**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to take timely and sufficient steps to implement interventions to prevent the development of pressure injuries, affecting one (#29) out of one resident reviewed for pressure injuries out of 29 sample residents. Resident #29 admitted to the facility with a stage 2 pressure ulcer to her left buttock and was identified as being at risk for pressure ulcer development related to multiple comorbidities including post-polio syndrome, adult failure to thrive, spinal stenosis, and fibromyalgia. Record review revealed Resident #29's pressure ulcer to her left buttock healed over three times. The facility failed to have a system in place to identify and review residents at risk for pressure ulcer development and pressure ulcer re-development. As a result, the facility failed to put appropriate interventions in place timely for Resident #29, which contributed to the development of a pressure ulcer. She developed a pressure ulcer to her coccyx which worsened to a stage 4 pressure ulcer. Although the wound to the left buttock healed, Resident #29 developed a wound to her left coccyx, documented on 6/20/19 as a deep tissue pressure injury (DTPI), which never healed and worsened to a stage 4 pressure ulcer. Record review and staff interviews revealed the facility failed to implement appropriate interventions timely. As Resident #29 continued to decline and spent more time in bed, staff did not recognize a need for increased nutritional support when Resident #29's meal intake decreased as well. The pressure reducing overlay mattress which was provided to Resident #29 was ineffective, and likely contributed to the pressure ulcer development. The staff did not implement an alternating air mattress until the wound had worsened on 8/22/19 (over a two month period since the development of the wound), which created an immediate jeopardy situation with the likelihood of causing serious harm to additional residents if not immediately corrected. Findings include: I. Immediate jeopardy A. Findings of immediate jeopardy Resident #29 admitted to the facility with a stage 2 pressure ulcer to her left buttock. She had multiple comorbidities including post-polio syndrome, failure to thrive, fibromyalgia, and spinal stenosis which placed her at a higher risk for pressure ulcer development and redevelopment. Nursing staff did not consistently review residents at risk for pressure ulcers for effective interventions, such as residents who had changes in condition including poor intake and spending more time in bed, as evidenced by record review, staff interviews and the resident's skin assessments, which did not always accurately describe the condition of the resident's skin. The wound assessments completed by the wound nurse did not include all the information needed to comprehensively assess the overall status and health of the resident's wounds. Finally, nursing staff did not review as an interdisciplinary team (IDT) systemic conditions affecting wound healing, such as nutritional and fluid support, or refusal of care including refusing to eat and to be repositioned in bed, implement preventative measures timely; and update care plans to reflect the current status of Resident #29's wound, which contributed to wound redevelopment which advanced to a stage 4 pressure ulcer. Observation, record review, and interviews with staff and health professionals revealed the facility failed to have an effective system in place to implement and monitor preventative measures for residents who were assessed to be at risk for pressure ulcers, which created a situation of immediate jeopardy with the likelihood of causing serious harm to additional residents if not immediately corrected. On 10/10/19 at 3:25 p.m., the nursing home administrator (NHA) was notified of the findings above, which created a situation of immediate jeopardy for serious harm. B. Plan to correct the immediate jeopardy situation On 10/10/19 at 7:50 p.m. the NHA submitted a final plan to remove immediate the jeopardy situation. It read as follows: Resident specific: In regard to (Resident #29) the resident is receiving daily wound care. Peri care is provided every 2 hours. Weekly wound measurement and skin assessment done. This resident is on a low air loss alternating pressure mattress. Hospice as well as the facility wound consultants have evaluated this resident and provided their recommendation which the facility has followed. Repositioned every 1-2 hours. This resident is asked prior to each meal what her preference of food and drink are. On October 9, 2019 RD (registered dietitian) did a nutritional assessment. The Assistant DON (director of nursing) has spoken with this resident as well as her family regarding her wound treatment and poor nutritional intake. Hospice has also spoken and discussed her wound issues with the resident and daughter. All residents will have a skin assessment, nutritional assessment and Braden (tool used to determine risk for pressure ulcer development) scale assessment completed by 2:00 p.m. on October 