**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Antibiotic medication error A. Professional reference [NAME] A, Triantafylidis L, O ' [NAME] N, et al. Improving Medication Reconciliation With Comprehensive Evaluation At A Veterans Affairs Skilled Nursing Facility: The Joint Commision Journal on Quality and Patient Safety (2021), was retrieved on 7/1/24 from https://www.jointcommissionjournal.com/article/S1553-7250(21)00153-7/fulltext. It read in pertinent part, Unintentional medication discrepancies due to inadequate medication reconciliation pose a threat to patient safety. Skilled nursing facilities (SNFs) are an important care setting where patients are vulnerable to unintentional medication discrepancies due to increased medical complexity and care transitions. SNFs represent a critical setting for medication reconciliation efforts due to challenges completing the reconciliation process and the concomitant high risk of adverse drug events in this population. Ineffective medication reconciliation continues to threaten patient safety across health care systems around the world. Best-practice guidelines outline the need for high-quality medication reconciliation in all care settings, including skilled nursing facilities (SNFs). Patients in SNFs are at heightened risk for medication reconciliation errors due to increased care transitions (for example, home to hospital to SNF to home) and medical complexity. Improving medication reconciliation in the SNF setting is challenging due to resource constraints, complex workflows, and variation in the capabilities of electronic medical records (EMRs). B. Facility policy The Documentation of Medication Administration policy, revised November 2022, was received from the nursing home administrator (NHA) on 7/1/24 at 3:35 p.m. The policy read in pertinent part, A medication administration record is used to document all medications administered. A nurse documents all medication administered to each resident on the resident's medication administration record (MAR). Administration of medication is documented immediately after it is given. Documentation of medication administration includes, at a minimum, the resident's name, name and strength of the drug, dosage, route of administration, date and time of administration, initials, signature and title of the person administering the medication, and the resident response to the medication. C. Resident #38 1. Resident status Resident #38, age greater than 65, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included neuromuscular bladder dysfunction and history of methicillin-susceptible staphylococcus aureus (MSSA) bacteremia staphylococcus infection (MSSA BSI). The 5/15/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident was independent with his activities of daily living. 2. Resident interview Resident #38 was interviewed on 7/1/24 at 1:14 p.m. Resident #38 said he took antibiotic medications three times a day. He said he took the medication to prevent an infection from returning to his spine. 3. Record review Review of Resident #38's July 2024 CPO revealed the following physician's order: Cephalexin 500 milligram (mg) tablets, give 500 mg orally (by mouth) three times a day, ordered 5/25/22. A 8/1/23 infectious disease (ID) physician note revealed Resident #38 was evaluated by the ID physician. The ID physician ordered a decrease in the resident's Cephalexin. The new order was for Cephalexin 500 mg tablets, two times a day. A 4/2/24 ID physician note revealed Resident #38 was evaluated by the ID physician. The note documented the resident had a history of MSSA BSI from an infection in his spine in 2020. The note documented the resident was to continue on Cephalexin 500 mg twice a day for infection prevention. The facility failed to change Resident #38's Cephalexin order on 8/1/23. From 8/1/23 to 7/2/24, the resident was administered the Cephalexin medication three times a day instead of two times a day. -There was no documentation in Resident #38's electronic medical record (EMR) to indicate a medication review and reconciliation had occurred following the resident's appointment with the ID physician in order to ensure the resident was receiving the correct dose of the Cephalexin antibiotic -Review of Resident #38's comprehensive care plan revealed the facility failed to develop an individualized care plan focus for Resident #38 for antibiotic stewardship and infection monitoring. D. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 7/1/24 at 1:05 p.m. LPN #1 said when any resident returned from outside appointments, the facility nurse should review the clinical documentation from the outside provider, which included a review and reconciliation of medication. She said when the nurse completed her review, it was the nurse's responsibility to contact the physician to discuss new or changed treatment orders. The DON was interviewed on 7/2/24 at 8:50 a.m. The DON said when residents returned to the facility from outside appointments, the nurse should review the clinical documentation from the outside provider. The DON said when changes to care were identified, the nurse should contact the physician for clarification and new facility orders if indicated. The DON said she was unable to locate documentation in Resident #38's EMR to indicate the nurse, the interdisciplinary team or the facility physician had completed