**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and arrange the appropriate mode of transportation and provide adequate supervision to prevent accidents during transfer to an outside appointment for 1 of 4 residents reviewed for transportation concerns, of a total sample of 10 residents, (#2). The facility's failure to provide care and services to ensure safety during transport resulted in preventable fractures and hospitalization, actual harm, for resident #2. Findings: Review of the medical record revealed resident #2, a [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included mood disorder, anxiety disorder, obesity, type 2 diabetes, generalized muscle weakness, osteoarthritis, rheumatoid arthritis, osteoporosis, chronic pain, pressure injury on her sacrum, metabolic encephalopathy (disorder or disease that affects brain function), and functional quadriplegia (inability to move due to severe disability or frailty, without spinal cord injury). The Quarterly Minimum Data Set (MDS) assessment with assessment reference date of [DATE] revealed resident #2 had a Brief Interview for Mental Status score of 11 out of 15 which indicated she had moderately impaired cognition. The document showed the resident did not reject care in the look back period. She required extensive assistance of one staff member for bed mobility and locomotion, and was totally dependent on two or more staff members for transfers between surfaces. The MDS assessment revealed the resident had unsteady balance during transitions and was only able to stabilize with staff assistance. The document indicated resident #2 used a wheelchair for mobility. Review of resident #2's medical record revealed she had a care plan for behaviors related to refusing medication, screaming, and yelling for help despite receiving requested and necessary care. The document read, Resident requested to get [out of bed] after [morning] care. Per request resident was assisted [out of bed] in [wheelchair] approximately after 5 mins of being in [wheelchair]. Resident stated if we didn't put her back in bed she would throw herself on the floor. The interventions instructed nursing staff to anticipate and meet the resident's needs [and] provide emotional support. Review of Progress Notes revealed a Skin/Wound Note dated [DATE] regarding the declining status of the pressure injury on resident #2's sacrum. The note indicated a Magnetic Resonance Imaging (MRI) exam was ordered to rule out osteomyelitis or a bone infection as the cause of the worsening wound. A Nursing Progress Note dated [DATE] revealed the resident left the facility for her MRI appointment at 1:17 PM. A Change in Condition note dated [DATE] at 2:15 PM read, While assisting with getting patient off the transport with staff assist. Patient was noted to be unresponsive with sternum rub. The document listed vital signs obtained the day before, [DATE] at 10:22 PM, but did not include data on resident #2's blood pressure, pulse, temperature, or oxygen saturation at the time of the change of condition. The section of the form titled Resident/Patient Evaluation indicated no changes observed related to mental status, functional status, behavior, respiratory status, cardiovascular status, and skin evaluation. The Change in Condition form revealed the resident had no pain and no neurological deficits such as abnormal speech or altered level of consciousness. The inaccurate document was signed by the Long Term Unit Manager (UM). A Nursing Progress Note dated [DATE] at 2:28 AM, written by Licensed Practical Nurse (LPN) H, revealed resident #2 had been admitted to the hospital with fractures of the shoulder and hip. On [DATE] at 3:26 PM, Receptionist I recalled on Friday [DATE], she worked at the facility's reception desk. She stated resident #2 had an outside appointment that day and a Certified Nursing Assistant (CNA) brought her to the lobby via wheelchair to wait for transportation personnel. Receptionist I stated the driver arrived soon afterwards, retrieved the resident, and pushed her wheelchair up a ramp and into the van. Receptionist I confirmed no facility staff accompanied resident #2 in the van. She recalled about an hour later, the driver returned and informed her he could not transport the resident because of the way she was positioned in the wheelchair. She said,He seemed nervous and scared. Receptionist I explained she immediately notified the Long Term and Short Term UMs and the Director of Nursing (DON) who came to the lobby area to assist the driver to take the resident out of the van. Receptionist I said, She was sweating really bad and they rubbed her sternum and could not arouse her and they called for oxygen.Someone called 911 and they transported her out. On [DATE] at 4:07 PM, in a telephone interview, Transportation Scheduler L confirmed she scheduled the transportation for resident #2 to get to the MRI appointment. She explained she sometimes traveled with residents in the company van used to transport the resident, but on that day she drove another resident to an appointment in the facility's van. Transportation Scheduler L stated the arrangement was she would drop off the other resident and drive to meet resident #2 at her appointment. She recalled she was on the way meet resident #2 