11, 2019. Any resident that is identified as a high risk for pressure ulcer development will have an individualized intervention established by 4:00 p.m. on October 11, 2019. All staff will be in serviced on pressure ulcer prevention interventions and review interventions for all residents receiving wound care will be started 10/10/19 and all staff will be educated and in serviced prior to the start of their shift. C. Removal of immediate jeopardy On 10/10/19 at 8:30 p.m., the nursing home administrator (NHA) was notified the immediate jeopardy had been removed based on the plan to complete skin, Braden, and nutritional assessments on each resident, with appropriate interventions for those identified. However, based on observation, interviews, and record review, deficient practice remained at a G (harm) level. Although the facility had interventions in place during the survey, the following did not occur until after the coccyx wound worsened and then developed to a stage 4 pressure ulcer: -The care plan documented to turn the resident every 2 hours and provide peri-care every 1-2 hours. However, the facility did not implement any new interventions when Resident #29 declined to be turned and was spending more time in bed (see wound notes and progress notes). -The hospice wound specialist did not assess Resident #29's wound until it worsened (see health status note 8/23/19). -The registered dietitian or facility staff did not identify and assess Resident #29's decreased meal intake until she had severe weight loss of 13.4% (see meal intake record for April and May 2019 and nutrition/dietary note 6/13/19). -Finally, the facility did not place Resident #29 on an alternating low air loss mattress until after the wound had worsened on 8/22/19 (see health status note 8/23/19). II. Facility policy and procedure The Wound Management policy, revised on 2/20/18, was provided by the director of nursing (DON) on 10/9/19 at 5:30 p.m. It read in pertinent part, the facility's wound management program identified staff participation and accountability to include: -A qualified RN (registered nurse) is responsible for weekly wound measurements. -All caregivers are involved in prevention and identification of skin integrity issues. -All caregivers are to observe resident skin integrity during the daily provision of the residents' personal care. -Comprehensive assessment of any wound will include: -Location of Wound; -Length, width, and depth measurements recorded in millimeters; -Direction and Length of tunneling and undermining; -Appearance of the wound base; -Type and percentage of tissue in wound; -Drainage amount and characteristics including color, consistency and odor; -Appearance of wound edges; and -Description of the peri-wound (area around the wound bed) condition or evaluation of the skin adjacent to the wound. -Wound Management principles provide the basis of effective wound care and should be considered in development of the plan of care. -Wound Management principles include, and are not limited to: -Control or elimination of causative factors such as: -Pressure; -Shear; -Friction; -Moisture; and -Circulatory impairment. -Provision of systemic support to reduce existing and potential co-factors such as: -Nutritional and fluid support per assessed need; -Control of systemic conditions affecting wound healing per medical plan of care; -Documentation and Care Planning; -Goals of the wound care plan are collaboratively determined with the resident, family and interdisciplinary team; and -Currently, it is the facilities protocol to have the MDS (minimum data set) coordinator created the initial care plan and subsequent updates. -Risk factors and interventions are documented within the care plan including, but not limited to: -Impaired mobility; -Need for pressure relief such as support surfaces, repositioning, and pressure relieving devices; and -Nutritional status. -Preventative measures and interventions shall include, but not limited to: Use air mattress to relieve pressure, especially to those who are bed bound or spend extended periods of time in bed. III. Professional References The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved from: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3, or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissue exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged. -In many situations, the level of tissue injury can be accurately assessed with visual inspection. However, the tissue surrounding the visible injury should be assessed for changes in sensation (e.g., pain), temperature (e.g., warmer from inflammation, colder as tissues die), firmness (firmer or boggy with tissue destruction and edema), color (signs of inflammation consistent with skin tone) and drainage expressed from surrounding tissues as they are palpated. This more thorough assessment of surrounding tissue may alert the clinician to more extensive damage than is readily visible. These additional findings should be described and documented. VI. Failure to prevent redevelopment and worsening of