**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide needed care of services, resulting in an actual decline in physical, mental and psychosocial well-being for one (#275) out of four residents reviewed out of 33 sample residents. Resident #275, who had a severe cognitive impairment, was admitted to the facility 1/26/23. The resident did not have a medical decision maker, so the facility proceeded to implement a medical health proxy on 3/5/23. The facility failed to notify and coordinate with the health care proxy regarding the resident's care, the contact documented with the health care proxy was 5/20/23. Resident #275 had lost weight since her admission to the facility on 1/26/23, 21.6% in total in four months, which was considered severe. Her admission weight was 108.4 lbs. (pounds) on 2/5/23 and on 6/1/23 she weighed 85 lbs. The registered dietitian (RD) implemented measures with the resident's weight loss; however, those interventions were ineffective due to the resident having ongoing swallowing problems and nausea/vomiting. Speech therapy worked with the resident due to her swallowing difficulties; however, the interventions were ineffective due to her medical condition. Resident #275 had an esophagram (a series of x-rays of the esophagus) on 3/3/23, however she did not see the gastroenterology outpatient provider until 5/5/23, which was over two months later. During this time, she lost an additional 4.6 lbs. Resident #275 went to a gastroenterology outpatient provider on 5/5/23 where they indicated she had narrowing of the esophagus. Resident #275 required a follow up diagnostic procedure, an esophagogastroduodenoscopy (EGD), to further examine her esophagus. Due to the facility's failures, including not coordinating with the health care proxy in a timely manner, Resident #275 continued to sustain significant weight loss as a result of impaired nutrition related to the narrowing of her esophagus. Resident #275 sustained an additional 10.4 lbs weight loss (10.7%) that occurred after the procedure was recommended on 5/5/23. Per the physician assistant at the outpatient clinic (see interview), the resident sustained the additional 10 lb weight loss as a result of her not getting the recommended procedure from the 5/5/23 appointment. Findings include: I. Resident status A. Resident #275 Resident #275, age [AGE], was admitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included dementia, subarachnoid hemorrhage (bleeding in brain), dysphagia (difficulty swallowing), fractured femur (broken leg), diabetes and muscle wasting. The 2/2/23 minimum data set (MDS) assessment revealed the resident had a severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15. The resident required two person physical assistance for transfer and toileting and one person assist for bed mobility, locomotion on the unit, dressing, hygiene and eating. Weight loss was not coded on the assessment. Difficulty with swallowing was coded on the assessment. The medical record showed the resident had a proxy decision maker by Statute dated 3/5/23. The proxy provided the authority to consent to medical procedures for Resident #275. II. Resident representative (health care proxy) and outpatient provider The healthcare proxy of Resident #275 was interviewed on 6/6/23 at 3:46 p.m. She said she had not been contacted by the facility to sign a consent form for the esophageal dilation until that week (the week of 6/6/23, which was over a month later). She said if she had been contacted on 5/5/23, she would have happily signed and showed up in person if that was needed. The gastroenterology physician assistant (GPA) was interviewed on 6/9/23 at 9:30 a.m. The GPA said she had seen the resident on 5/5/23 and it had been determined the resident required an esophageal dilation. She said the facility staff did not inform her or her office that the resident had a medical proxy in place since March 2023. She said the procedure could have been completed much sooner if the facility had communicated that to her. She said when she saw the resident, she was 95 pounds, and had lost approximately 10 lbs. of weight that was not needed because the facility failed to communicate timely. The GPA said the office tried to reach out to the facility previous to 6/1/23 to coordinate the follow up. III. Failure to ensure required medical procedure was scheduled Progress note dated 5/5/23 from the GPA showed the resident was seen for difficulty swallowing and nausea/vomiting. The GPA referred to an x-ray esophagram, which was done on 3/3/23. The esophagram indicated there was a