when she received a call from the facility and was instructed to return to the facility. Transportation Scheduler L stated resident #2 was already gone to the hospital when she got back. On [DATE] at 4:31 PM, the Short Term UM recalled on [DATE] he walked through the facility's lobby and noted the driver of the van speaking to Receptionist I. He stated the driver explained he had to bring resident #2 back to the facility as she slipped a little from the chair and his supervisor instructed him to bring her back. The Short Term UM said, He told me, we tried to pull her up and we couldn't do it. The Short Term UM stated he went into the van and noted the resident was slumped over in the wheelchair and it was hot in the van. He stated he tried a sternal rub but the resident only grunted, and he noted she had a weak pulse. The Short Term UM stated resident #2's wheelchair was held in place by multiple straps and he had to wait until the driver released them. He recalled, once inside the facility's lobby nursing staff attempted to get vital signs but were unsuccessful. He stated the resident wore a thin, long-sleeved sweater, and when they removed it, they noted large skin tears on both arms The Short Term UM explained the facility's protocol was confused residents were to be accompanied to appointments either by staff or a family member. He stated the resident's daughter approved of the arrangement for Transportation Scheduler L to meet her mother at the MRI appointment. On [DATE] at 4:48 PM and [DATE] at 4:57 PM, the Long Term UM recalled on the day of the incident, two CNAs got resident #2 ready for her appointment and transferred from the bed to the wheelchair with a full-body mechanical lift. She said,I knew she did not like to be up in the wheelchair. She pretty much stayed in bed. She stated she last saw resident #2 seated in her wheelchair in the lobby, waiting for transportation personnel to arrive. The Long Term UM said, I can't recall on that day why she did not have an escort. She recalled she next saw resident #2 that afternoon at about 2:15 PM when she was notified the driver had returned with resident #2 and needed assistance to take her off the van. She stated she joined the Short Term UM in the van but resident #2 did not respond her greeting either. The Long Term UM stated resident #2 still had the mechanical lift sling under her body in the wheelchair. She said, But it had slipped down a little. It was not the same as it had been when I saw her earlier. She explained while other staff attempted to obtain the resident's vital signs, she called 911. The Long Term UM stated a few days later the facility discovered resident #2 suffered fractures of the right shoulder and left hip. She explained prior to the incident, resident #2 was alert and oriented to person and place, and although her speech was slow, she was able to make her needs known and interacted well with staff. The Long Term UM recalled resident #2 was readmitted to the facility about one week later. She said, She came back totally different. Not talking, and staring at you like she didn't know who we were. On [DATE] at 10:27 AM, the Assistant Director of Nursing (ADON) stated she was in the lobby on [DATE] when staff removed the resident's sweater. She stated the resident had multiple, actively bleeding skin tears on both forearms. The ADON described the wounds as very noticeable. On [DATE] at 4:20 PM, in a telephone interview with resident #2's daughter, she stated her mother was recently hospitalized and died on [DATE]. She recalled prior to the MRI appointment on [DATE], her mother had not tolerated being seated in a wheelchair for almost one year. The daughter stated she was a nurse, visited her mother in the facility at least once weekly, and was very aware of her mother's abilities and behaviors. She said, She could not sit up anymore. She had become very stiff, and she had not left her room for a long time. In the wheelchair, she would throw herself back. I even told her several times she had to stop doing that because she was either going to hurt herself or somebody else. It was the mistake of all mistakes to transport her in a wheelchair. That's where they dropped the ball. The daughter stated there was always a regular wheelchair folded up in the corner in her mother's room, but she did not use it. She said, I cannot understand why, all of a sudden, they would think she could go in a wheelchair. I don't know what happened on that van trip, but I do feel like she pushed herself back in the wheelchair and slid down. In either sliding down or someone pulling her up, I can see that's how the injuries possibly happened. She had no bruises, lacerations, bumps, or wounds on her head, body, or extremities to indicate she fell out of the chair. Resident #2's daughter stated after the incident in February, she felt her mother probably willed herself to die. On [DATE] at 5:28 PM, CNA J stated in the past, she was assigned to care for resident #2 sometimes and also assisted other CNAs with bathing the resident. She recalled staff used a full body mechanical lift to transfer her and she would not tolerate sitting in a wheelchair for 15 minutes. CNA J said, She would throw herself back, whine, and complain of pain in minutes.We offered to get