure injury was regularly monitored; physician orders for dressing changes were not followed and dressing changes were not performed in a manner to prevent infection. a. Weekly assessments March: -On 3/7/24 - no skin assessment was completed -On 3/14/24 - no skin assessment was completed April: -On 4/3/24 - no skin assessment was completed -On 4/17/24 - no skin assessment was completed May: -On 5/2/24 - no skin assessment was completed -On 5/23/24 - no skin assessment was completed June: -On 6/27/24 - no skin assessment was completed b. Orders and dressing changes Orders: A 12/4/23 wound care order read: clean wound to the coccyx with normal saline and apply clean dressing until it was assessed by the wound care team. -However, Resident #5 was seen by the wound physician on 11/28/23, per the 11/28/23 wound physician's note. As such, the order for dressings change was added 7 days after Resident #5 was seen by the wound physician. A 6/21/24 wound care order read: coccyx - cleanse with quarter strength Dakin's (used for cleaning) solution, apply skin barrier cream with zinc to peri wound, cut and apply silver alginate to wound bed, Cover with border gauze dressing. Change dressing every other day. -However, the June 2024 treatment administration records (TARs) revealed Resident #5 received dressing changes daily from 6/23 to 6/25/24. (This treatment order was discontinued on 6/25/24.) A 6/26/24 wound care order read: coccyx - cleanse with quarter strength Dakin's solution, apply barrier cream with zinc to peri-wound (around wound edges but not in the wound), cut and apply hydrofera blue (specialized wound dressing) to wound bed, cover with border gauze change dressing every other day. Order was discontinued on 7/2/24. -However, the June 2024 TAR record revealed Resident #5 dressing was changed daily from 6/26 to 6/30/24, and 7/1 to 7/2/24. The DON was interviewed on 7/24/24 at 12:34 p.m. The DON said the physician should be called when wound care was not administered per the physician's orders. Infection control: On 7/25/24 at 11:50 a.m., Resident #5 was observed receiving care for his coccyx wound. The DON, RN #1, and CNA #1 were present for wound care. Wound care was completed as ordered during observation. -However, RN #1 failed to place a barrier pad under the resident's wound during care. RN #1 was interviewed on 7/25/24 at 12:25 p.m. RN #1 said she should have placed a barrier pad under the resident during wound care to protect him and the linen from being contaminated during wound care. RN #1 said not placing a barrier pad could put the resident at risk for germs to get into the wound. 3. Interviews, record reviews, and observations revealed the facility failed to ensure the nutritional support ordered on 2/21/24 (double protein) was consistently offered to Resident #5. Record review revealed on 2/13/24, an order for a double protein diet was initiated. Dietary aide (DA) #1 was interviewed on 7/25/24 at 3:51 p.m. He said meal tickets for residents will identify special diet considerations in bold letters and allergies were highlighted. DA #1 said a double protein diet means they get two servings of protein items served. DA #1 said protein items were eggs, meat, milk, and cheese. -However, observations revealed the resident was not served double protein: On 7/23/24 at 1:20 p.m., the resident was served two ham and cheese sandwiches. The tray card had written in double ham. However, the ham sandwiches did not have double ham. The sandwiches had one slice of ham and a slice of cheese. At approximately 2:00 p.m., the resident consumed one of the ham and cheese sandwiches. On 7/24/24 at 12:25 p.m., the resident received his meal. The resident received two ham and cheese sandwiches. The dietary tray ticket instructed double protein, and in writing the ticket wrote double ham. The sandwiches had a slice of ham and a slice of cheese. The sandwiches did not have double meat. On 7/24/24 at 12:45 p.m., the registered dietitian consultant (RDC) observed the sandwich served to the resident. She confirmed it was not double the ham. The RDC asked the resident if he would like additional meat for his sandwich and he replied It is a little late, as he had consumed the majority of the sandwich. The registered dietitian (RD) was interviewed on 7/24/24 at 4:55 p.m. -The RD said Resident #5 told her he wanted to have double protein in his meals, as he did not want the health shake of beneprotein. The RD said that the resident was refusing the dinner health shake she discontinued the order for health shakes (4/19/24) although the RD confirmed the resident was consuming the morning and afternoon administrations. The RD said only the dinner beneprotein could