**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents received the necessary treatment and services according to professional standards of practice to prevent the development of pressure injuries for one (#31) of two residents out of 26 sample residents reviewed for pressure injuries. Resident #31, who was receiving hospice services related to his diagnosis of senile dementia, was known to be at risk for developing pressure injuries. The resident was admitted to the facility on [DATE] without any pressure injuries. On 10/6/23, a weekly skin assessment was conducted for Resident #31 and documented the resident had no new skin issues. The facility failed to conduct a skin assessment between the dates of 10/6/23 and 10/18/23. On 10/18/23, multiple pressure wounds were noted to Resident #31's left foot. The wounds included an unstageable left lateral malleolus (outside ankle) wound which later evolved to reveal a stage 3 pressure injury, an unstageable lateral (outside) left heel wound, an unstageable lateral left foot wound which later evolved to reveal a stage 4 pressure injury, and an unstageable left fifth metatarsal head (joint between the foot and the small toe) deep tissue injury (DTI). The left fifth metatarsal wound resolved on 11/28/23 and reemerged as a DTI on 1/8/24. On 1/18/24, the left fifth metatarsal wound evolved into an unstageable pressure wound. On 10/22/23, the resident developed an unstageable pressure injury to his left hip. The facility had initiated a skin integrity care plan for the resident on 5/27/22, however, interventions, such as implementing a specialty air mattress and repositioning the resident, were not implemented until after Resident #31 developed the pressure injuries to his left hip and left foot. As a result of the facility's failures to implement timely pressure injury interventions, Resident #31 developed multiple advanced pressure injuries to his left foot and left hip. Findings include: I. Professional reference 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 2/15/24, 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. II. Facility policy and procedure The Pressure Wound Prevention and Skin Management policy and procedure was provided by the nursing home administrator (NHA) on 2/14/24 at 10:52 a.m. It read in pertinent part, Based on the resident's history, clinical status, head to toe skin assessment, and Braden scale, an acute temporary care plan should be initiated per definition and policy. Interventions to promote healing and/or prevent breakdown may include incontinence management, a turning and repositioning plan, initial treatment(s), off loading devices and any other pressure relieving strategies and resident goals for treatment. All residents are provided with pressure reducing mattresses. Special support surfaces (such as pressure relieving specialty mattresses or cushions) will be utilized as part of the treatment plan when residents are identified to be at higher risk for skin breakdown or having existing breakdown. Weight shifts may be implemented as part of both prevention and treatment for pressure wounds. When possible, weight shifting and off loading, which allows sufficient capillary refill and tissue perfusion may be implemented. III. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the February 2024 computerized physician orders (CPO), diagnoses included Alzheimer's disease, chronic kidney disease and peripheral vascular disease. The 12/29/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score of three out of 15. He was dependent with toileting, personal hygiene, bed mobility, required substantial/maximal assistance with transfers and supervision with eating. The assessment indicated the resident had one unhealed stage 3 pressure ulcer and four unhealed unstageable pressure ulcers not present on admission and was at risk for developing pressure ulcers. B. Observations On 2/13/24 at 12:30 p.m. licensed practical nurse (LPN) #1 was observed removing the dressing on Resident #31's left hip. A small amount of serosanguinous (yellowish with a small amount of blood) drainage was observed on the dressing. The wound bed was difficult to visualize due to the depth of the wound. There was no redness noted around the wound site. Resident #31 was observed on an air mattress. On 2/13/24 at 12:40 p.m. LPN #1 was observed removing soft heel boots from Resident #31's left foot for wound care. The left lateral malleolus (outside ankle bone) wound bed appeared pink without drainage or redness noted around the wound site. The left lateral heel wound bed appeared pink with a small amount of yellowish material and a small amount of brown black material. The left lateral foot wound bed appeared red with a small amount of red material. The left fifth metatarsal wound bed had brown black material. C. Record review The skin integrity care plan, initiated 5/27/22 and revised 12/20/23, indicated Resident #31 had actual and the potential for skin breakdown due to dementia, decreased mobility, fluctuating nutritional intake and incontinence. Interventions included air mattress, toileting regularly, encourage optimal nutrition and hydration, float heels, heel protectors to bilateral heels when in bed and wheelchair, keep skin clean and