a pressure ulcer to a stage 4. A. Resident #29 1. Resident status Resident #29, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included protein calorie malnutrition, post-polio syndrome, spinal stenosis, fibromyalgia, and adult failure to thrive. The 9/6/19 minimum data set (MDS) assessment revealed the resident was moderately impaired with a brief interview for mental status (BIMS) score of 12 out of 15. She exhibited the behavior of poor appetite or overeating nearly every day. She exhibited delusions and hallucinations, but did not exhibit verbal or physical behavioral symptoms or resist care (contrary to record review and interview - see below). She was totally dependent on two staff for bed mobility, transfers, dressing, and toilet use. Her weight was 118 pounds (contrary to the health status note dated 8/23/19 - see below). She had one stage 1 or greater over a bony prominence. She had two stage 2 pressure ulcers and one unstageable pressure ulcer. She was always incontinent of bowel and bladder. 2. Observation and staff interview Cross-reference F880, failed to perform proper hand hygiene prior to, during and after wound care to prevent possible contamination of the resident's wound. On 10/9/19 at 10:08 a.m. licensed practical nurse (LPN) #4 was observed providing wound care to Resident #29's coccyx. She had cleansed the surface of an over bedside table, draped the table, and placed all supplies on the clean field. Upon entering the room, certified nurse aides (CNAs) #1 and #3 assisted the resident to her right side and assisted with pulling the resident's brief down, while LPN #4 performed hand hygiene. LPN #4 washed her hands for eight seconds, turned the sink off with her bare hands and grabbed paper towels and dried her hands. LPN #4 donned gloves and removed the dressing from Resident #29's sacrum (area between the lumbar and coccyx bone). There was a large gaping wound to Resident #29's sacrum with a large amount of serosanguineous (thin watery pink or red fluid that contains red blood cells) drainage. LPN #4 said Resident #29's wound was measured weekly by the assistant director of nursing (ADON). LPN #4 doffed her gloves, and donned clean gloves. She did not perform hand hygiene. Then she cleansed Resident #29's wound with normal saline and a 4 x 4 gauze pad. Resident #29's coccyx wound bed was pink and red. It had a small amount of adherent slough (dead tissue), yellow/black/brown slough located at 12 o'clock of the wound. LPN #4 doffed her gloves and donned new gloves. She did not perform hand hygiene. She used a 4x4 to apply and dab Flagyl (antibiotic powder) to the wound bed, then placed calcium alginate rope (highly absorbent dressing) to the undermining (a pocket beneath the skin at the wound edge) areas. There was undermining almost completely surrounding the wound. LPN #4 said there was a small portion to the top of the wound which did not have undermining, but it was worse towards 5-6 o'clock of the wound. After applying calcium alginate to the wound she placed a Medihoney coated absorbent dressing (calcium alginate impregnated with 100% Leptospermum or Manuka honey) to the wound and then covered with Mepilex border (absorbent foam dressing). After repositioning the resident, LPN #4 changed the dressing to the resident's left lower extremity, doffed her gloves, washed her hands for seven seconds, shut the water off with her bare hands and grabbed paper towels to dry her hands. LPN #4 said she needed to apply additional dressings to Resident #29's arms as they were weeping. 3. Record review a. Care plans The skin care plan, initiated 9/5/18 and last revised on 5/30/19, revealed the resident admitted with a stage 2 wound to her left buttock which healed 11/15/18. On 1/18/19 the left buttock wound reopened and resolved on 1/24/19. Then on 4/23/19 the resident had currently a suspected deep tissue injury to her left buttock. Interventions included: -Administer treatment as ordered; -Assess/record/monitor wound healing weekly; -Avoid positioning the resident on her left buttock if possible; -Educate family and resident as to causes of skin breakdown; -Instruct/assist the resident to shift weight in wheelchair at least every 15 minutes; -The resident needed assistance to turn/reposition at least every 2 hours; -Monitor nutritional status; -The resident required pressure relieving/reducing device on bed (air mattress); and -If the resident refused treatment, confer with the physician IDT and family to determine why and try alternative methods to gain compliance. There were no revisions made to this care plan to include the reopening of left buttock wound stage 2 which was documented in the wound-weekly observation tool on 4/5/19 and when it resolved, the current stage of the resident's pressure ulcer on the coccyx which was a stage 4 observed during survey; and there was no update to the care plan to include an alternating low air loss mattress which was not placed until after the residents wound to her coccyx worsened from a documented shearing (see weekly wound tool 6/20/19) to a stage 