**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's nursing staff failed to adhere to standards of professional practice to promote skin integrity, obtain and implement appropriate wound care orders, and apply treatments and dressings as ordered for 2 of 2 residents reviewed for non-pressure skin conditions, of a total sample of 66 residents, (#61 & #30). The facility's failure to implement adequate preventative interventions and follow policies and procedures for skin and wound care resulted in actual harm for resident #61, preventable injuries during activities of daily living (ADLs) care and development of a skin infection. Findings: 1. Review of resident #61's medical record revealed she was admitted to the facility on [DATE] with diagnoses including cerebrovascular disease, heart disease, hypertension, depression, anxiety, and insomnia. The Quarterly Minimum Data Set (MDS) assessment with assessment reference date (ARD) of 1/23/23 revealed resident #61 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated she was cognitively intact. The document noted she had no mood or behavioral issues and did not reject care that was necessary to achieve the resident's goals for health and well-being. Resident #61 required limited assistance for bed mobility, and extensive assistance for transfers, dressing, and personal hygiene. The MDS assessment showed the resident had no impairments in functional range of motion of her extremities. On 2/27/23 at 10:30 AM, a large purple-brown discoloration was noted on resident #61's right arm. The area extended from above the elbow, around the joint, and faded towards her forearm. Certified Nursing Assistant (CNA) AA stated she last worked with resident #61 three days ago, on Friday 2/24/23, and there might have been a small bruise on her right arm, but definitely not as large as it was today. CNA AA lifted the resident's sheet to expose the left elbow which had a large dark purple bruise around the elbow, which extended from her upper arm to her forearm. Beneath the left elbow there was a large, dark red, pendulous area which had the appearance of a blood blister. A dressing dated 2/26/23 on the resident's forearm indicated the probable presence of a wound. CNA AA said, The left arm bruise was not there on Friday. It must have happened over the weekend. I already told the nurse this morning. The resident grimaced and guarded her left arm as CNA AA repositioned and supported the extremity on a rolled towel. The resident stated she had requested pain medication since the incident. Resident #61 said, The CNAs are very rough when they do things with me. She explained the injury and bruising occurred when a CNA took her clothes off. Review of the medical record revealed resident #61 had a care plan for ADL self-care performance deficit initiated on 7/02/19. The interventions directed nursing staff to conduct weekly skin inspections and observe for redness, cuts, and bruises. A care plan for actual skin impairment related to fragile skin, initiated on 7/02/19, had interventions that included avoid scratching, keep skin clean and dry, and use caution during transfers and bed mobility to prevent striking the resident's extremities. Resident #61 had a physician order dated 1/16/23 to check for bleeding and bruising every shift related to use of blood thinner medication, Clopidogrel 75 milligrams once daily. An order dated 2/15/23 directed staff to apply and moisturizing ointment to the resident's extremities for dry skin. A physician order dated 2/17/23 indicated weekly skin evaluations were scheduled on Tuesdays for the 3:00 PM to 11:00 PM shift. Review of resident #61's medical record revealed no Change in Condition forms regarding a recent wound or other skin injury. A Change in Condition form dated 2/15/23 indicated the physician was notified of the resident's decreased appetite and signs of depression. The document revealed the nurse completed a skin evaluation and noted no issues on that date. A Weekly Skin Integrity Review dated 2/21/23 showed resident #61's skin was intact, with no bruises, discolorations, or skin tears noted. The Treatment Administration Record (TAR) for February 2023 revealed nurses' initials to verify they monitored resident #61 for signs and symptoms of bleeding and bruising every shift from Friday 2/24/23 to Monday 2/27/23. However, review of nursing progress notes revealed no documentation to indicate if, when or how the resident suffered the bruises and skin tear. The TAR did not reflect any treatment order for the dressing dated 2/26/23 that was observed on resident #61's left arm. On 2/27/23 at 3:21 PM, during a meeting with the Interim Director of Nursing (DON) and the Administrator, they were informed resident #61 reported rough treatment by a CNA and showed evidence of significant bruising on both arms, neither of which was documented anywhere in the medical record. The DON stated her expectation was staff would report skin injuries immediately, and the Administrator stated nurses should have completed an incident report. On 2/27/23 at 3:52 PM, the Interim DON stated she assessed resident #61's left arm and confirmed the resident had a skin tear and a puffy area below her elbow where a large amount of blood seemed to have pooled. She acknowledged there was also a discolored area to the resident's right arm around the elbow. The Interim DON validated a nurse applied a dressing to the skin tear without making physician notification or obtaining an