**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to have nursing staff with the appropriate competencies to provide nursing services to maintain the highest practicable physical well-being of each resident. For 1 of 5 sampled residents reviewed for Medication Administration the facility failed to identify a resident prior to medication administration (Resident #181); and 1 of 3 residents reviewed for pressure ulcers the facility failed to addresss the risk of skin breakdown for a resident whose device placed them at high risk for skin breakdown (ID #282). The findings included: 1. Resident #181's diagnoses included multiple sclerosis and muscle spasm. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #181 was cognitively intact and required extensive assistance with personal hygiene, toilet use, and dressing. The Resident Care Plan dated 7/13/23 identified resident has spasms related to multiple sclerosis. Interventions included continuing Baclofen as ordered for muscle spasms. Review of current physician's orders dated 10/1/23 through 10/19/23 directed to administer one 20 mg tablet of Baclofen, one 750mg Tums tablet, and one 400mg tablet of Magnesium Oxide by mouth during the 9:00 PM med pass. Interview with Resident #181 on 10/17/23 at 11:35 AM identified an agency nurse, LPN #4, came into his/her room one of the previous Sundays to administer crushed medications around 8:00 PM. Resident #181 informed the nurse he/she did not take crushed medications and asked what they were. Resident #181 was informed one of the crushed medications was Seroquel, advised the nurse he/she did not take Seroquel, and did not take the crushed medications. Resident #181 indicated he/she reported the incident to RN#7 and showed the surveyor his/her identification bracelet that was kept in his/her wheelchair bag. Interview with RN# 7 on 10/18/23 at 11:10 AM identified the incident regarding Resident #181 receiving the wrong medications occurred on Sunday, 10/8/23, during the evening shift. RN#7 was informed of the incident on 10/10/23 by Resident #181, was told LPN #4, an agency nurse, attempted to administer him/her crushed medications and that Resident #181 informed LPN #4 he/she didn't take crushed medications. Furthermore, Resident #181 indicated LPN #4 returned to the medication cart to verify the resident's medications, brought back the appropriate scheduled medications, and that Resident #181 took his/her scheduled medications. Furthermore, Resident #181 indicated LPN#4 advised, prior to administering the correct medications, that he/she would chart the resident refused her medications that evening. RN#7 reviewed the medication administration record and found no evidence of that occurring and confirmed Resident #181 did receive her correct medications that evening. RN #7 further indicated he/she reported the incident to the Director of Nursing Services (DNS). Interview with Assistant Director of Nursing (ADNS) on 10/18/23 at 11:21 AM identified she was just informed of the incident on 10/17/23 involving an agency nurse attempting to give Resident #181 crushed medications. The ADNS indicated Resident #181 had specifically identified the medications she received during the 9:00 PM medication pass and informed Resident #181 had reported to the ADNS that he/she was not wearing his/her identification bracelet that evening. Resident #181 could not recall how he/she was identified by LPN #4 prior to attempting to administer the crushed medications. Interview with the ADNS on 10/18/23 at 2:15 PM identified an orientation was provided to agency nurses who work in the facility but that the orientation did not include how to correctly administer medications. Interview with the Director of Nursing on 10/19/23 at 9:35 AM identified medication administration was not part of the facility's orientation process for agency nursing staff. Interview with Person #1 from the nurse staffing agency on 10/19/23 at 11:13 AM identified competency review wasn't provided to the agency nurses prior to placement. Interview with Person #2 from the nurse staffing agency on 10/19/23 at 11:27 AM indicated the agency only hires nurses that already have nursing home experience and that no additional training was provided to them prior to placement. Review of the Medication Administration policy dated 3/15/23 directed to identify the resident by using the picture on the electronic medication administration record, resident identification band, or ask a team member to confirm the name of the resident. The Medication Administration policy dated 3/15/23 provides the procedural guidelines to support the accurate and safe administration of medications as right drug, right resident, right dose, right time and right route. 