dry, outside wound care to follow for weekly wound management, nutritional supplements, reposition frequently in bed and wheelchair and weekly skin checks. The hospice care plan, initiated 5/27/22 and revised on 12/21/23, indicated the resident was receiving hospice services due to senile dementia. Interventions included work cooperatively with the hospice team to ensure spiritual, emotional, intellectual, physical and social needs are met. Further review of the comprehensive care plan revealed turn and reposition frequently was initiated on 5/27/22 and reinitiated on 10/23/23, the air mattress was initiated on 9/13/22 and reinitiated on 10/25/23 and floating bilateral heels was initiated on 11/17/23. The February 2024 CPO documented physician orders: -An order for hospice services, ordered 3/15/23; -Float heels while in bed, ordered 5/13/22 and reordered 10/19/23 (after the wounds developed); -Left heel protector, ordered 6/14/22 and discontinued 7/6/22; -Left heel protection boot, ordered 7/6/22; -Air mattress, ordered 10/18/23 (after the wounds developed); -Bilateral heel protectors, ordered 10/19/23 (after the wounds developed); -Turn and reposition resident frequently in bed and in wheelchair, ordered 10/23/23 (after the wounds developed); -Left lateral malleolus, cleanse wound with wound cleanser or normal saline, pat dry and apply skin prep around the wound and leave open to the air every day and as necessary, ordered 1/31/24; -Left lateral heel, cleanse wound with wound cleanser and apply liquid medihoney and cover with bordered gauze. Change dressing every other day and as necessary, ordered 1/31/24; -Left lateral foot, cleanse wound with wound cleanser and apply wound with liquid medihoney and bordered gauze. Do not cover other wounds with this dressing, ordered 1/31/24; -Left hip, cleanse wound with wound cleanser, express drainage from wound and pack loosely with Dakins moistened 1/4 inch packing strips and cover with ABD (thick abdominal type dressing) and secure with medipore tape. Change dressing twice a day and as necessary, ordered 1/31/24; and, -Left lateral metatarsal, cleanse wound with wound cleanser. Apply skin prep around the wound and leave it open to air, ordered. -Review of the February 2024 CPO revealed the float heels while in bed, air mattress, bilateral heel protectors and repositioning orders were not implemented until after the identification of the pressure wounds. The 10/20/23 Braden Scale Assessment (a tool used to predict the risk of pressure ulcers) indicated Resident #31 was at a severe risk for developing pressure ulcers. The 10/6/23 weekly comprehensive nursing skin observation documented Resident #31 had no new skin issues and a boot for heels for heel redness. -There was no documentation to indicate a weekly skin assessment had been conducted between 10/6/23 and 10/18/23 (a period of 12 days). A 10/18/23 nursing progress note documented a hospice certified nurse aide (CNA) alerted a registered nurse (RN) to new wounds on Resident #31's left foot. The measurements to the wounds were 1.5 centimeters (cm) by 0.5 cm, 1.5 cm by 0.9 cm and 2.0 cm by 1.0 cm. The wounds were cleansed with a wound cleanser and bandages were applied. The director of nursing (DON), power of attorney (POA), physician and the hospice provider were notified. -The nursing progress note failed to document a detailed description regarding the location of each wound on Resident #31's left foot and which measurements pertained to each wound identified. The stage of the wound was not identified. A 10/18/23 change of condition note documented the identification of new foot wounds for Resident #31. The 10/22/23 nursing progress incident note documented a certified nurse aide reported a skin breakdown on the left hip. The measurements were 3.5 cm by 2 cm by 0.2 cm by 0.5 cm by 1 cm. It documented the hospice provider, the DON and the power of attorney (POA) were notified. -The incident note did not identify the stage of the wound. The 10/24/23 interdisciplinary team (IDT) progress note documented a referral to a wound physician for weekly wound management and wound treatment orders. -A comprehensive review of Resident #31's electronic medical record (EMR) failed to reveal documentation of turning and repositioning prior to the identification of the resident's wounds Review of the wound care physician assistant's (WCPA) notes revealed the PA initially evaluated Resident #31's wounds on 10/23/23 and continued to provide weekly wound care visits. The WCPA's initial visit note on 10/23/23 documented the following wounds: The left hip wound was documented as a shearing friction wound. The measurements were 6 centimeters (cm) by 3.5 cm by 0.1 cm. The wound bed had 50% slough (yellow/white material in the wound bed) and 50% eschar (black brown collection of dead tissue in the wound bed). The left lateral malleolus wound was documented as an unstageable pressure wound. The wound measurements were 2 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 1.8 cm by 1.7 cm by 0 cm. The wound bed had 100% eschar. The left lateral foot pressure wound was documented as an unstageable pressure wound. The measurements were 1.1 cm by 1.4 cm by 0 cm. The wound bed had 100% slough. The left fifth metatarsal