narrowing of the esophagus, which prevented the passage of a tablet. The GPA indicated that the resident needed an EGD procedure (a diagnostic procedure that examines the esophagus) and the nursing facility had been contacted to determine the next steps to obtain consent for the EGD. IV. Observations On 5/31/23 at 1:40 p.m. the resident in her room provided eating assistance with her meal. She was coughing after eating bites of food. On 6/6/23 at 12:20 p.m. the resident was in the dining room and was assisted by certified nurse aide (CNA) #1. Resident #275 was periodically coughing after eating bites of food. She was observed to consume approximately 75% of her meal. V. Weight loss documentation The resident's weights were as follow: 2/5/23: 108.4 lbs. (10 days after her admission) 2/6/23: 107.6 lbs. 3/1/23: 100.8 lbs. 3/13/23: 100.2 lbs. 4/13/23: 95.0 lbs. 4/19/23: 96.2 lbs. 4/25/23: 96.4 lbs. 5/10/23: 95.2 lbs. 5/15/23: 91.6 lbs. 5/24/23: 86.0 lbs. 6/1/23: 85.0 lbs. The resident had lost 21.6% in total body weight since admission 1/26/23. Resident #275 weighed 95.2 lbs on 5/10/23 (five days after her GI consultation appointment). By 6/1/23, her weight was 85 lbs, which was 10.2 lbs. (10.7%) weight loss in 22 days, which was considered severe weight loss. The 6/1/23 RD progress note documented the reason for the weight loss was due to frequent vomiting after consuming food or liquid which was related to narrowing esophagus. The resident had a weight loss of 10.7% in the previous two weeks, 15.2% over 2.5 months and 21.6% weight loss over four months. VI. Medical proxy documentation The 5/4/23 social services director (SSD) progress note documented the resident did not have a representative in place for decision making. The 5/12/23, 5/18/23 and 5/24/23 SSD notes documented she requested assistance with getting the resident a representative for decision making. -However, the health care proxy was initiated on 3/5/23 (see above) to make medical decision for Resident #275. The 5/20/23 case manager (CM) progress note indicated the medical orders for scope treatment (MOST) form was signed and sent back to the facility by the proxy. VII. Staff interviews CNA #1 was interviewed on 6/6/23 at 1:30 p.m. CNA #1 said she was familiar with Resident #275. She said Resident #275 did well today, however, that resident struggled with swallowing during meals. The RD was interviewed on 6/6/23 at 2:00 p.m. The RD stated Resident #275 had weight loss for several months. The RD stated over the past three weeks she had significant weight loss. She stated an esophageal dilation procedure was needed for the resident to improve and the CM was working on this. The RD stated dilating the esophagus would allow the food to flow into her stomach. The RD stated Resident #275 had previously had an appointment with a gastroenterologist and the facility was waiting on a proxy placement for the resident to have the procedure that would help her. The SSD and CM were interviewed on 6/6/23 at approximately 2:30 p.m. The CM said Resident #275 did not have next of kin or friends, so the facility used a resource from a list. The healthcare proxy was completed when the resident went to long term care around 2/16/23. -However, the health proxy was not initiated until 3/5/23 (see above). The SSD stated she had been looking for permanent guardianship/conservatorship for the resident since she was not sure if the healthcare proxy could be used for medical care decisions. The SSD said she then found out that the proxy would have to be there in person. -However, the SSD made no attempts to coordinate with the health care proxy who was willing to go to the appointments (see interview above). The director of nursing, (DON) was interviewed on 6/6/23 at 3:15 p.m. The DON said the resident had a healthcare proxy in place. She said the signed consent was sent to the clinic on 6/1/23. The DON stated the gastroenterology office would not accept a proxy and education was needed on the clinic side. She said she was told the proxy had to show up in person. -However, there was no documentation of what the gastroenterology office had indicated to the DON. In addition, the GPA indicated the clinic had not been informed of medical proxy and it did not interfere with the resident being seen more timely by the office. She stated she left a message for the proxy today to see if she could be there in person. The DON said the consent could have been faxed to the clinic over a month ago. VIII. Facility follow-up The 6/1/23 CM progress note (during the survey) indicated she left a message for the GI (gastroenterology) clinic to request consent forms for treatment which would be sent to Proxy for signature, then resident can be scheduled for treatment for esophageal narrowing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the resident's choices and provide needed care and services that are resident centered, in accordance with the resident's preferences, goals for care and professional standards of practice that will meet each resident's physical, needs for one (#28) of three residents reviewed for quality of care out of 33 sample residents. The facilities failure to provide Resident #28 with a wheelchair of the appropriate size to accommodate his weight and to provide a pressure relieving cushion that was the correct size for the wheelchair seat, contributed to the development of multiple stage 2 pressure ulcers on the resident's posterior thighs, causing undue discomfort. Cross-reference F686-failure to prevent the development of pressure ulcers. Findings include: I. Resident status Resident #28, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2020 computerized physician orders (CPO) diagnoses included acute kidney failure, Type 2 Diabetes Mellitus with hyperglycemia, muscle weakness, unsteadiness on feet, and spinal stenosis. The 12/26/19 minimum data set (MDS) assessment revealed he was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. There were no documented skin issues but he received applications of ointments/medications other than to his feet. He required extensive assistance of one staff member with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was at risk for pressure ulcers and no skin issues were documented. He was not steady during transitions, had no impairment of upper or lower extremities, and used a walker and wheelchair for mobility. II. Observations On 3/4/2020 at 10:21 a.m. Resident #28 was seated in his wheelchair in his room. The wheelchair appeared too small for the resident's size. His lower body from his waist, at arm rest height, through his hips and thighs, to where his knees bend at the edge of the seat, was touching the wheelchair surfaces of the side panels, armrests, back of the wheelchair, and the seat. He said he would like a bigger wheelchair because his hips and legs touch both sides and they become sore, especially on the right leg. He was seen rubbing his right outer thigh. On 3/5/2020 at 4:00 p.m. the resident had returned from being out of the facility for the day. He was seated in his wheelchair in his room. When an unknown certified nurse aide (CNA) and registered nurse (RN) #4 assisted him to the restroom, it was noted his pants (jeans) and the pad on top of the cushion underneath him in the wheelchair were saturated with urine. He said he would sit in his wheelchair for three to four hours at a time without being assisted to stand. When his pants were lowered and his posterior thighs were exposed it was noted that both thighs were discolored, reddened, and purple in color. The skin appeared hardened and macerated (skin coming in contact with moisture for too long), with open creased areas on the outer right thigh and scaly areas on the left thigh. RN #4 said his posterior thighs had been that way for months. The director of nursing (DON) was present at this time and used a flashlight to visualize the open areas, but had no comment. While he was seated in the restroom, observation of the wheelchair revealed the cushion under the pad he had been sitting on, was circular in shape and did not fit the wheelchair seat. There were several inches of gap on each side between the cushion and the edges of the seat. After RN #4 applied barrier cream to both thighs and his lower legs, he was assisted with a clean brief and jeans and was assisted back into his wheelchair. Resident #28 said he had outgrown that wheelchair and needed a new one. The DON was asked to look at the resident's wheelchair. She said the cushion in the seat did not fit the wheelchair and the resident needed a different type of cushion. III. Record review Review of the care plan initiated 6/10/19 and revised 3/5/2020 revealed Resident #28 had potential/actual impairment to skin integrity related to decreased mobility, weakness, and Diabetes Mellitus. Interventions included to identify/document potential causative factors and eliminate/resolve where possible, follow facility protocols for treatment of injury, needs pressure relieving cushion to protect skin while up in chair, and reposition for comfort as needed/tolerated. After the resident's admission on [DATE], physical therapy (PT) did not evaluate him until 