her up every day and she refused. CNA J stated resident #2 would not sit in the shower chair, so staff used a shower bed for bathing her. On [DATE] at 5:34 PM, CNA K stated during her last year in the facility, resident #2 remained in her bed and hardly even allowed staff to turn and reposition her. She stated the resident did not use the wheelchair in her room. On [DATE] at 5:38 PM, Registered Nurse (RN) N stated she was full time staff and regularly assigned to care for resident #2. She said, I never saw the lady up in a wheelchair. She transferred over here from the other unit about six months ago and she's been in bed ever since she's been over here. There was a regular wheelchair folded in the room. Never seen her in it. On [DATE] at 5:42 PM, LPN M verified resident #2 always refused offers to get out of bed. She stated the wheelchair in the resident's room was never used. On [DATE] at 5:43 PM, CNA O stated she was very familiar with resident #2's care needs and recalled in the six to twelve months prior to the incident in February 2023, she had not gotten out of bed except for mechanical lift transfers to the shower bed. On [DATE] at 8:44 AM, CNA P recalled on one or two occasions staff got resident #2 up to the wheelchair. She said, When they tried, she would scream and scream. They had to get her back in bed quick. They did bed baths or used the shower bed. She would not stay in a chair for long. On [DATE] at 8:46 AM, CNA Q recalled resident #2 verbalized her wheelchair was uncomfortable. She said,She wanted to go right back to bed, right away. CNA Q explained resident #2 could not stand, required a mechanical lift for transfers, and used a shower bed. On [DATE] at 12:19 PM, in a telephone interview, Transportation Scheduler L explained she probably asked the resident's assigned nurse about the required mode of transportation for the MRI appointment. She stated to her knowledge, either the nurse or the UM decided whether a resident required a wheelchair or stretcher for transportation to outside appointments. Transportation Scheduler L denied knowing resident #2 threatened or attempted to slide down or throw herself out of the wheelchair. When asked how she planned to get resident #2 out of the wheelchair and onto the MRI examination table, Transportation Scheduler L stated she was going to transfer her. She was informed the resident could not stand and required two or more staff members with a full body mechanical lift to move between surfaces. Transportation Scheduler L paused and said, If the resident could not stand, the MRI facility would use a [mechanical] lift. On [DATE] at 12:41 PM, in a follow up telephone interview, the Office Manager of the MRI Imaging Center stated the clinic site for resident #2's appointment on [DATE] did not have a full body mechanical lift. When asked if the Imaging Center accepted patients via stretcher, she stated the location had wheelchairs for patients. On [DATE] at 5:50 PM, the DON and the Administrator were informed interviews with resident #2's daughter and direct care staff on the Long Term Unit revealed she refused to remain seated in a wheelchair. They were told the resident would scream, try to slide out of the wheelchair, or throw herself backwards if not returned to bed. The Administrator stated the nursing management team never mentioned the resident's behavioral issues or discomfort in a wheelchair as possible causative factors for her injuries. On [DATE] at 2:09 PM, in a telephone interview with a Supervisor at the transportation company used by resident #2, he explained on [DATE], the assigned driver picked up the resident and secured her wheelchair inside the van. He stated at some point during the trip, the driver noted resident #2 was sliding down in the wheelchair so he pulled into a parking lot. The Supervisor explained the driver called him about the issue, and since he was nearby, he met the driver in the parking lot to offer assistance. The Supervisor stated they did not unbuckle or remove resident #2 from her wheelchair, but they used the mechanical lift sling that was under her body to reposition her. He stated he instructed the driver to take the resident back to the facility. He said, She needed a different wheelchair. The wheelchair seemed to be very small for the resident. She was squeezed into the wheelchair and appeared uncomfortable. She was sliding little by little while transporting. [The driver] noticed because her knees were coming forward. The Supervisor stated the van was appropriately equipped to transport patients in wheelchairs and the equipment was inspected every six months. He explained resident #2's wheelchair was secured in place by four straps, and there were two or three additional straps to secure the resident in the wheelchair. He stated if requested by the facility, the transportation company was able to provide services for patients who required stretchers or bariatric wheelchairs. On [DATE] at 4:20 PM, the Regional Director of Clinical Services (RDCS) explained the DON was responsible for overseeing that assessments, evaluations, and care plans were revised when necessary to reflect residents' current safety and care needs. She confirmed she was never made aware there might have been an issue with the mode of