2. Resident #228's diagnoses included fracture left patella (kneecap) with orthopedic repair, cerebral infarction, osteoporosis, hypokalemia, dementia, and anxiety. The Braden Scale for Prediction of Pressure Sore Risk dated 9/15/23 identified Resident #228 had potential problems related to friction and shearing. Further review identified the resident requires minimum assistance with movement. During a move, the skin probably slides to some extent, against sheets, chair, restraints, or other device. Maintains relatively good position in chair or bed most of the time but occasionally slides down. The resident was identified at risk for pressure ulcers and no interventions were identified. A physician's order dated 9/16/23 directed immobilizer to left lower extremity and weight bearing as tolerated, off-load heels every shift, skin assessment weekly on bath days, ted stockings from 8:00 AM to 8:00 PM and skin prep to bilateral heels twice a day for 14 days. The 5-day scheduled Minimum Data Set assessment dated [DATE] identified Resident #228 had no cognitive impairment, was at risk of developing pressure ulcers and required extensive assistance with bed mobility, transfer, locomotion, and personal hygiene. The Orthopedic office visit assessment on 9/29/23 identified Resident #228's left lower extremity incision over anterior knee was healing with staples in place. The staples were removed in the office and Steri-Strips were applied. There was no peri-incisional erythema or induration, there was no evidence of drainage, nontender to palpitation throughout, sensation was intact to light touch throughout all nerve distributions, tibial and doppler pulses were both positive with capillary refill less than 2 seconds to all toes. The resident transitioned from knee immobilizer to a hinged knee brace to be locked in full extension at all times for the next 2 weeks. In 2 weeks, the brace may be unlocked from 0-45 degree for therapy sessions only. At all other times locked strictly in full extension including sleep. The resident may shower in 2 days. Remove Steri-Strips in 1 week and the resident will be seen in the office for a clinical exam in 4 weeks. Review of the resident's clinical record from 9/29/23 to 10/3/23 failed to reflect left lower extremity skin assessment or skin protection under or near the hinged knee brace. On 10/4/23 during physical therapy treatment Physical Therapist (PTA #2) identified and documented hinged knee brace related left posterior lower leg pressure ulcer. The Physical Therapy Treatment Encounter Note dated 10/4/23 identified during adjustment of Resident #228's knee immobilizer, PTA #2 found pressure wound on posterior lower leg/heel, PTA #2 added padding underneath strap and reported findings to the nurse. In addition, distal left lower extremity also appeared more swollen and was warm to the touch which was also reported to the nurse. The nurse's notes dated 10/4/23 at 4:36 PM identified incision to knee with Steri-Strips in place, no drainage noted. Hinged brace to left lower extremity, resident to keep leg straight. Wound found to posterior left ankle underneath brace, foam dressing applied for protection. The wound nurse was notified, trace of edema noted to the left lower extremity, and the resident had no complaints of pain or discomfort. The Wound Assessment form dated 10/4/23 identified the resident with stage III pressure ulcer to left posterior lateral ankle, measuring 1.6 centimeter (cm) by 1.5 cm by 0.2 cm. Further review identified full thickness wound that extended to subcutaneous tissue without viable support structure noted. Etiology was likely a Medical Device Related Pressure Injury (MDRPI) from immobilizer, now stage III. The resident denied any pain, area was being offloaded and treatment in progress. The Physical Therapy Treatment Encounter Note dated 10/5/23 identified adjusted knee immobilizer and discussed with family talking to ortho about the brace due to it consistently loosening and getting out of place causing pressure on her/his wound. The wound care consult by Doctor of Osteopathy (DO #1) dated 10/5/23 identified the resident with stage III, medical device related pressure ulcer to left posterior lateral ankle, measuring 1.6 cm by 1.5 cm by 0.2 cm, with 30% thick adherent devitalized necrotic tissue and 70% granulation tissue. The wound was cleansed with normal saline and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, blade was used to surgically excise devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed. As a result of this procedure, the nonviable tissue in the wound bed decreased from 30 percent to 0 percent. Dressing treatment plan directed Calcium Alginate apply daily and off-load wound, reposition per facility protocol. Further review identified the resident with unstageable deep tissue injury with intact skin to left upper heel, measuring 4.2 cm by 1.1 cm and the depth was not measurable and there was no exudate. Dressing treatment plan directed to apply Betadine daily and off-load wound, reposition per facility protocol. The nurse's notes dated 10/6/23 at 9:08 AM identified the resident was seen by DO #1 on 10/5/23 during wound rounds and an additional wound was noted to the upper heel, likely MDRPI. The Resident Care Plan dated 10/6/23 (two days after stage III medical device related pressure ulcer to left posterior lateral ankle was identified and on the same date that deep tissue pressure injury to