have been discontinued, however, the resident had said he did not want to have it any longer and was now receiving double protein. But see observations above; the resident was observed not receiving double protein. -The RD said Resident #5 was not reviewed in a nutrition-at-risk meeting. The RD said she was aware the pressure wounds were worsening. The RD said the zinc and the vitamin C were recently bumped up a week due to the worsening. IV. Final interviews with the administration The NHA was interviewed on 7/29/24 at 11:05 a.m. The NHA said the interdisciplinary team (IDT) conducted daily clinical discussions which included talking about residents' wound and wound care needs. The NHA said he did not recall discussing Resident #5 ' s wound status and was not aware that Resident #5 ' s coccyx wound was infected. The NHA said he was more involved in working with the IDT on revamping the overall care and treatment programs for all residents, rather than knowing the individual treatment needs of each resident. The NHA said the DON took on the role of meeting the individual clinical needs of the residents. The NHA said he was working with the new DON to hire a full-time treatment nurse who would be tasked with managing resident wound care needs and working directly with the WCP to ensure proper treatment of the residents' wounds. The NHA said his goal was for the nursing department to make improvements in tracking and auditing the residents' wound care and treatment needs. The DON was interviewed on 7/29/24 at 11:15 a.m. The DON said she no longer followed the WCP. Instead, the wound care nurse was tasked with tracking the progression of a resident's wound and letting her know of any new and emerging issues so that she could help oversee what was happening with resident care. The DON said there was a lapse in communication from the IDT to her so that she could ensure proper follow-up. The DON said the floor nurses did not alert her of Resident #5's wound status in a timely manner. She said she was not aware immediately that the resident ' s wound was infected or that the floor nurses were not following wound care orders to only change the resident ' s wound dressing every other day, as ordered. The DON said there was also a lack of regular communication with the RD related to Resident #5 ' s nutritional needs and concerns. The DON said if regular communication had occurred, things like nutrition and other care issues would not have been missed. The DON said once she learned that Resident #5 ' s coccyx wound was infected, she made sure the resident was prescribed an antibiotic for proper treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe. -The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a Trilogy ventilator (ventilator) at bedtime and managed her trach care and ventilator care herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the resident's bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) responded and placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services, including a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. The resident required frequent suctioning on 3/5/24 and 3/6/24 to remove mucus plugs, and on 3/6/24 at 9:00 a.m., the resident's last inner cannula was plugged again and removed by the respiratory care director (RCD). No replacement inner cannula was available. While additional inner cannulas were requested from the respiratory vendor at 11:45 a.m., the cannulas did not arrive at the facility until 2:00 p.m., hours after the inner cannula was removed. During that time, the facility monitored the resident hourly, but that was not sufficient. The resident was observed at 2:05 p.m. struggling to breathe. -The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. Resident #99, cognitively intact, had a trach tube with oxygen. She used a ventilator at bedtime and managed her trach care and ventilator herself, although she said she did not know the ventilator settings. No orders or care plans for the resident's trach or ventilator were located in the resident's record. Further, on 3/6/24 at 1:45 p.m., observations revealed there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. -The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95 and proper trach care for Resident #20. Resident #95 had a trach and an order to receive nebulizer treatment via their trach. Registered nurse (RN) #1, unsure how to apply the nebulizer treatment to the trach, called for assistance and the assistant director of nurses (ADON) placed the nebulizer in the resident's mouth instead of attaching it to the trach. Resident #20's trach care was not conducted in a manner to prevent infection. Observations, record