pressure wound was documented as a DTI. The measurements were 0.4 cm by 1.1 cm. The wound was a non blanchable deep red, maroon or purple discoloration. The 10/31/23 IDT progress note documented interventions for frequent turning and positioning, air mattress and floating heels. -However, the interventions were implemented after the wounds were identified and assessed by the wound care PA. According to the most recent wound care notes dated 2/5/24, the WCPA documented the resident still currently had the five wounds with the following changes: The left hip wound was documented as an unstageable pressure wound. The measurements were 0.7 cm by 0.7 cm by 0.7 cm. The wound was documented as undermining. The wound bed had 100% granulation. The left lateral malleolus wound was documented as a stage 3 pressure wound (evolved from the initial unstageable classification). The measurements were 1.1 cm by 0.5 cm by 0 cm. The wound bed had 100% epithelialization. The left lateral heel wound was documented as an unstageable pressure wound. The measurements were 0.5 cm by 0.7 cm by 0.1 cm. The wound bed had 80% slough and 20% eschar. The left lateral foot pressure wound was documented as a stage 4 pressure wound (evolved from the initial unstageable classification). The measurements were 1.7 cm by 1.7 cm by 0.1 cm. The wound bed had 70% granulation, 15% slough and 14% epithelialization. The left fifth metatarsal head wound was documented as an unstageable pressure injury. The measurements were 1.1 cm by 2.0 cm. The left fifth metatarsal wound healed on 11/28/23 and reemerged on 1/8/24 as a DTI which evolved into an unstageable pressure wound on 1/18/24. -Although the WCPA had followed the wounds weekly since 10/23/23, after the wounds were identified, the facility failed to prevent them from occurring initially, despite knowing the resident was at risk of developing pressure injuries and there were not enough preventative measures put in place to prevent them from developing. IV. Staff interviews Registered nurse (RN) #1 was interviewed on 2/14/24 at 1:35 p.m. She said Resident #31 had multiple pressure wounds on his left hip and bilateral feet. She said she did not remember if he was on a pressure mattress before the identification of his wounds. She said he did have his heel protector boots on because of previous issues with wounds on his feet. She said since he was a dependent resident, was stiff and had previous skin issues, he should have had preventative measures in place and be frequently repositioned at least every two hours. The primary care physician (PCP) was interviewed on 2/14/24 at 10:23 a.m. He said he had been taking care of Resident #31 and the resident had previous issues with wounds about one year ago. He said Resident #31 was bed and wheelchair bound, on hospice and was at risk for developing pressure wounds. He said there was no guarantee he would not have developed the wounds, however, he said there was an absolute guarantee the wounds would develop if preventative measures were not in place. He said preventative measures should include an air mattress, special cushions, heel protectors, weekly skin assessments, nutritional interventions and frequent repositioning. The WCPA was interviewed on 2/14/24 at 10:52 a.m. She said she saw Resident #31 in October 2023, after he developed multiple pressure wounds. She said when she saw him an air mattress was in place and he was wearing heel boots. She said, with his comorbidities, he was at a high risk of developing pressure wounds and preventative measures would have helped decrease the risk of developing the wounds. She said preventative measures included air mattresses, heel boots, frequent repositioning and nutritional interventions. She said the resident's pressure wounds were improving. The director of nursing (DON) was interviewed on 2/14/24 at 3:45 p.m. He said he was the wound care coordinator who rounded with the wound care consultants. He said a full nursing assessment with a skin assessment was completed on all residents upon admission. He said skin assessments were done on a weekly basis and scheduled for each resident. He said if a new skin issue was identified it was reported to the physician, hospice and the DON. He said a risk report, such as a change of condition or situation, background, assessment, response (SBAR) was completed. The skin issue was discussed with the IDT, a root cause analysis completed and interventions to prevent further deterioration were implemented. He said the Braden Scale Assessment score acted as a guide for preventative measures. The DON said residents who were dependent and at risk should be put on an air mattress, special cushions for wheelchairs, heels should be floated and frequent repositioning should be done. He said Resident #31's wounds developed in October 2023 and the majority of interventions were put into place after the wounds were identified. He said Resident #31 was not on an air mattress before the wounds were identified. He said at risk residents should be frequently repositioned. He said there was no set frequency of how often residents were repositioned. He said the facility did not have a repositioning program and did not document how often or when a resident was repositioned.