7/16/19 when the order was entered. He was referred by nursing to skilled PT due to increasing assistance needed for transfers. He had impaired strength of both lower extremities. There was no documentation of what type of wheelchair or cushion was provided to him. He was discharged from PT on 8/27/19 with instructions for the restorative nursing program (RNP). He was not evaluated by occupational therapy (OT) after admission. He had no further therapy evaluations after his discharge from PT on 8/27/19 until the concern for his wheelchair size, cushion size, and the skin issues mentioned above were brought to the attention of the DON on 3/5/2020. Review of the March 2020 CPO revealed an order entered on 3/7/2020 for PT to evaluate wheelchair positioning. An order for OT to evaluate and treat was entered on 3/9/2020. (This was after the concern was brought to the facility staffs attention during survey) The 3/7/2020 PT evaluation indicated he was referred by nursing for wheelchair seating system assessment as he makes daily trips out of the facility from 9:00 a.m. to 4:00 p.m. He had impaired strength of both lower extremities with edema (swelling), impaired gross motor coordination, and sensory processing. Recommendations included a standard wheelchair 20 inches wide in order to continue to be able to self propel. Skilled PT was indicated related to a decline in functional mobility and posture in current seating system due to fluctuations in weight. Patient with bilateral lower extremities pressed firmly against sides of chair and complained of discomfort in current seating system. The 3/7/2020 PT treatment encounter note read: Wheelchair management training in new standard chair in order to accommodate patient hip width and improve comfort/posture and ease of mobility. Improvement noted in functional posture with newly issued wheelchair. The 3/10/2020 PT treatment encounter note read: Patient states difficulty with propelling chair and presents with mild forward thrust. Provided patient with anti-thrust cushion that has increase in thickness in order to improve patient alignment in chair and accommodate patient height as unable to raise chair further from wheels. Patient requires 2 inch thick cushion 20 inches wide by 16 deep. Will plan to evaluate 20 inch wide versus 22 inch wide wheelchair to improve patient alignment in wheelchair, however, 22 inch wide wheelchair may pose difficulty for patient in mobility and toilet transfers. IV. Interviews Resident #28 was interviewed on 3/4/2020 at 10:21 a.m. He said he would like a bigger wheelchair because his hips and legs touch both sides of the wheelchair and become sore. He said he had outgrown his current chair because he had gained weight. He said he had not had any therapy for quite some time and had never received a different wheelchair, just the one I have now. The DON was interviewed on 3/5/2020 at 4:51 p.m. She said she had been working at the facility for about a month and a half and was the facility's wound care nurse. She said when she started, Resident #28 was not on the wound round list for her to look at. She said she was unaware of the condition of the resident's posterior thighs. She was unaware of the open areas on the resident's posterior thighs. She acknowledged the wheelchair the resident currently had was too small for him and the cushion in the seat of the wheelchair was not the correct size or shape and the resident's outer posterior thighs likely rested on the edges of the cushion as the cushion did not extend to cover the entire wheelchair seat. She said he needed a different cushion and wheelchair and she would have PT and OT evaluate him for a new wheelchair and pressure relieving cushion. The therapy manager (TM) was interviewed on 3/9/2020 at 8:25 a.m. She said Resident #28 had not been evaluated or screened for therapy, a new wheelchair, or cushion since admission. She said residents were not screened or treated unless nursing entered an order to do so. She said they received an order on 3/7/2020 to evaluate Resident #28 for wheelchair positioning and she provided a copy of the PT evaluation/screening done on that day that resulted in the resident receiving a different wheelchair and cushion. V.Follow up-cushion still not fitting appropriately Resident #28 was interviewed again on 3/9/2020 at 9:00 a.m. He said as far as he knew he did not have the areas on the back of his thighs when he was admitted to the facility. He felt the wheelchair and the cushion were part of the problem. He said the cushion did not fit the wheelchair and the chair was too small for him. He said the areas hurt and they had not put any cream on them since last week. He was seated in a different wheelchair this morning and he said they put a different cushion in it, but felt it was still not right.