transportation selected or that resident #2's known behaviors in the wheelchair could have suggested an escort was advisable. The RDCS confirmed the facility was responsible for determining the safest mobility devices, transfer methods, and appropriate types of transportation for all residents throughout their time in the facility. Review of the facility's policy and procedure for Plans of Care revised on [DATE], revealed the facility would review, update and/or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident. The Facility Assessment dated [DATE] revealed the facility could meet the needs of residents with common diseases including psychiatric and mood disorders, quadriplegia, osteoarthritis, and diabetes. The document indicated care and services offered to meet residents' needs included assistance with activities of daily living and mobility. The Facility Assessment indicated residents would receive person-centered care such as identification of hazards and risks and inclusion of the family in care planning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide wound care and services according to professional standards to prevent the development and worsening of pressure injuries for 2 of 4 residents reviewed for pressure injuries, of a total sample of 10 residents, (#6 & #10). The facility's failure to implement appropriate preventative interventions, follow physician orders, and execute policies and procedures for skin and wound care, repeatedly over all shifts, resulted in preventable pressure injuries, actual harm, for residents #6 and #10. Findings: 1. Review of the medical record revealed resident #10, an [AGE] year-old female, was admitted to the facility on [DATE]. Her diagnoses included right hip fracture, dementia, osteoarthritis, and adult failure to thrive. Review of the Minimum Data Set (MDS) admission assessment with assessment reference date of 3/27/23 revealed resident #10's Brief Interview for Mental Score was 3, which indicated she had severe cognitive impairment. The document showed the resident did not reject care or exhibit behavioral symptoms in the look back period. The MDS assessment showed the resident was at risk for developing pressure injuries and on admission, she had one unhealed stage III pressure injury and four deep tissue injuries. The resident had a pressure reducing mattress and received pressure injury care. A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence. The injury is caused by pressure and can present as either intact skin or an open ulcer. According to the National Pressure Injury Advisory Panel, a stage I pressure injury is a localized area of redness on intact skin. Stage II pressure injuries show partial-thickness skin loss with an exposed pink or red wound bed. A Stage III pressure injury shows full-thickness skin loss with visible fat and/or granulation tissue. A stage IV pressure injury involves full-thickness loss of skin and tissue that leaves muscle or bone exposed. A deep tissue pressure injury (DTI) is a persistent non-blanchable deep red, maroon or purple discoloration or a blood-filled blister that is covered with intact or non-intact skin. An unstageable pressure injury involves full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed as it is hidden by dead tissue (retrieved on 4/10/23 from https://cdn.ymaws.com/npiap.com/resource/resmgr/NPIAP-Staging-Poster.pdf). Review of the Wound Care physician's initial Wound Care Consult note dated 3/24/23 revealed resident #10 had six pressure injuries. The document listed a left hip stage 3/DTI that measured 4.5 centimeters (cm) x 3.5 cm x 0.1 cm; a left heel DTI that measured 5.0 cm x 5.0 cm; a left lateral foot DTI that measured 1.0 cm x 1.0 cm; a left distal plantar/lateral foot DTI that measured 2.5 cm x 2.5 cm; a right heel DTI that measured 4.0 cm x 4.0 cm; and a right foot distal plantar DTI that measured 2.0 cm x 2.0 cm. The wound care physician ordered treatments and preventative interventions that included offloading the resident's heels and placing a pillow between her knees. He noted resident #10 had paper thin skin on extremities specifically her left hip, bilateral feet, and bilateral heels. A Wound Follow-Up note dated 3/31/23 revealed the Wound Care physician assessed resident #10 and noted improvement of the left hip wound which measured 2.0 cm x 1.5 cm x 0.1 cm. Her left foot distal plantar/lateral wound was stable and measured 2.5 cm x 2.5 cm. He noted a new DTI on resident #10's right lateral ankle that measured 3.5 cm x 2.5 cm and wrote an order for daily application of skin protectant and a foam dressing to the area. Review of the Order Summary Report revealed physician orders dated 3/24/23 to apply skin protectant to resident #10's bilateral heels every shift, and cleanse the left hip wound with Normal Saline, pat dry, apply Calcium Alginate, and cover with a foam dressing once daily and as needed. An order dated 3/31/23 instructed nurses to cleanse the left foot distal plantar and lateral areas with normal saline, pat dry, apply skin protectant, and cover with a foam dressing daily and as needed. An additional order dated 3/31/23 revealed the Wound Care physician required skin protectant and a foam dressing applied daily to resident #10's new right lateral ankle pressure