**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident, one (#26) of one reviewed for pressure ulcers, did not sustain an unstageable pressure injury out of 27 sample residents. Resident #26 was admitted to the facility for rehabilitation following a fall with a right hip fracture requiring surgery on 8/20/21. She was identified during her admission assessment to be at risk for developing pressure ulcers and the admission skin assessment identified a surgical wound only. The resident developed an avoidable unstageable wound to her coccyx 16 days after admission. The facility was aware she was at risk for pressure ulcer development and failed to ensure all potential preventative interventions to help prevent an avoidable pressure ulcer from developing on her coccyx were implemented in a timely manner. According to her skin care plan, an air mattress was to be in place and she was to be monitored for and assisted to be turned and repositioned frequently. Observations revealed she did not have an air mattress in place. There was no evidence found to demonstrate she was on a formal turning and repositioning schedule. She required extensive assistance with her mobility. In addition, the facility failed to investigate or conduct a root-cause analysis to determine how the pressure ulcer was acquired to prevent any further pressure injuries from occurring. Findings include: I. Professional reference National Pressure Ulcer Advisory Panel (2016) Pressure Injury Stages. Retrieved on 9/24/21 from: https://npiap.com/page/PressureInjuryStages. Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin 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. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 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. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. 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. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. 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 is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). The National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers, reads that steps to prevent the emergence of pressure ulcers in individuals identified as being at high risk include scheduled repositioning to avoid individuals being in a position that places pressure on a vulnerable area for a long period of time. The following steps should be taken to prevent the worsening of existing pressure ulcers and promote healing: -Positioning that places pressure on the pressure ulcer should be avoided. -The pressure ulcer should be assessed upon development and reassessed at least weekly. The results of assessments should be documented. -The ulcer should be observed with each dressing change for signs of infection, improvement, deterioration, or other complications. -Signs of deterioration in the wound should be addressed immediately. -The assessment should include: location, category/stage, size, tissue type, color, peri-wound (skin around the wound) condition, wound edges, exudate, undermining/tunneling, order. II. Facility policy and procedure A Pressure Ulcer policy, revised 7/21/21, provided by the director of nursing (DON) on 9/20/21 at 2:20 p.m. documented in part, The Centers will provide the necessary requirements to ensure that a patient receives treatment and care in accordance with professional standards of practice. Procedure: Upon admission, the nursing staff will complete a full skin evaluation and examine for any ulcerations or alterations in skin; In addition the (facility) shall describe and document the following: full evaluation of pressure sore including description of the wound, pain evaluation, the patient's mobility status, current treatments if applicable and MD and family notification. When a new skin concern is found, staff will: complete an incident report inside of risk management to include notifications to the physician, complete an SBAR (situation, background assessment and recommendation), place the patient on the 24-hour report and notify the director of nursing and wound specialist as needed. III. Resident status Resident #26, age [AGE], was admitted on [DATE]. According to the September 2021 computerized physician's orders (CPO) diagnoses included fracture of the right femur, diabetes mellitus, abnormality of gait, pain and need for assistance with personal care. According to the 8/27/21 minimum data set (MDS) assessment the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required extensive assistance from two staff for bed mobility, transfers and toileting. She was mobile per walker and wheelchair. She was coded at risk for developing pressure ulcers and had no pressure ulcers upon admission. Treatments included a pressure reducing device in her chair and bed, surgical wound care and application of ointments and medications other than to the feet. Her treatment did not include a turning or repositioning program. IV. Resident interview Resident #26 was interviewed on 9/14/21 at 9:05 a.m. She was sitting in her recliner at her bedside. The recliner was not upholstered and had a firm surface on the seat and back area. There was no supportive, offloading pad or cushion in the chair. The resident said that she had a sore on her bottom that was open. She said it happened after she arrived at the facility. She said the nurses were treating it with a bandage. She said she did not know how it happened but that she