review, and staff interviews revealed staff lacked sufficient knowledge in the management of residents requiring specialized respiratory care and services. Moreover, the facility lacked a process to ensure respiratory supplies were monitored and accessible to meet the routine and emergency needs of residents on mechanical ventilation and trachs. These failures created a situation of immediate jeopardy for serious harm. B. Facility notice of immediate jeopardy On 3/7/24 at 10:55 a.m. the nursing home administrator (NHA) and director of nursing (DON) were notified that the facility's failure to ensure staff was aware of the status of respiratory equipment, and understood respiratory care procedures for residents with trachs and ventilators, created a situation of immediate jeopardy for serious harm. C. Plan to remove immediate jeopardy 1. The plan On 3/7/24 the NHA presented the following plan to address the immediate jeopardy situation which read in pertinent part: Identification of residents affected or likely to be affected: the facility took the following actions to address the citation and prevent any additional residents from suffering any adverse outcomes. On 3/6/24 the respiratory provider evaluated all current residents with a tracheostomy. The DON/designee audited residents with tracheostomy medical records to ensure the presence of physician's orders and resident specific care plan interventions for the care of their tracheostomy. The DON/designee obtained a bedside supply list and assessed all current residents with a tracheostomy to ensure that any needed tracheostomy care equipment and supplies were at the bedside. The facility took the following actions to prevent any adverse outcomes from reoccurring. On 3/7/24, the policy for tracheostomy care and suctioning were reviewed/revised. Removed aseptic technique for trach care. On 3/6/24 the respiratory provider provided education to licensed nursing staff on tracheostomy care, suctioning, placement of the Trilogy (ventilator), providing nebulizers via trach and following the individualized interventions in each resident care plan, physician's orders for trach care and ensuring trach care equipment/supplies were readily available at the bedside. By 3/15/24, staff who were not present during training will be educated prior to their next working shift and provide return demonstration with training listed above. On 3/7/24 a PRN (as needed) order was added to Trilogy (ventilator) residents orders on placing residents on the Trilogy in the event the resident is not able to provide self-care. On 3/7/24 the DON/designee placed a respiratory flow sheet at the bedside for tracheostomy care documentation. On 3/7/24 the DON/designee provided training to licensed staff on the bedside supply list, respiratory flow sheet for documentation. The DON/designee will audit respiratory flowsheets five times weekly for 30 days, then three times weekly, for 30 days, then one time weekly for 30 days. Results will be reviewed in QAPI to determine further monitoring. Upon identification, the DON or designee will immediately address and remedy any audit deficiencies with the licensed nursing staff. The respiratory provider will audit supplies weekly and provide trach supplies for tracheostomy residents. In the event a supply is running low, nursing will reach out and order additional supplies from the provider. In the event of a respiratory change a Licensed nurse will evaluate the resident, provide care within their scope of practice, for further needs a provider will be contacted to provide further orders. If further emergency management is needed 911 will be contacted for hospital transfer. 2. Interviews with staff involved in the training outlined in the plan above revealed a continued lack of understanding regarding specialized respiratory care and services. Registered nurse (RN) #2 was interviewed on 3/7/24 at 5:47 p.m. She said she received training from the respiratory therapist (RT) on 3/6/24. She said she did not receive any instruction on how to work with the ventilator machine. She said she did not usually work with that resident and did not have contact with it. RN #3 was interviewed on 3/7/24 at 5:50 p.m. The RN said she had training on 3/6/24 on suctioning and trach care with a return demonstration. She said she did not receive ventilator training from the facility. LPN #6 was interviewed on 3/7/24 at 5:50 p.m. LPN #6 said she had done the training, however, she did not perform a return demonstration and only repeated the information back verbally. She said she did not get training on the ventilator. LPN #7 was interviewed on 3/7/24 at 5:54 p.m. LPN #7 said she had training on the suction machine and humidifier with the RT. She said she had received training on the ventilator on 1/31/24 before the resident was admitted . RN #4 was interviewed on 3/7/24 at 5:55 p.m. RN #4 said she received training but did not do a return demonstration and did not receive training for the ventilator or on administering a nebulizer treatment through a trach. LPN #5 was interviewed on 3/7/24 at 5:55 p.m. LPN #5 said she received training on 3/6/24 but not on the ventilator as she does not have one on her floor. 