4 pressure ulcer. The nutritional care plan, initiated 9/6/18 and revised on 9/4/19 revealed the resident had a potential nutritional problem related to unhealed pressure ulcers. Interventions included to weigh the resident weekly for the first month and then monthly per facility protocol, registered dietitian (RD) to evaluate and make diet change recommendations as needed (PRN), and provide and serve diet as ordered. There were no revisions made to this care plan to include the resident's weight loss. The activities of daily living (ADL) care plan, initiated on 9/5/18 and revised on 9/4/19 revealed the resident required total assistance by two staff to turn and reposition in bed every 2 hours, with dressing, personal hygiene, transfers, and toileting which included to be checked and changed every 2 hours. The care plan also revealed the resident had an alternating low air loss mattress; however, it did not document when the mattress was initiated, and skin/wound notes revealed it was not added until the wound worsened (see below). b. Meal intake record April 2019 Review of the April meal intake record 4/1/19-4/30/19 revealed the resident accepted 64 meals, she refused her meal 11 times, ate 0 (zero) - (to) 25% (percent) 45 times, ate 26-50% 12 times, ate 50-75% one time, ate 76-100% six times, and it was documented as not applicable 11 times; which meant the resident nutritional intake was less than 50% more than half of the time. May 2019 Review of the May meal intake record 5/1/19-5/31/19 revealed the resident accepted 50 meals, she refused her meal 27 times, ate 0-25% 39 times, ate 26-50% five times, ate 50-75% five times, ate 76-100% one times, and it was documented as not applicable 11 times; which meant the resident nutritional intake was less than 50% more than three (3) fourths (4) of the time. c. Progress notes, skin/wound notes, and wound-weekly observation tool The restorative program note, dated 3/11/19 at 1:14 p.m., documented program and equipment needs for the month of February 2019, the resident continued on a nursing level II program with the goal to prevent further loss of range of motion (ROM), exercises included active/passive ROM as the resident was unable to move extremities unassisted, she used a Hoyer lift for transfers, she was a total assist with meals, and she had a hi/low bed with an air mattress (air overlay mattress). The Wound-Weekly Observation Tool, dated 4/5/19 at 4:12 p.m., revealed the resident had a pressure ulcer stage 2 to the left buttock which was measured as a cluster with two open areas. The wound measured 1.6 cm (centimeters) x (by) 0.7 cm, peri-wound was within normal limits (WNL) and wound edges were irregular. The treatment was to apply calmoseptine (medicated cream) until resolved. -The resident had refused to be repositioned off her buttocks. When attempted to reposition the resident only tolerated for a few minutes and requested to be back on her back/buttocks due to comfort. The resident's family was notified; however, there was no documentation of the resident or the family being provided education of the risks of the pressure ulcer worsening on the Wound-Weekly Observation Tool or alternate intervention implemented. The skin/wound note dated 4/9/19 at 12:00 p.m., revealed the resident's left buttock was resolved. The progress note, dated 4/23/19 at 10:55 a.m., revealed the resident had a wound to her left buttock which measured 3.2 cm x 2.0 cm; it was a deep purple raised discoloration to left buttock which was the same area which had previous openings. The treatment provided was calmoseptine and border foam dressing. The Wound-Weekly Observation Tool dated 4/23/19 at 11:49 a.m. documented the left buttock wound was suspected deep tissue injury (SDTI) with 100% necrotic (brown, black, leather, scab-like) tissue present. The wound was dry with no drainage. The peri-wound had old scar tissue from a previous wound. -The resident had refused to be repositioned off her buttocks, when attempted to reposition the resident only tolerated for a few minutes and requested to be back on her back/buttocks due to comfort. The resident's family was notified; however, there was no documentation of the resident or family being provided education of risks of pressure ulcer worsening on the Wound-Weekly Observation Tool or the progress notes. The physician note dated 4/26/19 revealed the resident continued to decline and at previous visit she was referred to hospice but was declined. The skin/wound note dated 5/3/19 at 3:25 p.m., revealed the purple discoloration to the resident's left buttock was improving measured 0.5 cm x 0.5 cm. The restorative program note, dated 5/9/19 at 4:22 p.m., revealed the purple discoloration to the resident's left buttock measured 2.5 cm x 1.5 cm. The following two skin/wound notes dated 5/14/19 and 5/17/19 did not address the resident's left buttock. The skin/wound note, dated 5/23/19 at 4:44 p.m., revealed the purple discoloration to the resident's left buttock now had a small opening just medial to the purple discoloration and it looked