(see interview with DON below) The DON was again interviewed on 3/9/2020 at 10:46 a.m She said therapy provided a different wheelchair and cushion for Resident #28 on 3/7/2020. Upon observation of the new cushion with the DON revealed it still did not cover the entire surface of the wheelchair seat, with a gap on each side of approximately an inch. The DON acknowledged the cushion should cover the entire surface of the wheelchair seat to provide maximum protection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure one (#28) of five residents reviewed for pressure ulcers out of 33 sample residents, received the care and services necessary to prevent pressure injuries and to promote healing. The facility failed to complete routine skin evaluations, evaluate his wheelchair for size and positioning, and failed to evaluate the size and effectiveness of the pressure relieving cushion in the wheelchair, contributing to the development of stage 2 pressure ulcers to Resident #28's thighs. The facility also knew Resident #28, who presented with multiple risk factors for skin breakdown due to co-morbidities and his dependence on one staff member for mobility, was at risk. Futhermore, the resident was observed with open areas to his right posterior thigh which were undocumented. Cross-reference F684-quality of care pertaining to appropriate positioning/mobility Findings include I. Professional references A. The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (2/4/2018) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: 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. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers, Quick Reference Guide. [NAME] Haesler (Ed.). Cambridge Media: [NAME] Park, Western Australia; 2014: Steps to prevent the worsening of existing pressure injuries and to promote healing include: Avoiding positioning that places pressure on the pressure injury, assessment and documentation of the pressure injury when discovered and reassessment and documentation at least weekly. Assessment should include location, category/stage, size, tissue types, color, periwound (the skin around the wound) condition, wound edges, and evidence of undermining or tunneling, exudate, and odor. C. According to the National Pressure Ulcer Advisory Panel, Pressure Injury Prevention Points, April 2016, http://www.npuap.org/wp-content/uploads/2016/04/Pressure-Injury-Prevention-Points-2016.pdf (December 2017), the following recommendations were identified: -Cleanse the skin promptly after episodes of incontinence. -Reposition weak or immobile individuals in chairs hourly. II. Facility policy The Pressure Ulcer Skin Monitoring and Management policy and procedure, dated 11/2019, provided by the director of nursing (DON) on 3/9/2020 at 3:45 p.m., read in pertinent part: It is the policy of this facility that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new avoidable sores from developing. -Identify risk factors which relate to the possibility of skin breakdown and/or the development of pressure ulcers which include; Impaired/decreased mobility and decreased functional mobility Co-morbid conditions such as Diabetes Mellitus Resident's refusal of some aspects of care and treatment Exposure of skin to urinary and fecal incontinence History of healed pressure ulcer and its stage if known -Assessment of wounds on admission, readmission, weekly, and discharge -Use preventative measures as appropriate such as pressure reduction, continence care, and mobility. III. Resident status Resident #28, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the March 2020 computerized physician orders (CPO) diagnoses included acute kidney failure, Type 2 Diabetes Mellitus with hyperglycemia, muscle weakness, unsteadiness on feet, and spinal stenosis. The 12/26/19 minimum data set (MDS) assessment revealed he was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. There were no documented skin issues but he received applications of ointments/medications other than to his feet. He required extensive assistance of one staff member with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was always incontinent of urine and was frequently incontinent of bowel. He was at risk for pressure ulcers and no skin issues were documented. He was not steady during transitions, had no impairment of upper or lower extremities, and used a walker