order. Review of the medical record revealed the Regional Director of Clinical Services (RDCS) completed a Change in Condition form effective 2/27/23 at 5:12 PM. The document indicated resident #61 had a skin tear left elbow and discoloration to bilateral elbows.Resident states CNA from 3-11 shift was rough while removing her shirt causing a skin tear. The physician was notified on 2/27/23 at 4:55 PM and gave an order to apply triple antibiotic ointment, wrap with gauze and apply geri-sleeves. The resident's son was notified a few minutes later at 5:10 PM. On 2/28/23 at 9:44 AM, Registered Nurse (RN) R stated she was resident #61's regularly assigned day shift nurse on Tuesdays, Wednesdays, and Thursdays. She stated she was sure the resident did not have any bruises or discolorations on her arms on the past Thursday, 2/23/23. RN R stated when she checked the electronic medical record this morning she discovered resident #61 had suffered a skin tear at some point over the weekend and had a new treatment order. RN R confirmed resident #61's skin had always been very fragile but she never had an order for a geri-sleeve, a protective stocking sleeve, for her arms. She confirmed once made aware of bruises and skin tears, any nurse assigned to resident #61 should have completed change in condition and incident report forms, informed the physician and family, and done a thorough skin assessment. RN R explained the resident received a daily blood thinner and was at high risk for bleeding and bruising. She confirmed resident #61's left arm showed signs of significant bleeding under the skin. RN R measured the discolored area on the resident's right arm as approximately 15 centimeters (cm) x 17 cm. She stated the bruised area on the left arm was even larger. On 3/01/23 at 5:22 PM, a meeting was held with the Administrator, the RDCS, and the DON. The DON stated she interviewed resident #61 and determined she was alert and oriented and displayed good recall ability. She stated the resident reported an evening shift CNA on the past weekend injured her arm when she removed her shirt which was tight. The DON and RDCS acknowledged it was the CNA's responsibility to recognize the resident's shirt was tight, and remove it with the appropriate level of care and caution to avoid skin injuries. The RDCS verified the assigned nurse should have notified the physician to obtain an immediate treatment order, informed the family, and then contacted the DON regarding the incident. She stated nursing staff assigned to the resident over the weekend and on Monday morning should all have reported the issue to ensure the resident received appropriate care. The RDCS stated resident #61's day shift nurse on Monday received information on the skin tear in change of shift report and applied a treatment although there was no treatment order on the TAR. The RDCS explained the day shift nurse simply followed the treatment applied by a previous nurse without clarifying the absence of a physician order. The RDCS said, We are not calling this a bruise. The resident said the issue with her elbows comes and goes. As far as I see, it does not seem those are bruises. Her skin is thin and there's like a pocket. We are calling them discolorations. She already has something going on and she had orders for an ointment for her skin. We are waiting for [name of the Medical Director] or the Nurse Practitioner to see resident and she needs a dermatologist to diagnose her condition. The RDCS validated there was no nursing documentation in the medical record of bruises on the resident's elbow during the past four weeks. She confirmed she had not yet done additional research to see if resident #61 had a known dermatological condition that was never diagnosed or treated during her time in the facility. Review of a Progress Note dated 2/08/23 revealed resident #61 was assessed by an Advanced Practice Nurse practitioner (APRN) during a long-term care follow up visit. The note indicated nursing staff did not report any acute changes, and the resident was alert and oriented to person, place, and time, and had no complaints. The APRN's Physical Examination read, The elbows/forearms are normal in appearance, mobility, and are nontender. An integumentary or skin examination revealed the resident's skin was pale, but the texture was normal and there were no rashes, eruptions, or skin ulcers observed. On 3/02/23 at 10:41 AM, resident #61's attending physician, the facility's Medical Director, assessed her left arm. He removed the geri sleeve which had been applied only after the facility was informed of the resident's skin injuries. The geri-sleeve was soiled with a moderate amount of drainage from the wound. The Interim DON validated the dressing on resident #61's left arm was dated 2/28 which indicated daily wound care was not performed and a clean treatment not applied on 3/01/23 as ordered by the physician. The Medical Director used normal saline solution to loosen the dressing which was stuck to the wound to reveal the treatment in place was a petrolatum dressing and not the triple antibiotic ointment with gauze that was ordered. After removal of the dressing, resident #61's skin tear actively bled and the Medical Director had to hold pressure on the area with a gauze pad until the bleeding was controlled. The Interim DON confirmed it was not acceptable for a nurse to substitute a dressing without a physician's order. The Medical Director stated the skin tear measured 4 cm