3. Based on the interviews above, the facility conducted a second training with licensed nursing staff later in the day on 3/7/24. LPN #7 was interviewed on 3/7/24 at 7:45 p.m. LPN #7 said the staff had training on trach care, trach mask nebulizer treatments, suctioning, connecting the resident to the ventilator, updating the resident care plan, setting up an aerosol, changing the inner cannula, and connecting the ventilator to oxygen. She said the staff did return demonstrations on everything in the training. RN #3 was interviewed on 3/7/24 at 7:45 p.m. RN #3 said the training included suctioning, physician's orders, plans of care, trach site cleaning, nebulizer treatments and where to find supplies. She said supplies were in the crash (emergency) cart and resident rooms. She said the training also included information about the ventilator and how to put it on a resident. She said the staff performed return demonstrations. LPN #5 was interviewed on 3/7/24 at 7:46 p.m. LPN #5 said staff were re-shown how to do trach care with the insertion and removal of inner cannulas, sectioning sterile technique, how to apply nebulizer treatment to a trach, the ventilator machine application, compressor, humidifier adjustments based on oxygen level, cleaning the stoma (the area of skin around the trach), replacing the trach tube, what to do in an emergency, where the supplies are located in the resident's room and on the crash cart, how to suction through the ventilator, ventilator care plans, and physician orders. RN #4 was interviewed on 3/7/24 at 7:50 p.m. RN #4 said the training included suctioning, nebulizer, and connecting a resident to a ventilator machine. She said there was information on supplies and where to get them. She said the staff did a return demonstration. RN #2 was interviewed on 3/7/24 at 7:51 p.m. She said the staff were re-educated on trach care, cleaning, sterile suction, how to use the ventilator, nebulizer treatments given through the trach, care plans, and physician orders. She said the staff were also trained on where equipment and supplies were to be at the bedside, on the crash cart, and in the oxygen room. D. Removal of immediate jeopardy On 3/7/24 at 8:01 p.m., the NHA and the DON were notified that the immediate jeopardy was lifted based on evidence of the facility's implementation of the plan. However, the deficient practice remained at an E level, a pattern with the potential for more than minimal harm. II. Facility policy and procedure A. The tracheostomy care policy and procedure, dated 8/2013, was provided by the DON at 1:25 p.m., it read in pertinent part: The purpose of the procedure is to guide tracheostomy care and the cleansing of reusable tracheostomy cannulas. Tracheostomy care should be provided as often as needed, at least once daily. A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times. Check physician orders. Clean the removable inner cannula. Unlock the inner cannula. Gently remove the inner cannula by rotating counterclockwise while lifting away from the resident. Clean with a brush. Rinse with saline and dry with pipe cleaners. Replace the cannula carefully and lock in place. Ensure there is an emergency tracheostomy set at the resident's bedside. B. The mechanical ventilation: setup and monitoring policy and procedure, revised 10/2010, was provided by the respiratory care director (RCD) on 3/6/24 at 1:17 p.m. It read in pertinent part: The purpose of this procedure is to provide assisted or controlled ventilation to a resident with acute or chronic respiratory insufficiency. Verify there is a physician's order for this procedure. Review the physician's orders, including instructions for: Tidal volume (the size of the breath); Ventilatory rate (the number of breaths); Pressure limits (how high or low the pressure delivered by the machine should go). In an emergency, a qualified nurse may initiate (start) mechanical ventilation and then obtain specific orders. Review the resident's care plan to assess for any special needs of the resident. Only a qualified nurse or respiratory therapist can initiate mechanical ventilation, based on an appropriate physician order. Steps in the procedure. Check