left upper heel was identified) identified Resident #228 at risk for skin breakdown related to decrease in bed mobility, needs assistance with toileting, bowel, and bladder incontinence. Interventions directed to assist with turning and repositioning every two hours and as needed, and schedule skin check, report to licensure nurse any new skin issues. The Wound Assessment form dated 10/6/23 identified the resident with deep tissue pressure injury to the left upper heel, measuring 4.2 cm by 1.1 cm by less than 0.1 cm. Further review identified that the resident was seen on wound rounds by the physician on 10/5/23 and additional wound was noted to the left upper heel, likely MDRPI from immobilizer, the skin was intact with a deep maroon appearance, now deep tissue pressure injury, treatment with Betadine daily, areas are being offloaded and the resident denied any pain. Interview and clinical record review with RN #5 on 10/18/23 at 9:44 AM identified until 9/29/23 Resident #228 had ice wrap under knee immobilizer on left lower extremity. On 9/29/23, during orthopedic office visit, the ice wrap and immobilizer were replaced with hinged knee brace with directions to keep it locked in full extension at all times for the next 2 weeks, including sleep. There were no directions to remove it for assessment, therefore the resident's skin was not assessed for integrity under or near the brace and the areas were not padded on left lower extremity until 10/4/23 when stage III pressure ulcer was discovered. Interview with DO #1 on 10/18/23 at 11:20 AM identified he carefully partially removed the hinged knee brace on 10/5/23 to assess the entire left leg, pad the brace and to apply dressing. At that time DO #1 identified a second pressure ulcer that was Deep Tissue Injury (DTI). DO #1 further identified although, there were no directions to remove the knee brace for assessment, it would be good to call the doctor and ask, there should be more communication with the doctor. With new interventions implemented both areas are improving. DO #1 stated that both pressure ulcers happened from friction and/or shear from the hinged knee brace. A person with a brace or any medical device is more likely to develop a pressure ulcer than a person without, that is why we must be extra protective of the skin. DO #1 identified those pressure ulcers could have possibly been prevented. Interview with MD #3 on 10/18/23 at 2:25 PM identified there was no visible skin injury to left lower leg under the immobilizer while the resident was in the office on 9/29/23. The resident's surgical incision was healing well. MD #3 stated there should be understanding for everyone, that for any brace in use, there should also be skin checks at least daily during the resident's rest, that is basic care, that should be standard of practice, and the brace should be opened, reapplied, and readjusted if needed. MD #3 further identified that order will be given to the facility to remove the hinged left knee brace to provide pressure ulcer care and to assess the resident's skin daily. Interview with MD #1 on 10/19/23at 9:32 AM identified the resident's brace should have been removed to assess the resident's skin under the brace at least every 48 hours, so maybe the skin injury would be identified at stage I and staff would put interventions in place to prevent developing any further. MD #1 further identified that it was expected of the facility to call the doctor for directions, therefore facility policy will be revised, and staff will be educated. Interview with DNS on 10/19/23 at 11:03 AM identified although requested, a facility policy on prevention of pressure ulcers due to brace/medical devices was not provided. The DNS further identified although the resident was at risk for developing pressure ulcers, the facility followed what the doctor wrote to keep the brace in place for two weeks at all times and failed to call the doctor to clarify those directions or to notify that the brace position needed to be adjusted at times. The DNS further identified staff could have checked the resident's skin on the left leg around the knee brace but not to remove the brace. Review of Post-op Knee brace instructions for use provided by the facility identified the healthcare professional should inform the patient about everything in this document that is required for safe use of this device. The patient should immediately contact a healthcare professional if any pain, skin irritation, or unusual reaction occurs with the use of the device. The instructions further directed a healthcare professional should adjust the device length to provide optimal knee stabilization. Upper hinge arms should extend no higher than 5 cm from groin level. Lower hinge arms should extend no lower than calf/Achilles tendon junction. According to drugs.com (Hinged Knee Brace, reviewed June 2024) those with a hinged knee brace should inspect (their) skin often. A hinged knee brace may cause the skin to become irritated, red, or dry where it rubs against the brace. The skin should be checked for sores or other problems.