a review of the ID physician's treatment plan. The DON said the facility had an antibiotic stewardship program. She said the antibiotic stewardship program was responsible for reviewing all antibiotic orders to ensure antibiotics were used effectively. The DON said she was unable to locate documentation to indicate the facility reviewed Resident 38's prescribed antibiotic medication. The DON said she would contact the ID physician and ensure Resident #38 received the prescribed dose of Cephalexin going forward. Based on interviews and record review, the facility failed to ensure residents were free from significant medication errors for two (#4 and #38) of seven residents reviewed for medication errors out of 32 sample residents. Resident #4, who had diagnoses of schizoaffective disorder (mental health condition that causes people to experience symptoms of schizophrenia and mood disorders) and bipolar, had a physician'sorder for clozapine (an antipsychotic medication). The medication required a complete blood count (CBC) laboratory result to be sent on a monthly basis to the pharmacy in order for the pharmacy to refill the medication. On 6/11/24, Resident #4 was administered her last available dose of clozapine, however, the results of the monthly CBC had not been obtained from the laboratory and faxed to the pharmacy in order for the pharmacy to refill the medication. Due to the facility's failure to send the CBC laboratory results to the pharmacy, Resident #4 did not receive her clozapine on 6/12/24 and 6/13/24. The facility failed to contact the resident's physician in order to inform the physician the medication was unavailable and obtain further orders. Due to the facility's failures to obtain the antipsychotic medication timely, Resident #4 missed two doses of the medication and self harmed herself on 6/13/24 by burning her left forearm with a cigarette, causing a cluster of five blisters. Additionally, the facility failed to: -Ensure Resident #38 received antibiotic medication according to the physician's orders; and, -Complete a medication review and reconciliation of medications prescribed for Resident #38. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607, retrieved on 7/15/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. II. Antipsychotic medication error A. Facility policy and procedure The Adverse Consequences and Medication Errors policy, revised April 2014, was provided by the nursing home administrator (NHA) on 7/1/24 at 9:46 a.m. It read in pertinent part, A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of professionals providing services. Examples of medication errors include the omission of drugs (medication not administered). The Medication Shortages/Unavailable Medication policy, revised 1/1/22, was provided by the director of nursing (DON) on 7/1/24 at 10:25 a.m. It read in pertinent part, This policy set forth procedures relating to medication shortages and unavailable medications. Upon discovery that the facility has an inadequate supply of medication to administer to a resident, facility staff should immediately initiate action to obtain the medication from the pharmacy. If a medication is unavailable during normal pharmacy hours, the facility nurse should call the pharmacy to determine the status of the order. If the next available delivery causes a delay or a missed dose in the resident'smedication schedule, the facility nurse should obtain the medication from the emergency medication supply kit to administer the dose. If the medication is not available in the facility'semergency supply kit, the licensed facility nurse should call the pharmacy emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. If emergency delivery is unavailable, the facility nurse should contact the attending physician to obtain orders and directions. If the facility nurse is unable to obtain a response from the attending physician in a timely manner, the facility nurse should notify the nursing supervisor and contact the facility's medical director for orders and directions, making sure to explain the circumstances of the medication shortage. When the missed dose is unavoidable, the facility nurse should document the missed dose and the explanation for such missed dose on the MAR and TAR and in the nursing progress notes. The documentation should include a description of the circumstances of the medication shortage, a description of the pharmacy response upon notification, and actions taken. B. Resident #4 1. Resident status Resident #4, age less than 65, was admitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar, chronic obstructive pulmonary disease (COPD), depression and muscle weakness. The 5/16/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. The assessment revealed the resident was on routine antipsychotic medications and it had been documented by a physician that a gradual dose reduction (GDR) was contraindicated. 