injury. Resident #10 had a care plan for potential for impaired skin integrity initiated on 3/29/23. The goal was the resident would maintain clean and intact skin. The care plan interventions included follow facility protocols for treatment of injury, and monitor and document the location, and size of skin injuries. The document included instructions for nurses and Certified Nursing Assistants (CNAs) to report any skin abnormalities such as signs and symptoms of infection to the physician, and identify and eliminate possible causative factors. Review of the medical record revealed resident #10 had a care plan for pressure injuries on her left hip, left heel, and left foot that was initiated on 4/05/23. The care plan did not identify or address area(s) of concern on the the resident's right foot. The interventions instructed nurses to administer treatments as ordered and monitor for effectiveness. assess/monitor/record wound healing. and follow facility policies for the prevention and treatment of skin issues. The care plan indicated nursing staff were expected to monitor, document, and report any new skin breakdown. On 4/06/23 at 11:54 AM, CNA B transferred resident #10 from her wheelchair to bed in preparation for wound care. CNA B placed resident #10 in a supine position but the resident immediately rolled herself onto her right side and curled into a semi-fetal position. Resident #10 was very thin, frail, and had pronounced bony prominences. CNA B explained the resident preferred to lie on her right side at all times and would not remain on her left side or back unless she was turned and repositioned by staff. A pair of sheepskin heel protector boots was noted on the right side of the resident's nightstand. On 4/06/23 at 11:56 AM, Licensed Practical Nurse (LPN) A stated she was ready to begin resident #10's wound care tasks. She gathered supplies from the treatment cart and entered the room. LPN A glanced at the resident's tray table which had a cup of water, small scattered debris, and visible smears. She went to the resident's bathroom, removed a brown paper towel from the dispenser, placed it on the tray table, and stacked the treatment supplies on top of paper towel. LPN A washed her hands in the bathroom and applied clean gloves from a box in the bathroom. She removed the soiled foam dressing from resident #10's left hip and placed it on the the tray table to the left of the clean dressing supplies. While wearing the same gloves, LPN A opened the packets of Calcium Alginate, gauze pads, and foam dressing, and arranged them near the front edge of the tray table. Next, she wiped her scissors with an alcohol wipe and wet the gauze pads with Normal Saline. LPN A removed her dirty gloves and dropped them in a trash can near the bathroom door. She retrieved clean gloves from the bathroom and applied them without performing hand hygiene. LPN A used the moistened gauze to clean resident #10's left hip wound, then folded the gauze in half and used it to wipe the same area again. She dropped the soiled gauze and empty paper packets on the growing pile of trash on the left side of the tray table. LPN A continued wound care with the same gloves as she cut the Calcium Alginate and placed it on the resident's left hip wound. Next, she removed the resident's left sock and noted a foam dressing on the left lateral and distal foot that was dated 3/31. LPN A validated the treatment order was to change the dressing daily but it had not been done for five days. She removed her gloves, dropped them in the trash can, washed her hands in the bathroom, and applied clean gloves. LPN A moistened a gauze pad and wiped the resident's left distal foot DTI, applied skin protectant around the intact blister and applied a foam dressing. The nurse used the same gloves to apply skin prep to the resident's left heel and left outer ankle. LPN A did not recognize the dark red area on the resident's left lateral foot as a pressure injury noted on the physician's orders so she did not apply skin protectant to the DTI as ordered. Next, LPN A wore the same gloves to remove the resident's right sock and apply skin protectant to the right heel and to an undocumented DTI on the right lateral foot. LPN A removed her gloves and applied clean gloves without performing hand hygiene. She then removed a foam dressing on the resident's right outer ankle and verified it was also dated 3/31. The tissue surrounding the dark purple area on the resident's ankle was red, and LPN A applied skin protectant around the edges of the reddened area rather than to the intact skin on the bony prominence, and covered it with a foam dressing. CNA B positioned resident #10 on her left side, fluffed the pillows under her head for comfort, and covered her with a sheet and blanket. CNA B did not offload the resident's heels or place a pillow between her knees as ordered by the Wound Care physician. CNA B was asked if she planned to apply the sheepskin boots that were on the night stand. She said, I have never seen them before today. It was not even there this morning when I got her dressed. The facility's policy and procedure for Dressings, Dry/Clean revised in September 2013 provided guidelines for the application of dry,clean dressings. The policy instructed nurses to verify physician orders, check the treatment record, and gather equipment and supplies. The document indicated the first step in the procedure was Clean bedside stand. Establish a clean field. Place the clean equipment on the clean field. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field.Wash and dry your hands thoroughly. Put on clean gloves. Loosen tape and remove soiled dressing. Pull glove over dressing and discard into plastic or biohazard bag. Wash and dry your hands thoroughly. Nurses were expected to open clean dressing supplies using clean technique and then perform hand hygiene before applying clean gloves. The procedure specified a clean gauze should be used for each cleansing stroke from the least to most contaminated area. The document indicated gloves should be discarded once the dressing change to the wound was completed and the nurse would perform hand hygiene. Lastly, the nurse would clean the bedside stand and perform hand hygiene before leaving the room. On 4/06/23 at 12:31 PM, during review of the electronic CNA care plan or [NAME] with CNA B, she confirmed there were no instructions for staff regarding placement of heel protector boots, offloading heels, placing a pillow between the knees, or turning and repositioning resident #10. On 4/06/23 at 12:40 PM, during an interview with the Director of Nursing (DON) and LPN A, the DON was informed of multiple concerns related to pressure ulcer prevention and treatment, and promotion of wound healing for resident #10. LPN A acknowledged she did not clean the tray table, a high-touch surface, prior to setting up treatment supplies, nor use an impermeable barrier to maintain a clean field. She confirmed she utilized the left side of the table to accumulate discarded and soiled treatment supplies and empty packets instead of the trash can. LPN A provided the DON with the dressings dated 3/31/23 that she removed from resident #10's bilateral feet. The DON validated the date on the dressings proved the treatment was not done daily as ordered. The DON was informed LPN A did not perform hand hygiene appropriately, and did not practice a clean technique during wound care to prevent contamination and promote wound healing. He was told LPN A omitted one wound treatment, applied skin protectant to a new DTI that was not documented in the medical record, and applied the skin protectant to the periwound areas instead of to the intact blood blisters as the orders were not transcribed accurately. The DON was not aware pressure ulcer prevention measures ordered by the Wound Care physician were not included in the plan of care or implemented by nursing staff. He confirmed he expected all nurses to follow accepted standards of practice and facility policies and procedures related to wound care, application of treatments, and transcribing and following physician orders Resident #10's TAR for April 2023 revealed the order for the right ankle dressing was on the document, and there were no nurses' initials to indicate the dressing was done on 4/01/23 and 4/05/23. The initials NP6 on 4/02/23, 9580 on 4/03/23, and jme on 4/04/23 indicated three nurses signed the TAR to verify they changed resident #10's right ankle dressing as ordered although the task was not done. On 4/07/23 at 8:56 AM, resident #10 was in bed on her right side. Her heels were not offloaded and there were no pillows between her knees and ankles to prevent skin breakdown. The sheepskin heel protectors remained on the resident's night stand in the same position as the day before. CNA B stated she assumed care of the resident this morning at 7:00 AM and the heel protectors were still on the night stand where she left them yesterday. CNA B acknowledged she did not put the devices on the resident this morning. On 4/07/23 at 9:06 AM, during weekly rounds with the Wound Nurse and the Wound Care physician they observed resident #10's sheepskin heel protector boots on the night stand. They were informed the devices were provided yesterday but staff had not yet placed them on the resident's feet. The Wound Care physician stated he ordered the heel protectors two weeks ago at the time of his initial assessment and he assumed staff had been applying them. He explained resident #10 had fragile skin, was at high risk for skin breakdown, and her heels were particularly susceptible to pressure injuries. He stated a pressure relieving mattress was a basic intervention, but this resident required an additional level of protection to include the boots, frequent turning and repositioning, offloading devices, and use of pillows for positioning. The Wound Care physician expressed frustration regarding the futility of evaluations, assessments, and selecting appropriate treatments if staff were not aware of them or compliant with implementation. He assessed resident #10's left hip wound and noted it had worsened since wound rounds last week. He explained the wound was now deeper and had connective tissue rather than the 100% epithelial tissue noted last week when it had been healing. When informed LPN A used a single gauze pad to wipe the wound more than once, and did not maintain proper infection control practices throughout the task, the Wound Care physician stated it was essential to follow clean technique to prevent