**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide one (Resident #54) of one resident receiving outside wound care, with physician ordered antibiotics for seven days after wound debridement and bone biopsy for a toe infection, resulting in a hospitalization for cellulitis directly from the wound care physician's office. Findings included: During an interview, on 10/14/19, at 10:15 a.m. with staff member J, LPN, she confirmed Resident #54 received wound care outside the facility and was sent to the hospital during the appointment on 10/10/19. During an interview with staff member G, LPN, unit manager, on 10/14/19 at 10:20 a.m., the unit manager confirmed Resident #54 was sent to the hospital during his appointment. They had not heard any updates. The chart was filed in medical records. During an interview on 10/15/19 at 2:34 p.m. with staff member C, RN, she stated she worked with Resident #54 on 10/10/19 before his wound care appointment and stated she did not change his dressing that day due to his appointment. During an interview. on 10/15/19 at 3:45 p.m with the Director of Nursing (DON), she stated the resident went to wound care for a debridement on 10/3/19 and had a follow up on 10/10/19. The DON asked staff member G, unit manager, to join the interview, and he confirmed Resident #54 went to wound care on 10/10/19 after debridement on 10/3/19 and stated they may be amputating the right second toe. Review of the wound care physician notes, dated 10/3/19, reflected: wound #32 right toe second treated with topical lidocaine 4% to wound bed prior to debridement. Change dressing every other day. Primary dressing - apply adaptic or adaptic touch over sutures. Secondary dressing wound #32 Right toe second gauze - fold 4x4 in half lengthwise and cover toe from base to to toe over the top of toe. (Do how was done at wound care center when dressing changes is done). Edema control, wound #32 right toe second, Tubigrip Fx1, taped over toe area to form sock. If questions call wound care center. Bacteria identified in wound by culture - bone culture right second toe. Bone biopsy right second toe Medications clindamycin HCI 300 mg capsule - one capsule four times a day for ten days. Review of the transcribed physician order, dated 10/4/19, for wound #32 right 2nd toe reflected to discontinue current treatment. Start cleanse right 2nd toe with normal saline, pat dry and apply adaptic to suture line wrap with kerlix, secure with tubigrip and change every other day and as needed for surgical wound. Review of the transcribed physician order, dated 10/4/19, reflected monitor suture to right second toe during wound care treatment for signs and symptoms of infection for surgical wound. There was no evidence of the physician's order for clindamycin HCL 300 mg. being transcribed on the medication administration record. During an interview, on 10/15/19 at 4:34 p.m., with staff member G, LPN unit manger, confirmed he spoke to the nurse that documented the nursing progress note dated 10/6/19, and stated he told the nurse he did not agree that the resident had a change in condition after debridement and stated the resident's toe would have been swollen and warm after the debridement. The 10/6/19 nursing note reflected dressing change per order, second toe, slightly discolored, warmer than adjacent tissue/toes, color purplish, positive sensation, pre medicated prior to treatment. Resident has 4 intact sutures, toe nail intact, flap like separation, sutures in place, no drainage during dressing change but previous dressing serosanginous. New dressing applied, feet up, off heal. Tramadol effective, will continue to observe, toe does appear swollen. Vital signs stable and signed by Registered Nurse. Staff member G, LPN unit manager confirmed the nurses progress note, dated 10/4/19, reflected the toe without signs or symptoms of infection noted. Staff member G, LPN unit manager, reviewed the wound care note dated 10/3/19 which reflected Resident #54 with a bone culture and bone biopsy to the right second toe, positive for bacteria with clindamycin HCI 300 mg, one capsule four times a day for ten days. After reviewing the Medication administration sheets, staff member G, LPN unit manager, confirmed that the antibiotic should have been ordered and started on 10/3/19 and confirmed Resident #54 did not receive the antibiotics from 10/3/19 to 10/10/19 and confirmed the physician was not notified of the 10/6/19 documented changes. During an interview, on 10/15/19 at 4:52 p.m., with staff member K, LPN unit manager, stated, when a resident goes out to an appointment, the nurse would update the information and go over the information with the unit manager to confirm the information was changed and up to date. During a phone interview, on 10/16/19 at 09:53 a.m., with the wound care center, the nurse case manager stated, on 10/3/19 the resident came in for a bone biopsy and culture which showed multi organism growth and she called the facility on 10/9/19 to alert the staff. She confirmed she was transferred twice and did not know who she ended up speaking with, but it was a nurse that knew Resident #54 and she alerted the female nurse the resident was positive for MRSA and two strains of proteus. The nurse confirmed the clindamycin should have been started on 10/3/19, at latest 10/4/19, and she was not informed, as of 10/16/19, that the facility never ordered the medication. The nurse stated a concern she observed was the dressing would be changed the day of the appointment or the day before, which was not always correct, due to the dressing change ordered. The nurse described the right second toe as: blown up, angry, red and significantly inflamed. The nurse confirmed the goal was to order IV medication on 10/10/19 when the resident came to the wound appointment but, due to the changes observed, the resident was sent to the emergency room and had been in the hospital six days currently receiving IV medication for cellulitis. During an interview, on 10/16/19 at 12:45 p.m., with the Advanced Registered Nurse Practitioner (ARNP), he stated that he was not made aware of any changes with Resident #54 and confirmed the facility should have either sent a physician order to the appointment for them to fill out, or followed through on the wound care order for the antibiotic. The ARNP stated the unit managers get so busy with reports and meetings that they don't have time to assure the charts are correct. The ARNP stated he was not contacted about the wound or changes, and confirmed he reviews the entire record every month but does not go page to page. The ARNP stated he wanted to make sure the residents receive continuity of care, but does not dig through the