and wheelchair for mobility. IV. Observations On 3/4/2020 at 10:21 a.m., Resident #28 was seen seated in his wheelchair in his room. The wheelchair was too small for the resident's size. His lower body from his waist, at arm rest height, through his hips and thighs to where his knees bent at the edge of the seat, was touching the wheelchair surfaces of the side panels, armrests, back of the wheelchair, and the seat. He said he would like a bigger wheelchair because his hips and legs touched both sides (width) and they became sore, especially on the right leg as he rubbed his right outer thigh. On 3/5/2020 at 4:00 p.m. the resident had returned from being out of the facility for the day. He was seated in his wheelchair in his room. When the unknown certified nurse aide (CNA) and registered nurse (RN) #4 assisted him to the restroom, it was noted his pants (jeans), brief, and the pad on top of the cushion underneath him in the wheelchair were saturated with urine. He said he would sit in his wheelchair for three to four hours at a time without being assisted to stand. When his pants were lowered and his posterior thighs were exposed both thighs were discolored, reddened and purple in color, and macerated (skin coming in contact with moisture for too long). The skin was macerated (softening and breaking down of skin resulting from prolonged exposure to moisture), with open creased areas on the outer right thigh and scaly areas on the left thigh. RN #4 said his posterior thighs had been that way for months. The director of nursing (DON) was present at this time and used a flashlight to visualize the open areas, but had no comment. While he was seated in the restroom, observation of the wheelchair revealed the cushion under the pad he had been sitting on, was circular in shape and did not fit the wheelchair seat. There were several inches of gap on each side between the cushion and the edges of the seat. After RN #4 applied barrier cream to both thighs and his lower legs, he was assisted with a clean brief and jeans and was assisted back into his wheelchair. Resident #28 said he had outgrown that wheelchair and needed a new one. The DON acknowledged at this time the cushion in the seat did not fit the wheelchair and the resident needed a different type of cushion. The DON was interviewed on 3/5/2020 at 4:51 p.m. She said she had been working at the facility for about a month and a half and was the facility's wound care nurse. She said when she started, Resident #28 was not on the wound round list for her to look at. She said she was unaware of the condition of the resident's posterior thighs. She said, Barrier cream would be appropriate for moisture associated skin damage (MASD) since the resident would sit in urine alot. She was unaware of the open areas on the resident's posterior thighs. She acknowledged the wheelchair the resident currently had was too small for him and the cushion in the seat of the wheelchair was not the correct size or shape, and the resident's outer posterior thighs likely rested on the edges of the cushion, as the cushion did not extend to cover the entire wheelchair seat. She said he needed a different cushion and wheelchair and she would have physical therapy (PT) and occupational therapy (OT) evaluate him for a new wheelchair and pressure relieving cushion. V. Record review The care plan initiated 6/10/19 and revised 3/5/2020 revealed Resident #28 had potential/actual impairment to skin integrity related to bowel/bladder incontinence, decreased mobility, weakness, and Diabetes Mellitus. Interventions included to follow facility protocol for treatment of injury. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, maceration (occurs when skin is in contact with moisture for too long). Needs a pressure relieving/reducing chair to protect the skin while up in the chair. Resident #28 had potential for pressure ulcer development related to immobility with interventions that included: Administer treatments as ordered and monitor for effectiveness. Notify the nurse immediately of any new areas of skin breakdown noted during bath or daily care. Requires pressure relieving/reducing device on bed/chair. Weekly head to toe skin at risk assessment. Reposition for comfort as needed/tolerated. The 6/10/19 physician admission history and physical (H&P) documented Resident #28s skin as warm, dry, no rash. Review of the 6/15/19 initial licensed nurse skin evaluation, documented by RN #3, completed five days after admission, revealed five noted pressure areas: -Right thigh (rear)-Length (L) 2.8 centimeters (cm) x Width (W) 3.0 cm x Depth (D) .5 cm Stage II -Right thigh (rear)-L 2 cm x 1.0 cm x .5 cm Stage II -Right thigh (rear)-L 3.2 cm x 1.7 cm x .5 cm Stage II -Right thigh (rear)-L 3.0 cm x 2 cm x .5 cm Stage II -Sacrum L 1.5 cm x 1.5 cm x .02 cm Stage I Documentation read: Skin assessment reveals, posterior thigh pressure breakdown, shallow, open areas x 4. Red center, granular edges. Dried flaky skin surrounding. No drainage, blanchable and warm. Application of skin prep and barrier cream with peri care. teaching frequent weight shifts and encouraged him not to wear jeans as the thickness of the jeans may be the cause. sacral stage 1, blanchable, no heat, no odor, afebrile. oral mucosa pink moist, all other surface skin areas cdi (clean, dry, intact). The 6/10/19 admission Braden Scale for Predicting Pressure Sore Risk assessment was scored 18 indicating low risk, even though his skin assessment documented five pressure areas. The 6/17/19 MDS assessment documented Resident #28 was at risk for pressure ulcers but was negative for any unhealed pressure ulcers. He was not on a turning/repositioning program and did not receive pressure ulcer care. The 7/26/19 physician progress note documented the resident's skin as warm, dry, no rash. He was wheelchair bound. The July 2019 weekly skin evaluations documented by licensed practical nurse (LPN) #4 and RN #5 read: Skin clean, warm and intact. No skin concerns noted or reported. One skin evaluation was missing. The 8/14/2019 9:36 p.m. nursing note documented by an unknown nurse read: Found discoloration and maceration to posterior right thigh when resident assisted to bed. No open area noted. Resident with episodes of leaving facility in the morning and coming back at dinner. Also has episodes of refusing care when offered by staff. The August 2019 weekly skin evaluations documented by RN #5 and LPN #4 read: Resident skin remains clean, warm and intact.No skin concerns noted or reported. One skin evaluation was missing. The 9/10/19 Braden Scale score was 16 indicating low risk The 9/17/19 MDS assessment documented the resident was at risk for pressure ulcers and negative for unhealed pressure ulcers but was positive for MASD. He was not on a turning/repositioning program and did not receive pressure ulcer/injury care. The 9/25/19 and 12/26/19 MDS assessments revealed the resident was at risk for pressure ulcers, negative for any unhealed pressure ulcers, he was not on a turning/repositioning program and did not receive pressure ulcer care. The 10/9/2019 4:27 p.m. nursing note read: Resident's guardian asked nurse to do skin assessment in front of her. Patient was taken to his room. He stood up while holding onto the front wheeled walker and shirt and pants removed. Patient's buttocks cleansed (had small BM), brief changed and groin area examined. No redness noted. However, there was old scratch marks, and peeled off dry skin noted to posterior right thigh. When examined, there was a metal bottom to the corner of wheelchair right corner. Pt stated he sometimes sits on the bottom. Barrier cream was applied to the area, guardian stated she would go to the gym to talk to therapists to see if they could cover the metal bottom. The 12/10/19 Braden Scale score was 20 indicating low risk The 12/26/19 MDS revealed Resident #28s weight was 254 pounds. The 1/3/2020 weekly skin evaluation documented by LPN #2 read: Skin warm, dry and intact. Slight redness noted to buttocks and peri area, barrier cream applied as needed and with incontinence cares. No other redness or open areas noted. Review of the skin observation sheets for January and February 2020, completed by the CNAs on resident shower days, revealed no documented skin issues with multiple refusals by the resident. Review of the January 2020 treatment administration record (TAR) revealed Resident #28 was to have weekly skin evaluations completed on Mondays at 7:00 a.m. One evaluation out of four was documented as completed. The February 2020 TAR revealed two skin evaluations out of four were completed. 