for proper functioning of the lights, alarms, filters, fittings and the humidifier. Start the ventilator. Listen to the resident's lungs and document breath sounds. Connect the ventilator to the resident. Adjust the ventilator alarms so they can be heard by staff responsible for monitoring the resident. Document the resident's status and chart all ventilator settings. III. Resident #174 A. Resident #174, age [AGE], was admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. According to the March 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure with hypoxia (low oxygen), chronic respiratory failure with hypoxia, pneumonitis (inflammation of the lungs) due to inhalation of food and vomit, pneumonia, acute respiratory distress, pulmonary disease, chronic obstructive pulmonary disease (COPD), and hemiplegia (paralysis of one side of the body) and hemiparesis following cerebral infarctions (stroke) affecting right dominant side. 1. The 3/2/24 minimum data set (MDS) assessment documented the resident was unable to perform the brief interview for mental status (BIMS). The resident was dependent on maximal assistance for eating, personal hygiene, toileting, bathing, upper and lower body dressing, rolling left and right, and moving from sitting to lying in bed. 2. admission orders dated 3/2/24 read the resident had a tracheostomy with an inner cannula. An admission summary note on 3/2/24 at 2:09 p.m. documented the resident was unable to successfully use a speaking valve via his trach tube. 3. A review of the resident's record and observations revealed a brief hospitalization on 3/2/24, readmission on [DATE] with secretions and the need for suctioning, and respiratory distress on 3/6/24 when a mucus plug obstructed his airway. A respiratory therapy assessment and evaluation dated 3/2/24 at 12:17 p.m. documented the resident had coarse crackles bilaterally (both lungs) and had a strong productive cough with thick mucus. An admission summary note dated 3/2/24 at 12:22 p.m. documented the resident often needed suctioning. An alert note dated 3/2/24 revealed the resident was discharged to the hospital for a displaced trach tube. He returned to the facility on 3/3/24 with a diagnosis of pneumonia, and care plans for his trach care, respiratory care, and pneumonia were initiated. A medication administration note dated 3/5/24 at 10:04 p.m. documented that the resident required suctioning. A medication administration note dated 3/6/24 at midnight documented the resident required suction and that treatment was effective. A nurse's note dated 3/6/24 at 7:15 a.m. documented trach care rendered including suctioning several times with sizable phlegm (mucus). An observation of the resident on 3/6/24 at 2:05 p.m. during a brief tour with the respiratory care director (RCD) revealed Resident #174 was struggling to breathe. B. Staff interviews revealed the facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs and failed to outline procedures and responsibilities to obtain such supplies. 1. At the time of the observation of Resident #174 struggling to breathe (see above), the RCD said the resident's trach tube did not have the inner cannula in place. Further, the nurse said there were no suction catheters in the room; the RCD had to leave the room to obtain more supplies. 2. The RCD was interviewed on 3/6/24 at 12:52 p.m. and 1:43 p.m., and again on 3/7/24 at 9:00 a.m. -He said Resident #174 had a mucus plug on 3/6/24 at 2:05 p.m. when he was observed in respiratory distress. He said he had removed the inner cannula to the trach on 3/6/24 at 9:00 a.m. -He said Resident #174 had three inner cannulas when he returned from the hospital on 3/3/24 and the inner cannula he removed at 9:00 a.m. was the last inner cannula provided by the hospital. He said he had informed the DON that morning that the resident needed more inner cannulas due to the resident being out of supply. He said the nursing staff should have called the respiratory provider for supplies on 3/4/24 or 3/5/24. -He said the tracheostomy residents in the building did not have the supplies they needed for care. 3. The DON was interviewed on 3/6/24 at 2:50 p.m. and again on 3/7/24 at approximately 9:10 a.m. -She said she had called the respiratory service provider on 3/6/24 at 11:45 a.m. after the RCD informed her Resident #174 was out of inner cannulas and the inner cannulas were delivered at 2:00 p.m. She said nursing staff should contact the respiratory vendor when the last box of inner cannulas is opened. She said the resident had a history of plugging his trach with mucus plugs. -She said the facility could have requested a monitor that alarmed from the respiratory service provider for