had been in bed for a long time due to her hip surgery. She said the sore caused her discomfort sometimes but she just shifted her weight and it helped. She said no staff reminded her or helped her change positions because she could reposition herself. V. Record review A nursing comprehensive admission data collection dated 8/20/21 documented the resident's skin condition as follows: -Right trochanter hip surgical wound. -There were no other identified skin issues. The Braden scale (part of the admission assessment) identified her as at risk for skin breakdown related to deficits in sensory perception, moisture, activity level, mobility, nutrition and friction and shear. A skin care plan initiated 8/23/21 identified the resident as at potential risk for skin breakdown due to decreased mobility and a surgical wound to the right hip. Interventions included: -Air mattress to bed per facility guidelines; however the resident only had a standard pressure relieving mattress and not an air mattress (see DON interview below). -Apply moisturizer to skin. Do not massage over bony prominence and use mild cleanser for peri-care/washing. -Braden scale every week per protocol, and skin evaluation as ordered and as needed. -Monitor/remind/assist to turn/reposition frequently as needed or requested (was no consistently implemented per resident interview, see above). -Skin treatment per physician order. A nutritional assessment dated [DATE] revealed under the other nutritional risk factors that the resident had no nutritional factors and that she did not have a pressure injury. A Braden scale for predicting pressure sore risk dated 9/2/21 documented the resident with a score of 13 meaning she was at moderate risk. A nurse note dated 9/6/21 and time-stamped at 5:04 p.m. documented in part that a certified nurse aide (CNA) alerted the nurse about an open area on the resident's coccyx. The wound was open with slough present and red skin surrounding the wound. A wound initial evaluation dated 9/6/21 documented in part the resident was found to have an acquired pressure ulcer to the coccyx measuring 0.4cm (centimeters) x 0.3cm with no depth, described as unstageable. The wound summary documented the wound had slough and the surrounding tissue had slight blanchable redness. The resident was making progress with therapy but did fatigue easily. The resident verbalized understanding and performed a return demonstration for frequent offloading and repositioning. A care plan initiated 9/6/21 identified the resident with an unstageable pressure injury to the coccyx area. Interventions included: -Administer treatments as ordered and monitor for effectiveness. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue and exudate and any other notable changes or observations. A Braden scale for predicting pressure sore risk dated 9/9/21 documented the resident with a score of 14 meaning she was at moderate risk. -Although the resident was discovered to have an acquired pressure ulcer on 9/6/21. A wound progress review dated 9/10/21 documented in pertinent part the wound measured 0.3cm x 0.3 cm with no depth. The wound was documented as improving and documented as unstageable. A physician's telehealth progress note dated 9/13/21 documented in part the resident had a new stage 2 pressure ulcer to her coccyx. -However, it was previously documented as unstageable on 9/6/21. The physician did not document any new order changes or mention any other interventions. The September 2021 CPO revealed in part the following order: -Cleanse coccyx wound with normal saline, pat dry, apply medi-honey to wound bed, cover with a foam dressing. Change M-W-F and PRN (as needed) for soiling/dislodgement. Start date 9/6/21. -Barrier cream to coccyx/buttock/peri area/reddened area for prevention, q (every) shift and PRN. Start date 8/20/21. -Review of the September 2021 treatment administration record (TAR) revealed that on 9/17/21 and 9/20/21 there was no signature to demonstrate that the treatment (above) had been completed. In addition, there was no documentation found the resident received a PRN dressing change any time between 9/6/21 and 9/16/21 (see wound observation below). -Review of daily skilled notes and progress notes from 8/20/21 through 9/5/21 revealed the resident's skin was intact other than her surgical wound to her right hip until the discovery of the unstageable coccyx wound found on 9/6/21. In addition, documentation failed to demonstrate the resident was provided education and encouragement to change positions or off load to decrease pressure to her bottom. The resident's daily care record for September 2021 and the [NAME] (record of specific care needs) failed to demonstrate the resident was on a turning or repositioning program. VI. Wound care observation and interview On 9/16/21 at 2:08 p.m. wound care was observed with registered nurse (RN) #2. He said that the last time he took care of the resident she did not have a wound on her coccyx. He said it was not reported to him during report that she had a wound on her coccyx. RN #2 reviewed the resident's daily assessments and said that she did not have any documented coccyx wound prior to 9/6/21. Next RN #2 gathered his supplies and took them into the resident's room and placed them on her over the bed table. He then assisted the resident from her recliner to her bed. He washed his hands with soap and water and then donned a clean pair of gloves. He then assisted the resident to pull her pants and underpants down below her buttocks. The resident did not have a dressing in place over her coccyx. The RN then doffed his gloves, washed his hands again and donned a clean pair of gloves. Next he cleansed the wound and measured it. The wound measured 0.5 cm x 0.75 cm x 0.25 cm. There was no drainage from the wound and in the center there was white to slightly yellow slough. The peri-wound was pink and intact. RN #2 said the wound was unstageable and that when he spoke to the DON earlier she said that it was looking better and had decreased in size. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. The RN then dressed the wound with the prescribed treatment (see above), placed the protective dressing over the wound and dated it. The resident said she wanted to go back into the recliner and the RN assisted her to the recliner. The RN said the resident liked to stay in her recliner and that nursing encouraged her to shift positions often. VII. Staff interviews RN #3 was interviewed on 9/16/21 at 2:40 p.m. She said she was helping on the floor as a CNA today and was taking care of Resident #26 today. She said the resident was a one person assist for transfers and used her walker and a gait belt for stability. She said she helped the resident to the bathroom today and helped her clean up. She said she did not see a wound on her coccyx and did not see a dressing. RN #4 was interviewed on 9/16/21 at 4:13 p.m. She said on 9/6/21 she had received report from the day nurse that Resident #26 had a pressure injury on her bottom. She said the resident did not have one before then. She said she assessed the area and then reported it to the DON. She said when the resident first admitted to the facility she was chair and bed bound due to her right hip surgery. She said she required a lift at that time up until about a week ago. She said the resident had some urinary incontinence and was at risk for shearing until recently. She said she felt the wound had improved. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. The DON was interviewed on 9/16/21 at 3:44 p.m. She said Resident #26's wound was acquired in the facility and she saw it last week when it was brought to her attention on 9/6/21. She said she did not know how the resident had acquired it. She said she did the resident's skin assessment along with her DON consultant that was in the building at the time. She said she had seen it since then and it was improving. -However, according to the previous wound documentation on 9/10/21, the wound had increased in size. She said she remembered discussing the resident's wound in the IDT (interdisciplinary team) meeting the next morning and that it was discussed that the resident had decreased mobility and was thin. She said they may have discussed her nutritional status as well. She said there were no formal notes taken or kept from that meeting that she was aware of. She said that a risk management report should have been completed which would have triggered an investigation. She reviewed the resident's record during the interview and said that she could not find an investigation. She said she would look into it further and provide follow up. The nursing home administrator (NHA) was interviewed during an administrative meeting on 9/16/21 at 5:23 p.m. She said the facility watched residents with high risk for pressure ulcers closely. She said the IDT reviewed skin integrity for residents at risk and or with current skin concerns. She said residents ' identified with a concern or potential concern were reviewed for nutritional needs. The NHA said the IDT received feedback from therapy on residents ' mobility and positioning to identify potential risk or causation. She said resident skin was reviewed daily and documented under daily skilled nurse notes. She said when a facility acquired pressure ulcer was identified with a resident, the facility would identify a plan for off-loading/repositioning. The NHA said the resident would be placed on two hour rounds and therapy would also watch for lack of movement of the resident during the day. She said the facility would also conduct random audits and at times, full house audits reviewing residents ' skin risk for or current pressure ulcer development. She said Resident #26 had a Braden assessment completed to identify risk. She said the resident may have had a deep trauma issue to the area that was not identified during admission or through daily nurse observations between 8/20/21 (admission) and 9/6/21 (on set). She said she believed the skin checks were not thorough enough to identify the concern prior to the finding of an unstageable pressure ulcer. VIII. Facility follow-up The DON was interviewed a second time on 9/16/21 at 5:52 p.m. She said she found out Resident #26 did have a pressure relieving mattress in place upon admission and that they would not have an air mattress in place for an unstageable wound. She said the resident also had a pressure relieving cushion in her wheelchair. She said she also followed up with the registered dietician (RD) and she did not feel the resident was nutritionally compromised and that supplements were already in place. She said there was not an additional nutritional assessment done when it was identified the resident had a change of condition (wound). She said she did not find a risk assessment or an investigation for Resident #26's wound.