28 days had passed between the last evaluation in January to the first evaluation in February. The March 2020 TAR revealed no skin evaluation had been completed until 3/5/2020 after the facility was made aware of the posterior thigh skin issue noted above. It had been 17 days since the last skin evaluation was completed in February until the one was completed in March. The 3/5/2020 weekly skin evaluation-skin assessment completed by RN #1 read: Resident noted with MASD to left and right gluteal area, and resident noted with + 2 edema to BLE. Resident also noted with patches of skin that are rough to BLE that causes him to itch, notified physician of findings, new order to continue to apply barrier cream to buttock and right and left gluteal area. Physician will assess on tomorrow. The 3/6/2020 physician progress note revealed the resident was seen for follow up of wounds. Has MASD to buttocks. He primarily sits in wheelchair for most of the day. Will have in-house wound team follow as indicated. Monitor wounds for any signs of new skin disruption. The 3/9/2020 Braden Scale score was 14 indicating moderate risk The 3/9/2020 physician progress note read: He does now have a small opening on left buttock, already evaluated by wound RN and dressed. Primarily sitting in wheelchair most of the day. MASD to buttocks, small shallow open wound on buttock, being addressed by wound team and wound rounds. He is on wound rounds this week. On 3/9/2020 at 10:46 a.m. observation of the resident's posterior thighs with the DON revealed some of the areas on the right thigh have thin coverings of tan/reddish material over the open areas that were recognized on 3/5/2020 but one area remains open. The DON used a flashlight to visualize the area and acknowledged the one area was open, she did not measure the area or place any new treatment orders in the resident's chart. The 3/9/2020 wound/skin evaluation documented by the DON at 10:58 a.m. read: Open area to right thigh (rear) noted to be open. Wound bed noted to be pink. No drainage noted. No odor noted. Peri wound noted to be clean, dry and intact. No maceration noted. No complaints of pain or discomfort voiced. The 3/9/2020 5:25 p.m. nursing note documented by the DON read: Skin impairment noted to right upper thigh (rear) measuring approximately 1.5 x 0.3 x 0.1. Wound bed noted to be pink. Edges noted to be slightly macerated. Periwound noted to be clean, dry and intact without redness. No drainage noted. No odor noted. Continue to apply barrier cream to area. Education provided to resident regarding the needs and benefits of allowing staff to change brief frequently. The 3/9/2020 skin committee interdisciplinary team (IDT) note documented by the DON at 5:34 p.m. read: Skin impairment noted to right upper thigh (rear) measuring approximately 1.5 x 0.3 x 0.1. Wound bed noted to be pink. Edges noted to be slightly macerated. periwound noted to be clean, dry and intact without redness. No drainage noted. No odor noted. Continue to apply barrier cream to area. Resident is diabetic. Resident has history of pressure ulcers, decreased mobility, non-compliance with cares at times. Education provided to resident regarding the needs and benefits of allowing staff to change brief frequently. Resident continues to use cushion to wheelchair. Resident frequently goes out of facility for extended periods during the day. Resident is frequently observed to have wet pants upon return to facility. Resident evaluated by PT 3/7/2020 and OT 3/9/2020. VI. Interviews The DON was interviewed on 3/10/2020 at 9:27 a.m. She said she realized there was an issue with monitoring of the resident's skin and the weekly skin evaluations were not being done consistently and if they had been completed as required, the areas on his posterior thighs would have been recognized and addressed. She said the resident was on her radar now and on the routine wound rounds list to be seen by the wound doctor and she was going to ask him what product would be best to use for this resident because he was normally out of the facility for so long each day and sat in urine in his wheelchair all the time when he is away. LPN #3 was interviewed on 3/10/2020 at 9:51 a.m. He said residents' weekly skin evaluations were a head to toe assessment and were done routinely every week on a scheduled day and shift. He said they were to be done as scheduled and signed off as being completed by the LPN or RN. If a new skin issue was identified, a skin integrity form was to be filled out in the computer and an order for any treatments was to be obtained from the physician. He said there was no excuse for the skin check not being completed CNA #1was interviewed on 03/10/2020 at 10:26 a.m. She said when showers were given the CNAs were to look at all areas of the resident's skin and if any new areas were noted they fill out a shower sheet to document and describe the area. She said they were to report to the nurse as well if they identified a new area whether it was during a shower or during any cares. She said some of the nurses would come in during a shower to complete the resident's skin check but not all did that.