notes with each visit. The ARNP stated the resident required total assistance and has been observed with urine soaked dressings on his legs in the past. The ARNP stated the resident relies on the staff to change his briefs and has discussed amputation in the past with the resident, but he refused and has been treated for wounds for the last two years, so the wound center has been aggressively treating the resident. During an interview, on 10/16/19 at 11:54 a.m., with the DON, she stated that she was made aware of the medication error for Resident #54 on 10/15/19 in the afternoon, after the unit manager was reviewing the record with the surveyor. The DON stated that inservices and trainings were started last night and a medication error investigation was started with the nurse that documented on 10/6/19. However, that nurse is out of state and unavailable. The DON stated that they did not contact the wound center to let them know that the resident did not receive his antibiotic for seven days. The DON confirmed that when a resident goes out to a wound center and comes back the unit manager, nurse manager and nurse on duty should look at the new information and call the facility physician to get an order from the consult doctor, and should have called the wound care center when the change in condition was noticed for the resident. The DON confirmed that the facility physician was notified last night, 10/15/19. The DON stated if the wound care center called the facility, the nurse or person at the desk should have documented the new information in the resident record. The DON stated the nurse that signed off on the TAR (Treatment Administration Record) was new. During an interview, on 10/16/19 at 3:10 p.m., with the DON and Staff member C, RN, confirmed staff member C was the nurse on duty that day. Staff member C, RN, stated the initials were hers and confirmed the initials did not look the same as her initials on other days. Staff member C, RN, confirmed she changed the dressing on 10/10/19 before sending the resident to wound care, but did not document on the wound and could not remember what the wound looked like. The DON stated that his toe looked the same from the debridement on 10/3/19 and confirmed the chart did not reflect any documentation from 10/3/19 after the wound care appointment, and wound progress notes were missing from 10/8/19 and 10/10/19. Staff member C, RN, confirmed she documented on the wounds before, but did not document on the 8th or 10th. The DON stated, we chart by exception and we completed 24 hour chart checks. The chart record did not have a 24 hour chart check sheet. Review of the nursing progress notes dated 10/7/19 from staff member G, LPN unit manager, reflected the resident had a wound care follow up appointment on 10/3/19 at the wound care center. There was a excisional skin/subcutaneous tissue/muscle/bone debridement with a total of 1.1 sq cm performed to the right 2nd toe per the wound care center, pain was managed and controlled using lidocaine 2% injectable. Patient tolerated 4 intact sutures. Return to facility treatment wash with normal saline adaptic to suture line changed every other day. No signs or symptoms or complaints of pain. Facility physician and contact updated on current wound progression and changes. Review of the hospital medical record, dated 10/17/19, reflected Resident #54 currently receiving pipercillin-tazobactam/D5W 3.375 gm 50 ml IV piggyback every 6 hour every intervals and Vancomycin plus dextrose 5% in water 500 ml 1.75 gm 35 ml IV piggyback every 36 hours for cellulitis. Review of the wound care center progress notes, dated 9/26/19, reflected Resident #54 with follow up to wound #32 right toe second, debrided, change dressing every other day. Dress wound with calcium alginate with silver- cut to fit the size of wound bed, non boarder foam, medfix tape, use foam to cover wound and tip of toe. tubigrip F x 1, taped over toe to form sock. If questions call wound care center. Additional orders, patient to be toileted and changed every two hours to prevent urine into wound dressing and contaminating. Please document. Review of the wound care center progress notes, dated 9/12/19, did not reflect a wound #32 right toe second. Review of the medication administration form reflected Resident #54 not documented on 10/4/19 or 10/10/19 as receiving tramadol HCL 50 mg one tablet by mouth 30 minutes prior to dressing change daily as needed for pain. Review of the treatment administration form for Resident #54 documented on 10/4/19, 10/6/19, 10/8/19, 10/10/19 and 10/12/19 as receiving a dressing change. Further review of the treatment administration form found, monitor sutures to right 2nd toe during wound care treatment for signs and symptoms of infection for surgical wound, dated 10/4/19. The 10/4/19 to 10/10/19 dates were blank. Review of the physician order, dated 10/10/19, reflected the resident direct admit to the emergency room at 3:00 p.m. Review of the wound care progress note. dated 10/10/19 at 2:00 p.m reflected Resident #54 was sent to the emergency room. Review of the care plan reflected resident with vascular ulcer of the right second toe related venous insufficiency, dated 9/27/19, with a goal to have no signs or symptoms of infection through the review date. Interventions include wound care center to treat, monitor, document, report as needed for signs and symptoms of infection including redness and swelling, red lines coming from the wound. Supplements as ordered to promote wound healing. Treatment as ordered. Review of Resident #54's record reflected the resident with recent re-admission on [DATE] with a diagnoses of acquired absence of right great toe, atherosclerosis of native arteries of right leg with ulceration of other part of right lower leg, diabetes type 2. Review of facility policy for physician orders revised on 1/16/19, 2 pages reflected: 5. Specific procedures for medication orders: c. Written transfer orders: Orders are reconciliated and transcribed on the physician order sheet. Physician orders should be signed per state specific guidelines. Review of facility policy for Documentation in Medical Record, revised on 3/6/19, 1 page, reflected: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. The facility will document at minimum daily for all skilled residents and monthly for long term residents not limited to episodic events. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. Review of the policy for Notification of Changes, revised on 3/26/19, 2 pages, reflected: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician, and notify, consistent with his or her authority, resident's representative when there is a change requiring notification.