2. Resident interview Resident #4 was interviewed on 6/26/24 at 10:33 a.m. Resident #4 said the facility told her they ran out of her clozapine. She said she became anxious and was feeling distressed about not receiving her routine clozapine medication for two consecutive days. Resident #4 said on 6/13/24, due to the anxiety she was feeling about not receiving the medication, she used a cigarette to burn her left forearm which caused five blisters on her arm that required medical attention 3. Record review A review of Resident #4's behavior care plan revealed the resident was on an antipsychotic medication for schizoaffective disorder related to unprovoked verbal aggressive behavior. Interventions included monitoring behavior episodes and attempting to determine the underlying cause. -The care plan did not include an intervention for ensuring CBC laboratory results were faxed to the pharmacy in order to obtain refills of the medication. Review of Resident #4's June 2024 CPO, revealed the following physician's orders: Clozapine oral tablet 100 milligrams (mg). Give three tablets by mouth at bedtime related to schizoaffective and bipolar disorder, ordered 6/15/23. Monthly CBC for clozapine monitoring every day shift every month for clozapine use. Fax results to pharmacy for refill on medication clozapine, ordered 8/28/23. Review of Resident #4's June 2024 medication administration record (MAR) revealed the resident received her last dose of clozapine on 6/11/24. -Further review of the June 2024 MAR revealed the resident's clozapine was not administered on 6/12/24 and 6/13/24. -A review of the resident's progress notes on 6/12/24 revealed no documentation to indicate why Resident #4 did not receive her clozapine. On 6/13/24 at 11:39 p.m. registered nurse (RN) #2 documented the medication was unavailable. RN #2 documented the pharmacy required an updated CBC laboratory result in order to refill the medication. -The facility failed to send Resident #4's CBC laboratory results to the pharmacy prior to the resident's last dose of the medication on 6/11/24 in order to receive the next refill of the medication in a timely manner (see progress note above and interviews below). A 6/14/24 progress note documented Resident #4 reported to an occupational therapist that, due to feelings of distress and not receiving her medication, she self harmed by burning herself with a cigarette on the evening of 6/13/24. A wound care progress note dated 6/24/24 revealed Resident #4's blisters on her left forearm had developed into wounds and had received a status of not healed. The initial wound encounter measurements were 3.2 centimeters (cm) length by 3.7 cm width. An education for medication unavailability and shortages, dated 6/18/24, was provided by the NHA on 7/2/24 at 12:13 p.m. It read in pertinent part, Education completed with the primary nurse (RN #4) regarding how to access needed laboratory information for follow up, notifying the provider and the need to document steps taken to resolve issues as they arise. Licensed practical nurse supervisor educated on the need to follow up on information reported from floor staff. All nursing administration was educated regarding the above. C. Staff interviews RN #4 was interviewed on 7/2/24 at 11:02 a.m. RN #4 said she discovered, during medication administration on her shift on 6/12/24, that Resident #4 did not have clozapine available for administration. RN #4 said she contacted the pharmacy and was told the medication would be delivered with the next delivery. RN #4 said she did not administer the medication on her shift because the clozapine was unavailable and therefore Resident #4 missed a dose of the medication on 6/12/24. RN #4 said she passed the information on to the next shift's nurse but did not inform the charge nurse or the nurse manager about the missed dose due to the unavailability of Resident #4's clozapine. RN #4 said she failed to document her actions in the nurse progress notes. RN #4 said missing the doses of clozapine could have caused Resident #4 to inflict the injuries to her forearm with a cigarette on 6/13/24. RN # 4 said she had been educated by the director of nursing (DON) on the proper procedures to follow when medications were unavailable. RN #2 was interviewed on 7/2/24 at 11:40 a.m. RN #2 said she contacted the pharmacy on 6/13/24 during her nighttime medication administration when she discovered Resident #4's clozapine was not available. RN #2 said the pharmacy requested an updated CBC laboratory result before the medication could be refilled. RN #2 said she faxed the most current CBC laboratory test result to the pharmacy, however, she said she still did not receive the clozapine. RN #2 said she contacted the pharmacy again and was informed that the clozapine was not filled because the CBC laboratory test result was not current and, as a result, Resident #4 missed a second dose of the medication on 6/13/24. RN #2 said she informed the oncoming nurse about the unavailable medication, however, she said she did not notify the attending physician to obtain further orders and/or directions. RN #2 said she was unable to obtain the updated CBC laboratory test result for the pharmacy because the laboratory's website did not communicate with the facility's electronic medical record system RN #2 said Resident #4 received clozapine for her diagnosis of schizoaffective and bipolar disorder and missing two consecutive days of her medication could result in extreme behaviors, such as self-harm. RN #2 said she did not recall why she did not inform the nursing supervisor and the attending physician about the missed doses of the medication. RN #2 said she had received education on the proper procedures to follow when there were instances of medication shortage/unavailability and to document her actions per the facility's protocol. The