**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Care Plans-Comprehensive the facility failed to revise the comprehensive care plan for one of 21 residents (R# 31,) reviewed for care plans. Specifically, the facility failed to revise the care plan when R31 developed pressure ulcers after admission and did not include the current orders/approaches, such as the pillow and wedge, which were to be used in response to the resident's seven pressure ulcers. Actual harm was identified to have occurred when R31 developed seven avoidable pressure ulcers, which caused loss of multiple areas of healthy skin tissue/integrity as well as placed R31 at risk for pain, discomfort, and wound infection. Findings include: Review of the facility's Care Plans-Comprehensive policy, dated April 2010, revealed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs . the care planning team is responsible for the periodic review and updating of care plans at least quarterly .The resident's comprehensive care plans are revised as information about the resident and the resident's condition change . Revisions . The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans: . a. When there has been a significant change in the resident's condition . b. When the desired outcome is not met. 1. Review of the Face Sheet for R31 located in the Electronic Medical Record (EMR) on the Face Sheet tab revealed that R31 was admitted to the facility on [DATE] with one pressure ulcer. Review of the Wound Assessments for R31 located in the Wound Management tab of the EMR revealed R31 was currently receiving wound care treatments three times a week for seven pressure ulcers. Review of initial wound assessments dated 6/19/2020, 7/14/2020, 7/23/2020, 8/14/2020, 9/01/2021 and 12/24/2021 revealed that R31 had developed facility-acquired pressure ulcers to the left buttock ischium, right trochanter, left anterior outer knee, right lateral thigh, left inner knee, and top of the left foot. In addition to these six facility-acquired pressure ulcers, interview on 1/20/2022 at 3:25 p.m. with Licensed Practical Nurse (LPN) 1, who served as the Wound Care Nurse, revealed that although the pressure ulcer on R31's sacrum that was present on admission healed, it then re-opened on 05/31/21. (Refer to F686 for additional details.) Review of the Physician Order Report, for R31 dated 1/1/2022 through 1/18/2022 located in the EMR Orders tab, revealed R31 's Orders included an order dated 10/25/2021 which documented, Pillow between knees and wedge under distal bilateral knees every shift. Review of the Care Plan for R31 located in the EMR (RAI) tab; initiated 3/2/2020, revealed the Care Plan was not revised to include the development of new pressure ulcers, and did not include the current orders/approaches, such as the pillow and wedge, which were to be used in response to the resident's seven pressure ulcers. The Care Plan goal dated 6/2/2020 documented, Resident's wound will show evidence of healing and other skin will remain intact through the next review. The approaches section of the Care Plan included, 12/4/2020-wound care clinic. The Care Plan did not reflect the pressure ulcers that developed on 6/19/2020, 7/14/2020, 7/23/2020, 8/14/2020, 9/1/2021 and 12/24/2021. Interview on 1/20/2022 at 3:25 p.m., with Licensed Practical Nurse (LPN) 1 revealed that the 12/4/2020 intervention of wound care clinic was not reflective of the resident's current care, as R31 was not being transported by the facility to a wound care clinic, and a wound care physician came to the facility and provided wound care on site. During an additional interview on 1/21/2022 at 12:59 p.m., LPN1 stated she was assigned to complete wound-related care plans. LPN1 confirmed that she had not revised R31's care plan to reflect the new pressure ulcers that developed after the resident's admission to the facility, including approaches identified/ordered to promote healing for each new pressure ulcer. Cross refer F686

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review, review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, and review of the facility policy titled, Pressure Ulcer Prevention the facility failed to provide pressure reduction interventions, which resulted in the development of avoidable pressure ulcers for one of three residents (R31) reviewed for pressure ulcers. Actual harm was identified to have occurred when R31 developed seven avoidable pressure ulcers, which caused loss of multiple areas of healthy skin tissue/integrity as well as placed R31 at risk for pain, discomfort, and wound infection. Findings include: Review of the NPUAP 2019 Clinical Practice Guideline, Pressure Ulcer Prevention, revealed, Avoidable means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: . define and implement interventions that are consistent with resident needs . and professional standards of practice . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. Pressure Points and Tissue Tolerance . tissue closest to the bone may be the first tissue to undergo changes related to pressure. Pressure ulcers are usually located over a boney prominence, such as the sacrum, heel, trochanter, ischial tuberosity, fibular head, scapula, and ankle . due to the anatomy of mucous membranes, some ulcers cannot be staged. Pressure ulcers on the sacrum and heels are most common. Review of the NPUAP 2019 Clinical Practice Guideline, Pressure Ulcer Staging indicated, Unstageable-obscured full thickness skin and bone loss, obscured by slough or eschar. Stage II-Partial thickness skin loss with exposed dermis. Stage III-Full thickness skin loss. Stage IV-Full thickness, skin and tissue loss. Review of the facility policy titled, Pressure Ulcer Prevention revised 9/1/19, revealed, Any identified risks for breakdown will serve as a trigger for preventative measures. Pressure ulcer preventative measures will be implemented according to the identified level of risk on the Braden scale. Review of the facility policy titled, Pressure Ulcer Prevention Protocol revised 12/19/16, revealed staff were to, Position with pillows and support devices . avoid positioning on trochanter when in side-lying position. Review of the Owner's Manual for the Alternating Pressure Mattress (APM), indicated, Use flat sheets, knitted stretch-fit sheets, or deep-pocketed fitted sheets. Use as few layers of linens or under-pads beneath the patient as possible to allow the best possible pressure management performance. Review of the Face Sheet for R31 located in the electronic medical record (EMR) on the Face Sheet tab revealed that R31 was admitted to the facility on [DATE]. Diagnoses listed on the Face Sheet included traumatic hemorrhage of cerebrum [traumatic brain injury], chronic respiratory failure, obstructive uropathy [a condition in which the urine flow is blocked], pressure ulcer of sacral region Stage IV, gastrostomy [an opening into the stomach from the abdominal wall made surgically for introduction of food], and a tracheostomy [an opening surgically created through the neck into the trachea (windpipe) to allow direct access to a breathing tube]. Review of the quarterly Minimum Data Set (MDS), for R31 with an Assessment Reference Date (ARD) of 12/24/2021 located in the EMR on the RAI tab, indicated R31 had severely impaired cognitive status and was totally dependent on two staff for bed mobility, transfer, dressing and all activities of daily living. The MDS indicated R31 was unable to communicate verbally to make his needs known, had limited range of motion of upper and lower extremities, and received enteral feedings via a feeding tube [a medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake]. The MDS indicated R31 had a suprapubic urinary catheter [a catheter that is surgically inserted into the bladder through an incision above the pubis]. Review of the Physician Order Report, for R31 dated 1/1/2022 through 1/18/2022 and located in the EMR Orders tab, revealed R31 's Orders included an order dated 10/25/2021 which documented, Pillow between knees and wedge under distal bilateral knees every shift. Review of the Wound Assessments for R31 located in the Wound Management tab of the EMR, revealed R31 was currently receiving wound care treatments three times weekly for seven pressure ulcers. Review of R31's initial wound assessment dated [DATE], revealed the resident was admitted with one Stage IV pressure ulcer to the sacrum, 2.5 centimeters (cm) long by 2.9 cm wide. Review of the admission Braden Scale for Prediction of Pressure Sore Risk (Acuity), for R31 located in the EMR under the Reports tab and dated 3/2/2020; revealed R31's total Braden Scale Score was determined to be 9-very high risk, for pressure ulcer development. Further initial wound assessments dated 6/19/2020, 7/14/2020, 7/23/2020, 8/14/2020, 9/1/2021 and 12/24/2021 revealed that while a resident of this facility, R31 developed additional, facility-acquired, pressure ulcers. Review of the initial wound assessments provided by Licensed Practical Nurse (LPN) 1 revealed the following information about these facility-acquired pressure ulcers: 6/19/2020: in-house acquired Stage II pressure ulcer left buttock ischium, 1.9 cm long by 2.6 cm wide. 7/14/2020: in-house acquired unstageable pressure ulcer right trochanter with slough, 6 cm long by 6.5 cm wide with necrotic tissue [dead tissue]. 7/23/2020: in-house acquired unstageable pressure ulcer left anterior outer knee, 2.3 cm long by 1.7 cm wide with slough [dead tissue]. 8/14/2020: in-house acquired unstageable pressure ulcer right lateral thigh, 2 cm long by 3.8 cm wide with necrotic tissue. 9/1/2021: in-house acquired Stage III pressure ulcer left inner knee, 1.5 cm long by 1.7 cm wide serosanguineous with granulation tissue [tissue that will fill in a wound where there has been tissue loss]. 12/24/2021: in-house acquired Stage IV pressure ulcer lateral top of left foot 2.1 cm long by 0.5 cm wide by 0.1 deep with granulation tissue. Observation on 1/18/2022 at 2:23 p.m., R31 was observed in bed, positioned on his left side. Both legs were observed with the knees up toward his upper body. There was no pressure reduction wedge supporting his legs. His knees were touching skin to skin against the boney prominence. There was no pillow between the boney prominences of his knees. R31 was lying on an alternating air mattress and there were two thick cloth incontinent pads placed under his buttocks and upper trunk. R31 was observed with an adult disposable brief under his buttocks. Observation on 1/20/2022 at 2:30 p.m., R31 was observed in bed, positioned partially on his back and right side. There was no pillow between his knees and the inside of his knees were touching skin to skin on the boney prominences. During an interview on 1/20/2022 at 3:25 p.m., Licensed Practical