**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #22 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type 2 diabetes, systemic lupus erythematosus, phlebitis and thrombophlebitis of superficial vessels of the right leg. Systemic lupus erythematosus is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels (retrieved on 4/01/22 from www.cdc.gov). Thrombophlebitis is an inflammatory process that causes a blood clot to form and block one or more veins, usually in the legs. The affected vein might be near the surface of the skin or deep within a muscle (retrieved on 4/01/22 from www.mayoclinic.com). Review of the MDS admission assessment with ARD of 3/18/22 revealed resident #22 had a Brief Interview for Mental Status (BIMS) score of 9 which indicated she had moderate cognitive impairment. She required extensive to total assistance with Activities of Daily Living (ADLs). The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #22 was at risk for developing pressure ulcers and pressure injuries and had skin conditions including pressure ulcers and pressure injuries presenting as deep tissue injury. A care plan for actual impairment of skin integrity as evidenced by pressure wound to sacrum, deep tissue injury right big toe, deep tissue injury left and right heel, pressure ulcer left ischium and excoriation to right buttocks was initiated on 3/14/22. Interventions included follow facility protocols for treatment of injury and staff to ensure bilateral boots to lower extremities are on at all times, may remove for ADL care. Review of resident #22's medical record revealed a physician order dated 3/16/22 for bilateral boots to lower extremities applied every shift. Review of the Treatment Administration Record (TAR) for March 2022 revealed nursing documentation of resident #22's bilateral boots applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #22 had a suspected deep tissue injury on her right heel that measured 1.8 cm long, 2.0 cm wide and 0.1 cm deep. A Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident also had a suspected deep tissue injury on her left heel 0.5 cm long, 1.0 cm wide and 0.1 cm deep. On 3/28/22 at 5:12 PM, 3/29/22 at 11:01 AM and 3/30/22 at 5:01 PM, resident #22 was observed in bed without boots on her feet. She was also observed in her wheelchair on 3/28/22 at 3:55 PM, 3/29/22 at 2:40 PM and 3/30/22 at 12:29 PM without boots to both feet. On 3/31/22 at 10:06 AM, CNA F verified she was assigned to resident #22. She stated she was familiar with the resident and worked with her last week. CNA F stated she did not know if resident #22 had bilateral boots. She explained she had not seen any boots previously. CNA F searched resident #22's room but did not locate any boots. On 3/31/22 at 10:33 AM, LPN G confirmed she was the nurse assigned to resident #22. She said she saw the resident with bilateral boots last week but did not remember seeing them this week. LPN G reviewed the physician orders and noted resident #22 had an order for bilateral boots. She observed the resident and acknowledged she was not wearing any boots. LPN G searched the room but did not find the boots. She identified resident #22 was at risk for skin breakdown and needed the boots to protect her heels, promote healing and prevent further breakdown. On 3/31/22 at 1:45 PM, the DON reported resident #22 had pressure ulcers on both heels. She confirmed the resident should have bilateral boots in place to promote healing and prevent further breakdown. 3. Resident #55 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, dementia and peripheral vascular disease. Review of the MDS Significant Change in Status assessment with ARD of 3/12/22 revealed resident #55 had a BIMS score of 0 which indicated she had severe cognitive impairment. She required extensive to total assistance with ADLs. The document revealed the resident did not exhibit any behavioral symptoms including rejection of care. The assessment indicated resident #55 was at risk for developing pressure ulcers and pressure injuries but did not have any at the time of the assessment. A care plan for actual impairment of skin integrity revised 3/24/22, indicated resident #55 had a pressure ulcer to her right heel. Interventions included Podus boot to right foot for offloading. Review of resident #55's medical record revealed a physician order dated 3/19/22 for Podus boot on right foot for offloading. Review of the TAR and MAR for March 2022 revealed no documentation to validate resident #55's podus boot was applied as ordered. Review of Pressure Ulcer Wound Rounds form dated 3/28/22 revealed resident #55 had a Stage 3 pressure ulcer on her right heel that measured 3.0 cm long, 3.0 cm wide and 0.1 cm deep. On 3/28/22 at 10:27 AM, resident #55 was observed in her reclining chair without a Podus boot on her right foot. On 3/29/22 at 12:00 PM, 3/29/22 at 2:59 PM, 3/30/22 at 9:41 AM and 3/30/22 at 5:01 PM, the resident was observed in bed without a Podus boot on her right foot. On 3/31/22 at 10:11 AM, CNA F