x 2 cm and nurses should have called him and/or the Wound Care specialist physician in a timely manner to report the injury and obtain treatment orders. He explained the resident's skin was fragile and thin, and could be bruised or torn during regular ADL care. The Medical Director acknowledged preventative skin protection measures such as geri-sleeves and staff taking precautions during care were important. He said, This is an opportunity for CNA education. When informed the RDCS suggested a dermatological consult was necessary for a possible untreated skin condition, the Medical Director disagreed. He stated he was very familiar with resident #61 and explained she sometimes developed clear, fluid-filled blisters on her bilateral arms as a result of low albumin levels, despite supplementation. The Medical Director informed the Interim DON he recommended a collagen or hydrogel type dressing to promote healing, and consultation with the Wound Care specialist physician for evaluation and treatment. He assessed the skin surrounding the wound and resident #61's left elbow and said, She has developed a cellulitis. The Medical Director explained he would also order an oral antibiotic to treat the resident's skin infection. Cellulitis is a bacterial skin infection that causes redness, swelling, and pain in the infected area. If untreated, cellulitis can spread and cause serious health problems. Good wound care and hygiene are important for preventing cellulitis (retrieved on 3/14/23 from www.cdc.gov). 2. Review of the medical record revealed resident #30 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including type 2 diabetes, hypertension, obesity, and insomnia. Review of the Annual MDS assessment with ARD of 1/28/23 revealed resident #30 had a BIMS score of 15 which indicated he was cognitively intact. He required extensive assistance for ADLs including bed mobility. transfers, dressing, and personal hygiene. The MDS assessment showed the resident had no skin issues. Resident #30 had a care plan for ADL self-care performance deficit initiated on 8/15/22. The interventions included weekly skin inspections to observe for issues such as redness and open areas, and report changes as indicated. A care plan for potential for skin impairment related to fragile skin, incontinence, and decreased mobility was initiated on 8/15/22. The interventions directed nursing staff to keep the resident's skin clean and dry, apply lotion on dry skin, and use caution during transfers and bed mobility. On 2/27/23 at 2:43 PM, resident #30 stated he had an unknown type of wound on his bottom, possibly even an infection. CNA AA stated the resident still had a dressing on his sacrum, but the area was now completely healed and the dressing was in place for protection of the skin. Resident #30's Weekly Skin Integrity Review forms revealed on 2/15/23 his skin was intact. A skin evaluation dated 2/20/23 indicated the resident had a pressure ulcer to his left buttock with an intact, clean, dry dressing. The document read, no other open areas, bruising, or redness noted. On 2/28/23 at 9:34 AM, CNA AA prepared to provide ADL care for resident #30. She stated she usually informed nurses when she was ready to start morning care as it was a convenient time for her to assist nurses to turn and reposition the resident for wound care and application of the dressing to his sacrum. CNA AA recalled yesterday, Monday 2/27/23, when she asked the day shift nurse if she was ready to do the dressing change, the nurse informed her there was no order for a dressing in the electronic medical record. With resident #30's permission, CNA AA repositioned him to his right side to expose a bordered dressing on his sacrum which was soiled with feces and slightly lifted around the right side edges. The dressing was dated Sunday 2/26/23 on the 7:00 AM to 3:00 PM shift. Resident #30's sacrum was slightly pink and no open areas were noted. Review of the TAR for February and March 2023 revealed resident #30 had an active physician treatment order initiated on 2/08/23. The order read, Clean Left buttock area with normal saline, apply skin prep to peri wound. Apply Calcium Alginate to wound bed. Cover with Foam dressing. Secure with tape, every day shift for open blister. Review of the TARs revealed nurses' initials to verify the daily treatment was done as ordered except on 3/01/23. On 3/02/23 at 12:33 PM, the Interim DON was informed resident #30 had a two-day-old dressing in place on his sacrum that did not reflect the physician order, and there was no blister as noted on the TAR. She validated nurses were expected to follow physician orders, and if there was a discrepancy, they should seek clarification from the provider. On 3/03/23 at 12:22 PM, the Interim DON stated she assessed resident #30 with the [NAME] Wing Unit Manager and they found his skin was intact and he no longer had a dressing to his sacrum. She explained the facility had a Wound Care specialist and a nurse who rounded with him, and nurses should have alerted either provider or any member of nursing management that the area was healed. The Interim DON could not explain why nurses continued to apply a dressing without appropriate orders or documentation. Review of the facility's policy and procedure for Dressing Change revised on 12/06/17 revealed clean dressings would be applied to wounds to promote healing. The procedure directed nurses to apply treatments as ordered and then document in the medical record.