DON was interviewed on 7/2/24 at 12:10 p.m. The DON said the staff should have followed the facility's protocol for medication shortages and unavailability by notifying the nurse supervisor and the attending physician about the circumstances of the medication and the missed doses. The DON said she believed the lack of awareness of staff led to the significant medication error and she had completed training for all nursing staff about the facility's policy regarding medication unavailability and medication errors. -A voicemail was left for the pharmacist during the survey, however, the phone call was not returned by the survey exit on 7/2/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, record review and interviews, the facility failed to ensure one (#46) of three residents reviewed for pressure ulcers out of 27 total sample residents, received care consistent with professional standards of practice to prevent pressure injuries. Resident #46 was at high risk for developing pressure injuries due to being admitted to the facility with diagnoses of malaise (debility/lack of health), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left dominant side, and unspecified protein-calorie malnutrition. Resident #46 was admitted to the facility on [DATE] and was admitted with intact skin to both heels. The facility developed a care plan for the resident which did not include initial interventions for protecting the resident's heels from pressure injury development. On 6/29/21, the resident developed a deep tissue injury (DTI) to his left heel that was a stage 3 pressure wound following surgical debridement (removal of dead tissue) of the wound by the wound physician on 9/1/21. The facility failed to develop, document, and implement appropriate interventions for Resident #46 to prevent the resident from developing an avoidable left heel pressure injury. Findings include: I. Professional reference According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from http://www.npuap.org (10/18/21): 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). According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (10/18/21), Repositioning to prevent and treat heel pressure ulcers: The reduction of pressure and shear at the heel is an important point of interest in clinical practice. The posterior prominence of the heel sustains intense pressure, even when a pressure redistribution surface is used. Because the heel is covered with a small volume of subcutaneous tissue, mechanical loads are transmitted directly angular to the bone. Given the small surface area of the heel, it is challenging to try to redistribute load from the heel through the use of pressure redistributing devices. Inspect the skin of the heels regularly. Ensure that the heels are free of the surface of the bed. Ideally, heels should be free of all pressure - a state sometimes called floating heels ' . Pressure can be relieved by elevating the lower leg and calf from the mattress by placing a pillow under the lower legs, or by using a heel suspension device that floats the heel. Consequently, the pressure will instead spread to the lower legs, and the heels will no longer be subjected to pressure. II. Facility policy and procedure The Pressure Injury policy, last revised 12/18/18, was provided by the nursing home administrator (NHA) on 10/12/21 at 3:08 p.m. It read in pertinent part, Purpose: To ensure that a resident who is admitted to the facility without a pressure injury does not develop a pressure injury unless clinically unavoidable and that a resident who has an injury receives appropriate care and services to promote healing and to prevent additional injuries. Reduce pressure over bony prominences by offloading and positioning. Develop turning and repositioning plans for residents in bed or chair. Provide special attention to suspending (offloading) heels. Evaluate the need for a pressure-reducing mattress or overlay. III. Air mattress product guide The product owner's manual for the alternating pressure mattress, obtained on 10/14/21 from https://www.smpcares.com/wp-content/uploads/2017/05/P10331-APM2-SS-OM-with-5900-Control.pdf, read in pertinent part, Indications for use: The alternating pressure (APM) models are powered, flotation therapy mattresses providing a pressure management surface for the prevention and treatment of pressure ulcers. Use in wound care: Use of APM models is only one element of care in the prevention and treatment of pressure ulcers. Frequent repositioning, proper care, routine skin assessment, wound treatment and proper nutrition are but a few of the elements required in the prevention and treatment of pressure ulcers. As there are many factors that may influence the development of a pressure ulcer for each individual, the ultimate responsibility in the prevention and treatment of pressure ulcers is with the health care professional. IV. Resident status Resident #46, age younger than 70, was admitted on [DATE]. According to the October 2021 computerized physician orders (CPO), diagnoses included other malaise, hemiplegia, and hemiparesis, following cerebral infarction affecting left dominant side, unspecified protein-calorie malnutrition, and uncomplicated alcohol and psychoactive substance abuse. The 9/14/21 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of nine out of 15. He required two-person limited assistance