verified she was assigned to resident #55. She stated she did not know if the resident had a boot and had not seen her with one. CNA F lifted the covers and acknowledged resident #55 was not wearing a Podus boot. She searched the resident's room but did not find the boot. On 3/31/22 at 10:24 AM, LPN G observed resident #55's right foot and verified she had a pressure ulcer on her right heel. She acknowledged the resident did not have a Podus boot on her right foot. LPN G reviewed resident #55's physician orders and verified resident #55 had an active order for a Podus boot to right foot. LPN G stated she had never seen resident #55 with a boot. On 3/31/22 at 1:45 PM, the DON stated resident #55 was at risk for skin breakdown and had a pressure ulcer on her right heel. She acknowledged resident #55 did not have a Podus boot. She explained the reason for the Podus boot was to prevent the pressure area from getting worse. Based on observation, interview and record review, the facility failed to provide care and services to prevent the development of a pressure ulcer and shear injury (#10), and failed to ensure application of pressure reducing devices to prevent further skin breakdown (#22 & #55) for 3 of 7 residents reviewed for pressure ulcers of a total sample of 44 residents. The facility's failure to implement preventative interventions consistent with resident #10's risk for skin breakdown, and failure to identify areas of skin injury according to accepted standards of practice resulted in actual harm, development of a stage 3 pressure ulcer to the right ear. Findings: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses of heart disease, enlarged heart, hardening of the blood vessels in the brain, muscle weakness and chronic pain. Review of the Minimum Data Set (MDS) Quarterly assessment with Assessment Reference Date (ARD) of 3/09/22 revealed resident #10 had severe hearing impairment and did not speak. The MDS assessment indicated she had both short- and long-term memory problems and severely impaired cognitive skills. The resident was incontinent of bladder and bowel, required oxygen therapy and needed extensive assistance from two staff for bed mobility and transfers. The MDS assessment also indicated resident #10 was at risk for pressure ulcers and had one unhealed, stage 4 pressure ulcer. The document listed current skin and pressure ulcer treatments such as a pressure reducing device for the bed, but it did not include a turning/repositioning program. According to the National Pressure Injury Advisory Panel (NPIAP), a pressure ulcer is a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction. The injury can present as intact skin or an open ulcer and may be painful. The NPIAP defines a stage 3 pressure injury is a full-thickness loss of skin that may have rolled wound edges with fat and slough visible in the wound (retrieved on 3/31/22 from www.npiap.com). Slough is dead tissue, often wet, that needs to be removed from a wound for healing to take place (retrieved from www.woundsource.com on 4/5/22). A skin injury caused by shear or friction occurs when skin is dragged across a coarse surface. Shear is defined as a mechanical force that acts internally on the skin tissue in a direction parallel to the body's surface. These forces can cause older adults to be vulnerable to deeper pressure injuries to their skin (retrieved on 4/04/22 from www.dermatoljournal.com). Resident #10 had care plans for potential impairment to skin integrity related to fragile skin and for a pressure ulcer to her sacrum. The goal was the resident would be free from injury. The care plan interventions directed staff to monitor, document, and report any changes in skin status as needed. The document listed an additional intervention to teach the resident the importance of changing positions for prevention of pressure ulcers and encourage her to make small frequent position changes. However, due to resident #10's cognitive impairment, memory problems and need for extensive assistance for movement, the interventions were not appropriate for the resident. The care plan directed staff to follow facility policies and protocols for the prevention and treatment of skin breakdown. Other approaches included staff to identify and document potential causative factors and eliminate and resolve them where possible. The care plan did not include an intervention related to frequently turning and repositioning resident #10 while she was in bed Review of the medical record revealed a physician order dated 12/02/21 for nurses to perform weekly skin sweeps every evening shift on Tuesdays. The order specified the nurse was to complete a head to toe skin sweep under the assessment tab. On 3/28/22 at 11:03 AM, resident #10 was in bed turned to her left side, and faced the door. She had a nasal cannula, dated 2/25/22, that was connected to an oxygen concentrator. Resident #10's head rested on a pillow and she had a small black scabbed area noted on the cartilage of her right, outer ear. Her hair was