Nurse (LPN) 1 stated she had been the facility wound care nurse for approximately six months. LPN1 stated that when she first started as the wound care nurse, staff were not turning and positioning residents a minimum of every two hours or when needed. The interview with LPN1 confirmed R31's current pressure ulcers were all developed in the facility. She stated that in addition to the six new facility-acquired pressure ulcers, the pressure ulcer on R31's sacrum that was present on admission healed, and then re-opened on 05/31/21. LPN1 confirmed that the resident's pressure ulcers were avoidable due to the facility's failure to provide pressure reduction interventions. LPN1 was unable to provide an initial wound assessment for the sacral pressure ulcer that re-opened during R31's stay on 5/31/2021. Observation on 1/21/2022 at 8:15 a.m., R31 was observed with no pillow between his knees and his knees were skin to skin against the boney prominences. R31 was observed lying on two thick cloth incontinent pads placed under his buttocks and upper trunk. R31 had a urinary catheter preventing any urine from contaminating his skin and he was lying on an adult disposable incontinent brief. R31 was lying on an alternating air mattress. During a continuous observation on 1/21/2022 between 8:20 a.m. and 9:30 a.m., LPN1 was observed providing pressure ulcer wound care to R31. The Infection Preventionist (IP) assisted LPN1 with the wound care. LPN1 measured, staged, and verbally described each wound during the observation with the following information: Right lateral thigh-Stage III developed in-house, 3.4 cm long by 1.7 cm wide. The wound bed is flat, serosanguineous drainage, wound bed is red. This pressure ulcer developed in the facility. Right trochanter-closed pressure wound with protective dressing. Left inner knee- 1.8 cm long by 1.4 cm wide Stage II pressure ulcer developed in the facility. Sacrum- This was an admitted pressure ulcer that was healed but it re-opened. The area is the right upper buttock, but the doctor calls it the sacrum, this is 0.2 cm long by 0.6 cm wide and 0.4 cm deep. Left outer knee is 1.7 cm long by 2.8 cm wide, this started as an unstageable pressure ulcer in the facility. Left ischium area on boney prominence is 0.9 cm long by 1.2 cm wide. This is a healing Stage IV that healed and then reopened in the facility. Left lateral foot, the doctor calls it the top of the foot. This is a healing Stage III developed in the facility. 0.1 cm long by 0.7 cm wide. Following the wound care observation on 1/21/2022 at 9:40 a.m., the IP stated the staff used the cloth incontinent pads under R31's buttocks and upper body to catch respiratory secretions and to lift the resident in bed. The IP agreed that due to the presence of the urinary catheter, R31's skin was not moist from urine. An interview on 1/21/2022 at 11:10 a.m. with the Director of Nursing (DON) and the Administrator. The Administrator denied that R31's pressure ulcers were avoidable, due to his comorbidities. The Administrator provided a copy of R31's Long Term Care Physician Progress Note dated 7/26/2021 which documented, Resident is at risk for further impaired skin integrity, wounds are not likely to improve or heal related to condition and comorbidities. The Administrator was unable to provide documentation from R31's physician that the pressure ulcers developed in the facility were unavoidable. During this interview, the DON provided no information about the development of the facility-acquired pressure ulcers. During an interview on 1/21/2022 at 1:33 p.m., the Registered Dietitian (RD) stated, I have known the resident [referring to R31] since he was admitted . He had a Stage IV pressure ulcer on admission and nutritional interventions have been consistent and evaluated every month. He has received adequate protein supplements since admission and his albumin and protein levels have been consistent every month. His nutritional status is not a factor in the development of pressure ulcers. He is nutritionally sound. Review of R31's Physician Order Report dated 1/1/2022 through 1/18/2022 located in the EMR Orders tab, confirmed R31 was receiving nutritional supplements including folic acid, Juven 1.5 grams of protein powder twice daily, Pro-stat amino acids daily, vitamin-B-1 100 milligrams (mg) daily, calcium 500 mg twice daily, and Benecalorie nutritional supplement three times daily for pressure ulcers. During a telephone interview on 1/21/2022 at 6:15 p.m. , R31's attending physician (MD) 1 who was also the facility Medical Director, stated, Yes, I know this resident [R31] well; they may not be providing the special care those residents with trachs [tracheostomies] and feeding tubes require. The resident needs special attention due to his condition. I would expect the staff to ensure each resident is positioned based on their individual needs to prevent pressure ulcers. Of course, they would say they (the pressure ulcers) are unavoidable. I agree that he (R31) is nutritionally sound, and he is receiving full protein needs with enteral feedings. The dietitian follows him very closely. They (facility staff) need to ensure the resident has tissue off-loading to ensure pressure ulcers don't develop. There is no medical reason this resident has seven pressure ulcers. If they are on boney prominences, they have not reduced pressure. They will take a long time to heal.