Resident #174 but had not done so. 4. Licensed practical nurse (LPN) #8 was interviewed on 3/7/24 at 9:22 a.m. -LPN #8 said the RCD had informed her of the removal of the resident's inner cannula on the morning of 3/6/24. She said Resident #174 had a lot of secretions and needed to be cleaned and suctioned frequently and that morning, they had increased their monitoring of the resident to hourly. -She said she had put her head into the resident's room on 3/6/24 and he had waved her into the room for care when he was having difficulty breathing. She said she had not realized the resident was out of inner cannulas before 3/6/24. She said she had checked the suction supplies but not the inner cannula supply on 3/4/24 and she had not called the respiratory service provider because she did not realize there was a problem. She said she believed the RCD was to call for supplies. 4. The certified respiratory therapist (CRT) from the respiratory service provider was interviewed on 3/6/24 at approximately 2:50 p.m. -The CRT said their service came to the facility as needed or when a request was made for supplies. He said a member of customer service came to the facility once a week; however, that person did not carry supplies. He said the service only comes to the facility if the facility calls in a request. -The CRT said he comes to the facility once a month to perform trach changes. He said not having an inner cannula on the resident's type of trach (Shiley XLT) meant an ambu-bag could not be connected if there was an emergency. He said a resident could develop a plug if an inner cannula was not in place. -The CRT said he had done nurse training on trach care and suctioning in January 2024. IV. Resident #99 A. Resident #99, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March CPO, diagnoses included obesity with alveolar hypoventilation (low ventilation of the lungs), acute pulmonary edema, tracheostomy, obesity, fluid overload, hypertension (high blood pressure), pulmonary hypertension (high blood pressure affecting the lungs), history of pulmonary embolism (blood clot), and history of Covid-19. 1. According to the 1/24/24 MDS assessment, the resident was cognitively intact with a BIMS score of 15 out of 15. The resident respiratory requirements were not listed in the MDS or the person-centered care plan. 2. Record review revealed the resident had a trach tube and used a Trilogy ventilator (ventilator). A nurse's note dated 10/14/23 at 8:26 p.m. documented the resident was dependent on a trach tube with oxygen and used a ventilator at bedtime. A nurse note dated 10/21/23 at 5:55 a.m. documented the resident required assistance with trach care. A physician history and physical note dated 10/24/23 at 6:10 a.m. documented the resident was admitted with chronic hypoxic (low oxygen) respiratory failure and continued on the ventilator. Resident #99 had 2 liters (L) of oxygen requirement while resting and 3L with exertion and nighttime ventilator use since February 2022. A readmission summary note, dated 1/24/24, documented the resident returned from the hospital and was trach-dependent with 2L of oxygen. B. The facility failed to have plans, orders, and equipment to manage Resident #99's routine and emergency ventilator care. 1. Resident interview Resident #99 was interviewed on 3/6/24 at 1:35 p.m. She said she did her own trach care and suctioning. She also said she put the ventilator on herself at night; however, she said she did not know what her ventilator settings were. 2. Record review On 3/6/24, at the time of the survey, the resident's care plan for respiratory care initiated on 2/7/24 documented the resident was at risk for complications with the respiratory system due to chronic respiratory failure. Interventions included administering IS (incentive spirometry) every two hours as needed. -However, Resident #99 did not have a care plan for tracheostomy care, suctioning, trach changes, or use of the ventilator at night. On 3/6/24, at the time of the survey, a review of Resident #99's orders revealed the orders did not address the ventilator she wore at her trach tube (invasive ventilation) at night. On 3/6/24, a review of Resident #99's record revealed no evidence that the facility documented her use of the ventilator at night. 