pulled back and she had clumps of yellowish, dried crusty substance in her hair above the right ear and also at the crease of her right ear where the tubing of the nasal cannula rested. On 3/28/22 at 12:45 PM, resident #10 remained on her left side facing the door and still wore the nasal cannula dated 2/25/22. Her face was unwashed and there was mucous that drained from her nostrils and accumulated under the nasal cannula. The nasal cannula tubing fit tightly around her neck and there were purple-colored marks on her neck, under the tubing, coming up towards her right ear. On 3/28/22 at 2:05 PM, resident #10's position was unchanged. She still lay on her left side with her head on a pillow, facing the door. The yellow crusty substance remained clumped in her hair above the right ear and the same nasal cannula,dated 2/25/22 was in place. On 3/28/22 at 3:46 PM, during an observation of resident #10 with the East Wing Unit Manager (UM), the resident was in bed and still lay on her left side. The East Wing UM acknowledged the date on the resident's nasal cannula tubing showed it had not been changed for over a month. She explained nurses were expected to change the nasal cannula tubing once weekly on Fridays. She validated there was crusted, yellowish drainage in resident #10's hair above her right ear. The East Wing UM observed the dark colored wound to the resident's outer ear and confirmed she had no previous knowledge of the area of breakdown. She carefully pulled down resident #10's right ear and removed the nasal cannula which was lying in the crease of her upper ear. A wound about the size of a small raisin where the nasal cannula had been resting was identified. The wound was open and draining, with redness noted to the surrounding tissue. The East Wing UM rolled resident #10 to her right side and removed the nasal cannula tubing from behind her left ear and found the skin underneath reddened and moist. She reported she was not aware of the wounds to resident #10's right ear. She explained the resident's last skin assessment would have been performed the past Tuesday, 3/22/22. The East Wing UM explained the wound behind the resident's right ear was at the minimum a stage 3 wound and the wound to the outside of her right ear was unstageable. On 3/28/22 at 4:10 PM, the East Wing UM stated she was unable to find any documentation of skin assessments for resident #10 for the past 10 weeks, since 1/18/22. She confirmed the assigned floor nurses were supposed to perform skin sweeps weekly on the 3 PM to 11 PM shift on Tuesdays as ordered by the physician. On 3/28/22 at 4:20 PM, the Wound Care Registered Nurse (RN) assessed resident #10's wounds. She validated there were purplish marks around the resident's neck, and two wounds to her right ear. On 3/28/22 at 4:26 PM, Certified Nursing Assistant (CNA) C stated she had just completed care for resident #10. She confirmed she washed the crusty substance from the resident's hair. CNA C said checking the resident's skin was part of daily hygiene care and she was aware any skin issues should be reported to the nurse. On 3/28/22 at 5:30 PM, the Wound Care RN described taking resident #10's nasal cannula off to assess the wound to the back of her right ear. She stated she assessed the wound to the back of the right ear as a stage 3 pressure ulcer as it was open and the tissue in the wound was yellow and draining. She noted the wound to the outer ear was an unstageable pressure ulcer as it was blackened. The Wound Care RN recalled she assisted the Wound Doctor that morning during care to the resident's sacral pressure wound. She remembered the resident was turned to her left side. She added that CNAs should turn and reposition the resident to prevent worsening of the existing wound and development of new wounds. The Wound Care RN acknowledged the wounds to resident #10's ear could have been there since the past weekend. On 3/28/22 at approximately 5:35 PM, the Assistant Director of Nursing (ADON) stated CNAs were supposed to wash residents and observe for any skin issues. He explained the expectation was for CNAs to immediately report any changes in a resident's skin condition. He stated the CNAs were to let the nurse know even if the resident's skin was just pink. He indicated that treatments put into place at an early stage could prevent further damage to the skin. The ADON explained CNAs should turn the resident every two hours to prevent skin breakdown because her skin was so fragile and she was at high risk for skin breakdown. He validated the wounds to resident #10's ear should have been identified as part of her hygiene care when the CNA washed her face, including her ears. He explained the floor nurse was supposed to do a whole-body assessment during the skin sweep and confirmed that no skin sweeps were done in the past 10 weeks, since 1/18/22. He validated there was a breakdown in preventative treatment for resident #10 as the wounds were not identified. The ADON stated if the CNAs had washed resident #10's face, they should have seen the wounds to her ear and notified the nurse. The ADON agreed the wound was possibly there since Saturday. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:30 PM, revealed an unstageable, pressure type wound 0.2 centimeters (cm) by 0.3 cm by 0.1 cm to resident #10's right ear that was not present on admission. The wound bed was described as 100% dead tissue with no drainage. Review of the document Pressure Ulcer Wound Rounds dated 3/28/22 at 4:31 PM, revealed a stage 3, pressure type wound measuring 0.5 cm by 0.6 cm by 0.2 cm to the back of resident #10's right ear that was not present on admission. The wound bed was described as yellow slough with redness in the area around the wound. Review of the Medication Administration Record revealed nurses charted they performed the Weekly skin sweep that directed them to complete the head to toe skin sweep under assessment tab consistently every week of January, February and March of 2022. However, review of the medical record revealed the Weekly Skin Integrity Review was actually documented by nurses only 5 times over the 6 months prior to March 2022. The last skin sweep assessment for resident #10, completed on January 18, 2022, indicated her skin was intact on that date. Review of the CNA care plan or Bedside [NAME] Report for resident #10 dated 3/31/22, revealed directions for a weekly skin inspection requiring an observation of redness, open areas, scratches, cuts or bruises and to report to nurse and changes. The [NAME] report detailed that resident #10 required total assistance from 2 staff for turning and repositioning for bed mobility as necessary, but it did include the required frequency for the task to meet the needs of resident #10 who was at high risk for skin breakdown. Review of the CNA task documentation report revealed no documentation of bed mobility performed on the day shift on 3/26/22, the night shifts on 3/27/22 and 3/28/22 and for the entire day of 3/29/22. On 3/29/22 at 10:15 AM, Licensed Practical Nurse (LPN) B stated she worked with resident #10 on the Friday 3/25/22 evening shift and Monday 3/28/22 day shift. LPN B stated CNAs were to provide care and wash the resident including behind the ears while the nasal cannula was moved. She confirmed the CNA did not notify her of any skin changes, and she was not aware of the wounds to resident #10's right ear. LPN B stated checking the resident's skin was part of the nurse's assessment during her shift. She stated she did not look at resident #10's nasal cannula during the day shift on Monday. She recalled she was too busy and did not look behind resident #10's ears during the shift although it was normally part of her assessment. She explained wounds from a medical device like a nasal cannula might be prevented if kept from resting on the skin by placing a cushion or gauze. She said another intervention to prevent pressure ulcers was frequent repositioning and as the nurse she was responsible to ensure CNAs turned and repositioned residents frequently. LPN B recalled resident #10 was turned toward the door during the day shift on Monday. On 3/29/22 at 12:38 PM, LPN E stated she was familiar with resident #10 as she was assigned to her on the day and evening shifts on Sunday 3/27/22. She explained resident #10 was at risk for skin breakdown and should be repositioned every two hours. She stated she did not check resident #10's skin nor was she informed by the CNA of any skin impairments for resident #10 during either shift. On 3/29/22 at 1:05 PM, CNA A stated she cared for resident #10 on Monday 3/28/22 on the 7AM to 3 PM shift. CNA A explained bed baths included washing the resident's face, body and hair and stated resident #10 needed total care from her. She said she gave resident #10 a bed bath, and combed her hair, but did not wash behind her ears or under her nose where the nasal cannula rested. She explained she thought she was not supposed to touch the nasal cannula, so she did not wash the areas where the cannula rested. CNA A did not explain how she gave the resident a bed bath but did not notice the wound to her outer right ear, the red marks on her neck, the dried drainage in her hair and her injured right ear. CNA A acknowledged resident #10 should be turned every two hours and stated she had turned her. She could not explain how resident #10 was turned every two hours if she was observed on her left side facing the door for 5 hours from approximately 11:00 AM until 4:00 PM during her shift on 3/28/22. She recalled resident #10 had a favorite side and possibly moved herself. However, CNA A then verified resident #10 was unable to move her upper body including her torso, shoulders and head on her own to change positions. CNA A confirmed resident #10's upper body was turned to her left side, towards the door during those hours. On 3/30/22 at 12:07 PM, the Hospice nurse and LPN B were at resident #10's bedside and acknowledged the resident was not able to turn herself. The Hospice nurse noted she performed a