as though the dressing peeled a piece of dry flaky skin from the wound. The Wound-Weekly Observation Tool, dated 5/23/19 at 4:47 p.m., revealed the resident's wound was improving and measured 1.5 cm x 0.6 cm. The wound continued to have 100% necrotic tissue. The plan of care note, dated 5/30/19 at 11:03 a.m., revealed the resident had only been staying up out of bed for a short time and staff reported the resident refused to turn and reposition in bed. She was on an air mattress and palliative care for pain. She was refusing to eat and drink and had a resolving suspected deep tissue injury. -There was no mention of an IDT review of the resident's poor nutritional intake, refusal to be turned, the resident becoming bed bound, education provided to the resident or family of the potential wound worsening, and no notification to the physician or family documented in the care plan note. The health status note, dated 6/1/19 at 5:43 a.m., revealed hospice was in on 5/31/19 to evaluate the resident (she was placed on hospice 6/5/19). The skin/wound note, dated 6/20/19 at 3:38 p.m., revealed the resident's left outer buttock had purple discoloration and was almost resolved. However, there was a new area of purple/red discoloration to the resident's left coccyx area, measuring 2.7 cm x 1.4 cm. The treatment orders were to cleanse the area with normal saline, pat dry, skin prep peri-wound, apply calmoseptine, and cover with border foam daily. The resident continued on an air mattress, repositioned every 2 hours and continued on hospice services. There was no documentation of any IDT review for further interventions. The skin/wound note, dated 7/1/19 at 10:53 a.m., revealed the resident had a new stage 2 wound to right inner buttock which measured 1.0 x 1.2 cm. She also had several cuts/abrasions to her inner groin from wearing Attends briefs, and the plan was to leave the briefs unfastened. The skin/wound note, dated 7/4/19 at 12:46 p.m., revealed skin to the resident's left coccyx was sloughing (shedding) off. The Wound-Weekly Observation Tool, dated 7/18/19 at 3:51 p.m., revealed the resident's left coccyx wound was pink and moist, surrounding tissue pink, and was documented as a shearing. Epithelial tissue present, with a scant amount of serous drainage, irregular with two open areas measured as a cluster with peeling skin between the two openings. The wound measured 2.0 cm x 4.0 cm. The Wound-Weekly Observation Tool, dated 8/9/19 at 12:53 p.m., revealed the resident's left coccyx wound had two distinct open areas with 10% necrosis, documented as shearing. It measured 2.5 cm x 1.5 cm x 0.1 cm. It was documented as worsening, hospice nurse to report findings to the hospice physician in their next IDT meeting. The skin/wound note, dated 8/18/19 at 15:10 p.m., revealed the resident's coccyx wound had eschar, and an area with tan/gray stringy tissue and what appeared to be an open cavity underneath. The resident was encouraged to lie on her side which she did not like to do because it caused pain in her neck. -Education was provided to the resident as her wound was getting worse, but there was no immediate action taken to provide any other pressure relief interventions such as treatment changes until 8/20/19. The Wound-Weekly Observation Tool, dated 8/20/19 at 11:31 a.m., revealed the resident's left coccyx wound was documented as SDTI and was worsening. The wound was documented as one wound it measured 2.0 cm x 2.5 cm x 1.0 cm. It had a tunnel measuring 1 cm at 7 o'clock. The wound bed had 75% slough. There was a small amount of serosanguineous and tan colored drainage. The peri-wound was pink and scarred. New treatment orders were obtained to cleanse the area with normal saline (NS), pat dry, apply Medihoney (paste or gel) to the wound bed, lightly pack tunneled area with gauze packing, and cover with bordered foam dressing daily. The skin/wound note, dated 8/21/19 at 12:06 p.m., revealed the resident's coccyx wound was worsening and staff discussed with the hospice nurse options to help relieve pressure and assist with wound healing/prevention. The resident had been on air overlay mattress, and could benefit from an alternating low air loss mattress (pressure relieving mattress). The hospice nurse agreed and ordered the mattress. -Although on 8/21/19 the alternating air mattress was discussed and then implemented on 8/22/19, it was not implemented until after the resident had acquired multiple pressure ulcers which healed over. One pressure ulcer (coccyx) developed into a stage 4 ulcer because the facility failed to implement the preventative mattress timely for Resident #29 as she had a known history to lie on her back (see above), had become bed bound (see above and hospice physician interview below), and had poor nutritional intake and multiple comorbidities, which placed her at greater risk for pressure development. The health status note, dated 8/23/19 at 9:10 a.m., revealed the resident and family agreed to have a wound care specialist observe the wound and provide recommendations. New treatment orders were