contamination and worsening of wounds. He measured the resident's left foot distal plantar blood blister and stated it had increased in size. He was informed LPN A applied skin protectant to the periwound area. The Wound Care physician clarified his orders were to apply skin protectant to the surfaces of the blood blisters and DTIs as the purpose was to protect the skin so that it remained intact. He assessed resident #10's right lateral foot and said, This is a new area. It was not here last week and not reported to me. The Wound Nurse denied knowledge of the newly acquired DTI. She explained all assigned nurses and CNAs should have seen the area during care and notified her or the physician. The Wound Care physician assessed resident #10's right ankle and stated that DTI had worsened as it increased in size over the past week. He noted redness around the dark purple area. He was informed the dressing applied during last week's wound rounds had remained in place for five days and when changed yesterday, the nurse did not apply the skin protectant to the pressure injury. Review of the Wound Follow-Up note dated 4/07/23 revealed within the past seven days resident #10's left hip wound had declined and the left foot distal plantar/lateral wound had increased in size from 2.5 cm x 2.5 cm to 3.0 cm x 3.5 cm. The document indicated the resident's right lateral ankle wound that measured 3.5 cm x 2.5 cm on 3/31/23 had declined and now measured 4.0 cm x 3.0 cm. The wound note described a new DTI on the resident's right lateral foot that measured 1.0 cm x 1.0 cm. On 4/07/23 at 1:16 PM, Central Supply Staff E stated the facility usually had items such as air mattresses, heel protectors, and offloading cradle cushions in stock. She recalled the DON called her yesterday to request heel protectors for resident #10. Central Supply Staff E said, I dropped them on the bed yesterday morning. [Name of Wound Care physician] told me this morning that he ordered the heel protectors two weeks ago.Nobody told me anything about it or else I would have brought them before. I had them in stock. On 4/07/23 at 3:34 PM, the Wound Care physician reiterated nursing staff had to be diligent in their actions and follow orders to prevent skin breakdown and promote wound healing. He acknowledged staff failure to do thorough skin evaluations daily, follow treatment orders, and implement preventative approaches contributed to resident #10's two acquired pressure injuries since admission and the declining status of some wounds. He explained if resident #10's dressings were not changed for five days, the skin was more prone to break down underneath the dressing and nursing staff would not be able to observe the condition of her skin. On 4/07/23 at 3:54 PM, the Wound Nurse confirmed she expected floor nurses to follow professional standards of practice related to all skin concerns. She stated the failure of assigned nurses to change resident #10's dressings as ordered, and to do so for such a long time, was inhumane and neglectful. The Wound Nurse explained the dressings remained on the resident's feet for five days, and the skin protectant was not applied as ordered, possibly causing the new and worsening skin breakdown on her feet. 2. Review of the medical record revealed resident #6, a [AGE] year-old male, was admitted to the facility from the hospital on 4/04/23. His diagnoses included osteomyelitis or bone infection, and amputation of the fourth toe on his left foot. The Florida Agency for Health Care Administration 5000-3008 Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form dated 4/04/23 revealed resident #6's primary diagnosis was left fourth toe pain. The form showed resident #6 had a red area on his tailbone, and a surgical incision on his left foot. The document did not list any other lesions, wounds, pressure ulcers or pressure injuries. Review of the Admission/readmission Data Collection form dated 4/04/23 at 4:30 PM revealed a skin evaluation showed the resident had a fourth left toe amputation, redness to the coccyx or tailbone, and a rash above his left hip. The document indicated resident #6's skin was warm, dry, and otherwise intact. On 4/05/23 at approximately 1:30 PM, resident #6 was in bed with the privacy curtain partially closed. The resident's lower legs were visible from the hallway outside the room and a white dressing was noted around the left foot which rested on the mattress. Two visitors stood near the foot of the bed. On 4/05/23 at 1:35 PM, from the hallway, one visitor was observed lifting the resident's legs while the other visitor placed a pillow to offload resident #6's heels and separate his ankles. Resident #6's daughter stated her father was admitted to the facility on the previous afternoon. She explained on arrival this morning, she removed her father's post-surgical shoe to check his foot and noted a new skin issue, a reddened area on his left ankle. Physical Therapist G entered the room and the daughter pointed to a light red, nonblanchable area on her father's left inner ankle. Physical Therapist G informed the daughter it might not be a pressure injury. The daughter explained she was a nurse and recognized the nonblanchable redness on a bony prominence was a stage I pressure injury. Resident #6's