complete assessment and resident #10 was barely able to move. On 3/29/22 at 2:05 PM and 2:19 PM, the Director of Nursing (DON) stated the standard of care was for residents to be turned every two hours or more if needed. She identified resident #10 was at high risk for skin breakdown because she was bed bound. The DON verbalized CNAs were supposed to wash behind the ears and under the nose when they provided care to residents. She acknowledged CNA A's statement regarding not washing or looking behind resident #10's nasal cannula. The DON confirmed she assessed resident #10's wounds as unstageable and explained that she always considered anything above the neck as unstageable. The DON stated that turning and repositioning was an area of improvement for the facility. She acknowledged the issue of skin sweeps not being performed per physician orders was not identified until Monday 3/28/22, when it was brought to their attention. On 3/30/22 at 11:34 AM, the Executive Director and DON stated a possible reason the resident was turned to her left side towards the door for approximately 5 hours, from 11:00 AM until 4:00 PM on 3/28/22, was the wound doctor asked for her to be offloaded for the debridement he performed in the morning to the pressure wound to her sacrum. Review of the Order Summary Report dated 3/28/22 at 4:04 PM, revealed no orders for nurses to leave resident #10 on her left side after her procedure that morning. On 3/31/22 at 10:55 AM, the wound physician confirmed he asked the nurse to offload resident #10 due to the debridement procedure he performed. However, he said, I did not give an order for her not be moved or to lay on one side. He stated he expected resident #10 to be turned every two hours as a standard of practice. He explained the ear is different from other parts of the body and could break down quickly because it had very little fatty tissue. The wound physician explained he felt the wound to resident #10's right outer ear was caused by shearing forces when her body was moved without lifting her head. He stated the wound to the back of her right ear was a stage 3 pressure wound. The wound physician said, The nurses should be evaluating them head to toe and looking at them everywhere, behind the ears included. He noted if a nasal cannula was in the same position for a while it needed to be offloaded from the skin to prevent breakdown. The wound physician explained, if you didn't look under something like a nasal cannula you could miss a problem. He elaborated that for most residents, the skin assessment should be done at a minimum weekly, but resident #10's skin should be checked at a minimum daily due to her poor nutrition and high risk for skin breakdown. On 3/30/22 at 1:00 PM, during a telephone interview, the Medical Director stated he assessed resident #10 via video. He stated resident #10 was at high risk for skin breakdown and explained interventions like turning and repositioning were important for prevention. He confirmed the wounds to her ear and stated the nasal canula rubbing around her skin could cause skin breakdown. He explained the nasal cannula around her neck, rubbing the skin likely caused the purplish marks to her neck. He noted the wounds to resident #10's ear would not typically appear on their own and were likely caused from the nasal cannula. The Medical Director stated he expected nurses to do skin assessments at least weekly. Review of the undated document Job Description- Clinical Nurse I, revealed the purpose of the position was to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by the nursing assistants. The document described duties and responsibilities which included the nurse conduct and document a thorough assessment of each resident's medical status throughout their course of treatment, and complete required documentation in an accurate and timely manner. Specific requirements of the Clinical Nurse I included demonstration of knowledge and skills necessary to provide care appropriate to the age-related needs of the residents served. Review of the Job Description - Wound Care Nurse dated 1/15/16, revealed duties and responsibilities included assistance in implementation and monitoring of compliance with policies, procedures and standards of practice consistent with corporate and external regulatory guidelines, monitoring of accurate and effective documentation, assistance with implementing an individualized treatment plan for each assigned resident. Review of the Policies and Procedures, Clinical Guideline Skin & Wound with effective date 4/01/17 revealed an overview, To provide a system for identifying skin at risk, implementing individual interventions including evaluating and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Procedures included licensed nurse to complete skin evaluations weekly and document in the medical record, CNA to complete skin observations and report changes to licensed nurse, and to develop individualized goals and interventions and document on the care plan and CNA [NAME].