for bed mobility, dressing, toilet use, and personal hygiene. He required two-person extensive assistance for transfers. He was at risk for developing pressure ulcers/injuries and had a Stage 3 pressure ulcer which was not present upon admission. The resident was on hospice. V. Wound observation On 10/11/21 at 1:33 p.m., Resident #46's left heel Stage 3 pressure ulcer was observed during the wound dressing change performed by licensed practical nurse (LPN) #2. Certified nurse aide (CNA) #1 was also present during the dressing change to assist LPN #2 with positioning the resident's leg so LPN #2 could change the dressing. Resident #46 had an alternating pressure mattress to his bed. Resident #46 was sitting up in his wheelchair in his room. He was wearing foam heel protectors on both feet. LPN #2 removed the foam heel protector and sock from the resident's left foot. LPN #2 removed the previous dressing from the resident's left heel. There was minimal drainage observed on the old dressing. The wound was observed to be a penny-sized open area to the back of the resident's left heel. The open area of the wound presented with red granulation (healthy) tissue over the entire surface. There was no eschar (dead) tissue observed inside the wound. The skin surrounding the wound was intact with some small areas of dry, flaky skin. LPN #2 cleaned the wound with normal saline. She then removed her gloves, washed her hands, and re-gloved prior to applying a clean dressing to the wound. She reapplied the resident's sock and foam heel protector to his left foot. LPN #2 then cleaned up her wound supplies, washed her hands and exited the resident's room. Resident #46 tolerated the wound dressing change well and said that the wound only hurt when he bumped it. VI. Record review The 5/4/21 Braden Scale assessment (a guide utilized for assistance with predicting pressure ulcer risk) documented Resident #46 was at high risk for developing pressure ulcers based on a score of 11 out of 23 (a lower score indicates higher risk of developing pressure ulcers). The assessment documented the resident had slightly limited sensory perception, was bedfast, had very limited mobility, his food intake was probably inadequate, and his potential for friction (the force of rubbing two surfaces against one another) and shear (gravity force pushing down on the resident's body with resistance between the resident and the chair or bed) was a problem. Review of the Skilled Nursing Documentation assessment completed upon Resident #46's admission to the facility on 5/4/21 revealed the resident was admitted with a perineal area that was reddened and irritated from constant bowel movements. There were no other skin concerns and no wounds documented on the assessment. Review of the Weekly Nursing Documentation (weekly skin) assessments from 5/11 through 6/22/21 revealed the only skin concerns identified for Resident #46 were redness from his scrotum to the top of his coccyx and swelling in his right knee. There were no concerns documented regarding the resident's heels. The Weekly Nursing Documentation (weekly skin) assessment dated [DATE] documented Resident #46 had redness from his scrotum to the top of his coccyx, swelling in his right knee, and a right heel DTI. -The assessment documented incorrectly that the DTI was on the resident's right heel, however the DTI was actually on Resident #46's left heel. Review of Resident #46's comprehensive care plan, initiated 5/7/21 and last revised 9/29/21, revealed the resident was at risk and/or had the presence of skin breakdown related to incontinence and decreased mobility. He had erythema (redness) to his scrotum and coccyx, and an improving stage 3 left heel wound. Further review of Resident #46's at risk for skin breakdown care plan revealed the initial interventions put into place on 5/7/21 to prevent further skin breakdown included applying barrier cream to the resident's buttocks, coccyx, perineal area, and groin, encouraging and assisting the resident with positioning, monitoring/documenting/reporting as needed any changes in skin status, providing incontinence care as needed, and weekly skin checks performed by a licensed nurse. -Despite the resident's admitting diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the left dominant side, the initial care plan did not include interventions for offloading the resident's heels or for an alternating pressure mattress. The following pertinent interventions were added to Resident #46's skin breakdown care plan after the discovery of the left heel DTI on 6/29/21: administering supplements as ordered, administering treatments as ordered and monitoring for effectiveness, assessing/recording/monitoring wound healing weekly, measuring length, width and depth where possible, assessing and documenting the status of the wound perimeter, wound bed and healing progress, reporting improvements and declines to the medical doctor, resident is anxious at times and repeatedly removes his Prevalon boots, continuing to encourage the resident to wear boots related to the wound, and the use of a pressure relieving air mattress. -The foam heel protectors which Resident #46 was observed wearing multiple times during the survey were not included in the interventions on the care plan. -Despite the care plan indicating the resident repeatedly removed his Prevalon boots (which are