3. Observations On 3/6/24 at approximately 1:45 p.m. during a brief tour with the RCD of Resident #99's room, there was no ambu-bag at the bedside, the water in the humidification chamber was pink in color instead of clear, there was no backup trach at the bedside and the ventilator was not plugged into a red outlet, indicating it was not connected to the generator if the power should fail. 4. Staff interviews The DON was interviewed on 3/6/24 at 1:40 p.m. She said there was a ventilator in the building used for invasive ventilation at night through Resident #99's trach tube. She said there should be orders and a care plan for the tracheostomy and ventilator settings. She said the facility did not think about the ventilator being a ventilator, only as a BIPAP (bilevel 2 positive airway pressure support). She said the night shift took care of the resident's ventilator care. The RCD was interviewed on 3/6/24 at 1:43 p.m. He said there should be a care plan and orders for the ventilator and it should be plugged into a red outlet. He said there should be a backup trach set at the bedside. The DON was interviewed again on 3/6/24 at approximately 2:50 p.m. She said the ventilator should be plugged into a red outlet in case of a power outage. She said it could lead to death if the ventilator should stop working while the resident was attached to it and the power went out. V. Resident #95 A. Resident #95 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, pneumonia, tracheostomy, chronic respiratory failure, obstructive sleep apnea, hypertension, reduced mobility, and convulsions. The resident's record revealed the resident had a tracheostomy. B. The facility failed to ensure proper administration of specialized respiratory treatment for Resident #95. 1. Observations Registered nurse (RN) #1 was observed on 3/5/24 at 1:02 p.m. administering medications to Resident #95. RN #1 went into the resident's room to administer an Albuterol nebulizer treatment via trach. She said she was unsure how to apply the nebulizer treatment to the resident's trach and she called for assistance. The assistant director of nursing (ADON) came to help. The ADON said the resident was able to hold the nebulizer in her mouth; however, the nebulizer device did not have a mouthpiece attached to it. The resident was unable to hold it on her own; staff had to hold it for her. The ADON placed the corrugated end of the nebulizer into the resident's mouth and held it for the resident. RN #1 and the ADON were needed elsewhere and they requested another nurse come to hold the nebulizer treatment in the resident's mouth until it was completed. LPN #1 came into the resident's room and said the nebulizer should not have been in the resident's mouth, but rather attached to the trach. LPN #1 turned off the nebulizer machine and attached the nebulizer to the resident's trach for proper administration. 2. Staff interviews LPN #1 was interviewed at 1:35 p.m. and said the resident may not have gotten the effect of the medication since it was not initially delivered via the trach. LPN #1 reviewed the resident's orders and they did not direct the resident to receive the nebulizer treatment via her mouth. The RCD was interviewed on 3/5/24 at 1:40 p.m. He said nebulizer treatments should be given via trach if the resident had one to ensure medication reached the lungs. The CRT was interviewed on 3/6/24 at 3:02 p.m. The CRT said the easiest way to administer the nebulizer via trach is by way of the trach mask. He said when a nebulizer is administered via mouth, it should have a mouthpiece. He said the corrugated end should not be in the resident's mouth. The ADON was interviewed on 3/7/24 at 2:35 p.m. The ADON said she was flustered and should have taken the time to appropriately administer the nebulizer treatment. She said giving the medication via mouth may not have been as effective as if the resident had gotten it via the trach. She said the mouthpiece was missing from the nebulizer and she should have gotten a new setup or applied it directly to the trach. VI. Resident #20 A. Resident #20 was admitted to the facility on [DATE] with diagnoses that included pneumonia and respiratory failure. A review of the resident's record revealed the resident had a tracheostomy B. The facility failed to ensure proper trach care for Resident #20. 1. Observations Resident #20's trach care was observed on 3/6/24 at 8:40 a.m. LPN #9 performed trach care on Resident #20. LPN #9 used four swabs, swabbing all the way around the tracheostomy site with each swab. LPN #1 said the inner cannula was to be changed every three days and she had checked it earlier in the morning and it was clean. 2. Interview The CRT was interviewed on 3/6/24 at approximately 2:50 p.m. He said staff should be using a one-swab technique for trach care, using one swab on top and tossing it in the trash, one swab on the bottom and tossing it, and the same on the other side of the trach tube. He said staff should not go all the way around the trach tube with one swab, stating it could create infection or cause problems in the area around the tube.