daughter informed Physical Therapist G the red area was not there the day before. Physical Therapist G informed the resident's daughter she was there to do an evaluation for Physical Therapy and the skin issue would be a nursing concern. On 4/06/23 at 12:49 PM, Advanced Practice Registered Nurse (APRN) C stated she assessed resident #6 yesterday and observed redness to his left ankle. She said, I assumed there were orders in place. She explained the facility had a Wound Nurse and Wound Care physician who should also be notified of all skin and wound concerns to ensure they were addressed appropriately. On 4/06/23 at 1:39 PM, APRN C assessed resident #6's left ankle and confirmed the red area was now a darker red color than it was when she noted it yesterday. She confirmed no staff updated her on the change in appearance of the pressure injury. APRN C explained she would order a skin protectant treatment to prevent the area from becoming a stage II pressure injury. Review of the Order Summary Report revealed the order, Left ankle inner: apply skin prep every shift for wound prevention dated 4/06/23 at 2:14 PM. On 4/06/23 at 1:53 PM, CNA F checked the CNA care plan or [NAME] for instructions related to care of resident #6's skin. She confirmed there were no resident care instructions on the [NAME] on promotion of skin integrity and explained she received information via verbal report from other CNAs. She stated after the assigned nurse changed the resident's dressing this morning, she told her to keep his foot elevated with a pillow. On 4/06/23 at 2:13 PM, the DON stated every newly admitted residents had a complete skin assessment on admission. He explained staff members who cared for residents were required to report any changes in skin condition. He was informed resident #6's daughter reported a new reddened area on her father's ankle to Physical Therapist G. The DON confirmed Physical Therapist G should have informed the assigned nurse immediately. On 4/06/23 at 2:44 PM, Physical Therapist G said, I did not report the skin issue to the nurse. She was not there at the time. On 4/06/23 at 3:42 PM, the Assistant Director of Nursing (ADON) explained any areas of skin breakdown must be reported, evaluated, and treated per protocol to prevent worsening. She stated it was usually necessary to obtain a physician's order for offloading boots, skin protectant, air mattresses, and padded cradle cushions. However, the ADON validated offloading potential pressure areas, floating heels, and regularly turning and repositioning residents were nursing interventions that could be implemented without a physician's order. On 4/07/23 at 8:51 AM, resident #6 was supine in bed, with his heels on the mattress and his ankles touching. The resident had slid down to the foot of the bed, and the plantar surface of his foot from the ball to the heel was pressed onto the footboard. There was no pillow under the resident's lower legs or between his ankles. CNA F confirmed the resident's heels were not floated when she arrived at work and she had not placed a pillow as directed by the nurse yesterday. She explained members of nursing management rounded earlier that morning to check the dates on all dressings, but none of them attempted to reposition resident #6's feet or instructed her to do it. When asked where the extra pillows were, CNA F pointed to a pillow resting on the bed above the resident's head. On 4/07/23 at 11:55 AM and 3:46 PM, the Wound Care physician assessed resident #6 and confirmed the stage I pressure injury on the left inner ankle. He was informed APRN C was made aware there were no orders for skin protectant and she ordered the treatment two days after admission. He noted a dressing on the resident's sacrum and was told there was no physician order for a treatment to the area. The Wound Care physician removed the dressing and stated the area required skin protectant only. He explained it was important for staff to be able to inspect the skin on the resident's coccyx regularly. He said, If intact skin stayed covered, there was the possibility a wound would develop and be unnoticed. The Wound Care physician explained it was as important to prevent wounds as it was to treat wounds. A new offloading cradle cushion was noted on the resident's night stand. The facility's Clinical Guideline Skin & Wound effective 4/01/17 revealed the facility would .provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. The document indicated nursing staff would complete skin observations and evaluations and report and document new skin impairment as indicated. The clinical guideline read, Licensed Nurse to report changes in skin integrity to the physician/practitioner and resident/responsible party and document in the medical record. The document revealed the facility would develop person-centered goals and interventions and make the information available on the nursing and CNA care plans. Review of the Facility Assessment dated 1/16/23 revealed the facility could provide care and services for skin integrity issues including pressure injury prevention and care, skin care, and wound care. Competencies for all staff included infection transmission and prevention and hand hygiene, and CNAs are required to show competency in skin and wound care.