different from the foam heel protectors the resident was observed wearing), review of progress notes revealed only one note dated 7/14/21 regarding the resident's refusal to wear the Prevalon boots. The note read in pertinent part, Refuses to keep boots on for a prolonged period. reapplying boots as needed (PRN), but the patient takes them off within the hour. Multiple attempts at education and application of boots. A skin/wound note documented on 6/29/21 read in pertinent part, Right heel wound, unopened. Discolored and hardened in areas.Wound measuring 1.5 inches by 2 inches in diameter. Director of nursing (DON), hospice and wound doctor (WD) were notified. -The 6/29/21 skin/wound note incorrectly documented the pressure wound was on Resident #46's right heel, however, the wound was on the resident's left heel. A Risk Management Review note dated 6/30/21 documented the following: Type of incident: New pressure injury Root Cause: friction from moving heels on mattress Treatment required : Betadine Interventions put into place: Prevalon boot applied Referrals made: Wound physician to see Medical doctor notified/response: Medical doctor will be in to look at tomorrow Resident/Responsible Party communication: Hospice Notified. Review of the wound doctor (WD) progress notes revealed the following wound notes, in pertinent part: 7/1/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable (discoloration of the skin that does not turn white when pressed) deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Initial wound encounter measurements are 6 centimeters (cm) in length by 4 cm in width with no measurable depth. Wound bed has 100% epithelialization (the process of covering denuded (loss of the outer layer of skin caused by prolonged moisture and/or friction) epithelium, which is the layers of cells that make up the outer surface of the body). Cleanse the wound with normal saline and apply betadine to the area two times per day (BID) and as needed (PRN). 7/8/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. ISubsequent wound encounter measurements are 3.5 cm in length by 4 cm in width with no measurable depth. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with normal saline and apply betadine to the area BID. 7/14/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.5 cm in length by 4 cm in width with no measurable depth. Wound bed has 100% eschar (dead tissue). There is no change noted in the wound progression. Cleanse the wound with normal saline and apply betadine to the area BID. 7/22/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 3.5 cm in length by 3.5 cm in width with no measurable depth. Wound bed has 100% eschar. The wound is improving. Cleanse the wound with normal saline and apply betadine to the area BID. 7/29/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.5 cm in length by 1.8 cm in width with no measurable depth. Wound bed has 100% eschar. The wound is improving. A skin/subcutaneous (layer between the skin and muscle) level surgical debridement was performed. Subcutaneous tissue was removed along with devitalized tissue: necrotic/eschar. Post debridement measurements: 1.5 cm length by 1.8 cm width by 0.1cm depth. Cleanse the wound with normal saline and apply betadine to the area BID. 8/4/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 1 cm width with no measurable depth. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with normal saline and apply betadine to the area BID. 8/11/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 1 cm width with no measurable depth. Wound bed has 100% epithelialization. There is no change noted in the wound progression. Cleanse the wound with normal saline and apply betadine to the area BID. 8/18/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.2 cm length by 0.8 cm width with no measurable depth. Wound bed has 100% eschar. There is no change noted in the wound progression. Cleanse the wound with normal saline and apply betadine to the area BID. Leave open to air. 8/25/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1 cm length by 0.7 cm width with no measurable depth. Wound bed has 100% eschar. The wound is improving. Cleanse the wound with normal saline and apply betadine to the area BID. 9/1/21: Wound #1 left heel is a deep tissue pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm length by 0.7 cm width with no measurable depth. There is a moderate amount of drainage noted. Wound bed has 100% eschar. The wound is deteriorating. A skin/subcutaneous level surgical debridement was performed. Subcutaneous tissue was removed along with devitalized tissue: necrotic/eschar. Post debridement measurements: 0.7 cm length by 0.7 cm width by 0.1cm depth. Cleanse the wound with wound cleanser. Apply Alginate with silver and cover with foam dressing. Change dressing every other day. 9/8/21: (Wound documented now as a stage 3 wound) Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 0.7 cm length by 0.5 cm width with no measurable depth. There is a small amount of drainage noted. Wound bed has 100% epithelialization. The wound is improving. Cleanse the wound with wound cleanser and apply betadine to the area BID. Leave open to air. 9/15/22: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.2 cm depth. There is a moderate amount of drainage noted. Wound bed has 100% granulation (healthy tissue). The wound is deteriorating. Cleanse