obtained. The coccyx wound measured 2.0 cm x 3.0 cm x 1.0 cm. There was undermining from 6 o'clock to 1 o'clock that measured 1.4 cm. The resident weight was down to 106 pounds. The resident's mattress was changed to an alternating low air loss mattress on 8/22/19. -The coccyx wound was not staged in the 8/23/19 health status note. The resident's wound continued to worsen over the next couple of months as documented in the skin/wound notes (see below). The skin/wound note, dated 8/27/19 at 1:25 p.m., revealed the wound to Resident #29's coccyx had a strong foul odor and the wound bed was black and stringy. The skin/wound note, dated 8/30/19 at 4:34 p.m., revealed the wound to Resident #29's coccyx was worsening, had 100% necrotic tissue present and the wound measurements were increasing in size. New wound treatment orders were obtained. The skin/wound note, dated 9/12/19 at 12:24 p.m., revealed the wound to Resident #29's coccyx continued to worsen, and measurements of the wound continued to increase daily. The wound continued to have a large amount of brown drainage. Staff were changing the wound dressing more than daily. The wound had large pieces of tissue sloughing off, black/brown in color. The wound had odor even though they had started applying Flagyl (antibiotic powder) to the wound. The skin/wound note, dated 9/17/19 at 3:23 p.m., revealed the wound to Resident #29's coccyx continued to worsen as evidenced by the wound measurements increasing. The skin/wound note, dated 9/26/19 at 4:59 p.m., revealed the wound was showing improvements as it had less necrotic tissue 45% and 55% granular tissue; however, it continued to have a large area of undermining to most of the wound except at 6 o'clock. The skin/wound note, dated 10/3/19 at 2:01 p.m., revealed the wound to Resident #29's coccyx had improved; however, at this point the wound was a stage 4 pressure ulcer (see Wound-Weekly Observation Tool below). The Wound-Weekly Observation Tool (most current wound status during survey), dated 10/3/19 at 12:40 p.m., revealed Resident #29's coccyx wound was a stage 4 pressure ulcer. It measured 7.5 cm x 8.5 cm x 1.5 cm, it had undermining from 9-12 o'clock equal to 4.0 cm, 12-3 o'clock equal to 3.5 cm, 3-6 equal to 3.0 cm, 6-9 o'clock equal to 3.6 cm. The wound had granular tissue and slough present, the slough covered 35% of the wound, and it had a large amount of serosanguineous drainage. The peri-wound had induration (associated with inflammation, a hardened mass or formation) right border near right buttock, three purple discolorations with small opening measured 6.0 cm x 3.5 cm. d. Air overlay mattress According to Direct Supply (2018) Air Overlays vs. Mattresses, retrieved from https://www.directsupply.com/blog/air-overlays-vs-mattresses-which-is-best-for-my-resident: Most air overlays only measure three inches thick, and are not nearly large enough to prevent a typical resident bottoming out. When this happens, all benefits of immersion are lost as the body's peak points of pressure will rest on the surface underneath, providing the ideal condition for pressure ulcers. e. Nutrition/dietary note and weight loss The nutrition/dietary note, dated 9/17/18 at 2:24 p.m., revealed the resident needed increased nutrient needs related to the demands of wound healing as evidenced by multiple wounds, plan to trial mighty shakes twice a day and offer current diet as tolerated. The resident's weight was 138 pounds and her body mass index (BMI) was 24.4. The nutrition/dietary note, dated 3/8/19 at 4:12 p.m., revealed the resident was below the recommended amount for her fluids and the plan was to monitor for signs and symptoms of dehydration. The nutrition/dietary note, dated 6/13/19 at 3:24 p.m., revealed the resident had a severe weight loss of 19 pounds in one month (13.4%), the resident was not eating or drinking and her intake was less than 50% of most meals. The resident did not have wounds, continue current diet and honor preferences, the resident was on hospice. f. Braden scale The Braden scale dated 9/4/18 revealed the resident was at risk for pressure ulcer development with a score of 15 (15-18 at risk, 13-14 moderate risk, 10-12 high risk, and nine or below very high risk). The Braden scale dated 11/30/18 revealed the resident was a moderate risk for pressure ulcer development with a score of 13. The resident's Braden scale score continued to decrease as the resident became more at risk for developing pressure ulcers. On 9/4/19 she was high risk for developing pressure ulcers with a score of 10. g. Skin assessments The skin assessment, dated 6/24/19 at 10:37 a.m., documented the resident's left buttock sore was resolved and applying calmoseptine as preventative; however, it did not address the new area to the left coccyx identified in progress notes and skin/wound documentation 6/20/19 (see above). The skin assessment, dated 7/1/19 at 10:46 a.m., documented the resident had an open sore, stage 2 to right inner buttock; however, did not address the resident's coccyx wound. The skin assessment, dated [TRUNCATED]