the wound with wound cleanser. Apply Alginate and cover with foam dressing. Change dressing every other day. 9/22/21: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.1 cm depth. There is a small amount of drainage noted. Wound bed has 100% granulation (healthy tissue). There is no change noted in the wound progression. Cleanse the wound with wound cleanser and apply betadine to the area BID. 9/29/21: Wound #1 left heel is a stage 3 pressure ulcer pressure injury. Persistent non-blanchable deep red, maroon or purple discoloration pressure ulcer and has received a status of not healed. Subsequent wound encounter measurements are 1.0 cm length by 0.5 cm width by 0.1 cm depth. There is a moderate amount of drainage noted. Wound bed has 100% granulation (healthy tissue). There is no change noted in the wound progression. Apply Alginate and cover with foam dressing. Change dressing daily. Review of the October 2021 CPO revealed Resident #46 had a physician's order to cleanse the left heel with wound cleanser, apply Alginate to the wound bed and cover with a foam dressing daily. The start date of the order was 9/29/21. VII. Interviews LPN #2 was interviewed on 10/11/21 at 1:53 p.m. She said Resident #46 acquired his left heel wound at the facility. She said he was seen weekly by the WD. She said his wound had gotten a lot better. LPN #2 said Resident #46 was not compliant with the Prevalon boots. However, she said he would wear the foam heel protectors without taking them off. The DON and quality improvement specialist (QIS) #2 were interviewed together on 10/12/21 at 10:53 a.m. The DON said Resident #46's left heel wound was discovered on 6/29/21. She said the WD assessed the wound on 7/1/21 and said it was a DTI. She said the WD debrided the wound on 9/1/21 and classified it as a stage 3 pressure injury after the debridement. The DON confirmed that Resident #46's care plan documented that the alternating pressure mattress was initiated as an intervention on 7/1/21. However, she thought he had been utilizing the mattress since his admission to the facility. She said they did not float heels because that could frequently lead to pressure injuries on the back of the calf where the floating device was in place. The DON agreed the care plan did not document any other interventions in place to prevent heel pressure injuries prior to Resident #46 developing his left heel wound. She said he was participating in a restorative program three to six times per week effective 5/11/21. She said the program was put in place to assist him with bed mobility, which also would have improved his blood circulation to his heels. QIS #2 said Resident #46 was significantly debilitated when he was first admitted to the facility. She said he was non-compliant with wearing Prevalon boots. QIS #2 said the resident would wear the foam heel protectors. She confirmed that the foam heel protectors were not documented as an intervention in the care plan. QIS #2 said she thought the WD said Resident #46's left heel wound was unavoidable, but she did not think that was documented. -There was no documentation to indicate the resident refused to wear the Prevalon boots except for the progress note dated 7/14/21 (see above). QIS #2 said the alternating pressure mattresses the facility used were set based on height and weight of the resident. She said they were also set up to allow for the comfort of the residents. She said the nurses were to monitor the mattresses to ensure they were functioning properly and were inflated effectively. QIS #2 said restorative nurse aide (RNA) #1 was in charge of setting up the alternating pressure mattresses for residents. She said RNA #1 remembered setting up an alternating pressure mattress for Resident #46 upon his admission to the facility. The WD was interviewed on 10/12/21 at 11:59 a.m. The WD said when he first assessed Resident #46's left heel wound it was a DTI with necrotic tissue covering the wound. He said he debrided the necrotic tissue after the necrotic tissue began to slough (non-viable fibrous yellow tissue damaged tissue in the wound) because slough contributes to delayed wound healing. The WD said the wound was determined to be a stage 3 pressure injury after the debridement. The WD said he had not deemed the wound to have been an unavoidable wound. He said when residents are determined to be a high risk for pressure injuries, prevention of wound development should be top priority. He said if a resident was considered a high risk for pressure injury development, Prevalon boots would be the best intervention. The WD said if a resident was non-compliant with the Prevalon boots, foam heel protectors should be put in place to protect the heels and prevent the potential development of heel pressure injuries. Restorative nurse aide (RNA) #1 was interviewed on 10/12/21 at 1:04 p.m. RNA #1 said she had been trained how to set up the alternating pressure mattresses by the vendor who supplied the mattresses for the facility. She said she remembered setting up a mattress for Resident #46 when he was admitted he was very thin and weak. RNA #1 said she did not document or keep a list of which residents had alternating pressure mattresses. She said she just knew who had them. The facility's wound nurse was out of the country during the survey, and was unable to be interviewed regarding Resident #46's wound.