**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and facility policy review, it was determined that the facility failed to provide care and treatment to promote healing of pressure ulcers and prevent new ulcers from developing for one of three sampled residents (R) (R#101) reviewed for pressure ulcers. Specifically, the facility failed to complete weekly skin assessments to allow for identification and treatment of new areas of skin breakdown; failed to complete weekly measurements and assessments of existing pressure ulcers to track healing progress or determine if deterioration had occurred; and failed to complete pressure ulcer treatments per the physician's orders to promote the healing and prevent potential infection for R#101. The failures resulted in R#101's pressure ulcer deteriorating from a stage 2 wound to an unstageable wound. The facility identified nine residents who had pressure ulcers. Findings included: A review of a facility policy titled, Skin Assessment, dated as implemented 2/1/22, revealed, A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. A review of a facility policy titled, Pressure Injury Prevention and Management, dated as implemented 2/1/22, indicated, This facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. The policy also indicated, Assessments of pressure injuries will be performed by a licensed nurse and documented on the (fill in blank for designated form). The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set]. Additionally, the policy specified, Evidence based treatments in accordance with current standards of practice will be provided for all residents who have a pressure injury present. A review of an admission Record revealed R#101 had diagnoses that included hypertension, diabetes, chronic kidney disease-stage 3, and chronic deep vein thrombosis (a condition in which blood clots form in veins located deep inside the body, usually in the thigh or lower legs). A review of Weekly Skin Assessments, completed by a licensed nurse, revealed skin assessments were completed weekly from 3/25/21 through 7/21/21. The results of the 7/21/21 weekly skin assessment for R#101 indicated the resident had no pressure injuries but had a skin tear to the left lower leg. The next weekly skin assessment was dated as completed four months later, on 11/23/21. This skin assessment indicated R#101 had a stage 2 pressure injury to the left buttock measuring 1.5 centimeters (cm) long by (x) 1.7 cm wide x 0.1 cm deep. The nurse documented the date of onset for the pressure injury was 11/23/21. Review of a Progress Note, dated 11/23/21 by the treatment nurse, revealed staff had requested she assess R#101. The nurse documented the resident had a shear injury involving superficial skin. She noted there was no drainage or signs of infection. The note indicated the treatment nurse cleansed the wound and applied a protective dressing. A review of the November 2021 Treatment Administration Record (TAR) revealed that on 11/26/21, a treatment was added for R#101's left buttock wound to be washed with soap and water, patted dry, and covered with a foam dressing as needed every Monday and Friday. The treatments were signed as completed on Friday, 11/26/21 and Monday, 11/29/21. A review of a quarterly MDS, dated [DATE], revealed R#101 had a Brief Interview for Mental Status (BIMS) score of three, indicating the resident was severely cognitively impaired. The MDS indicated the resident had no behaviors, including rejection of care. According to the MDS, R#101 required extensive to total assistance for all activities of daily living and had one stage 2 pressure injury that was present on admission. A review of a weekly skin assessment list, completed by licensed nurses, revealed weekly skin assessments for R#101 were completed on 12/2/21, 12/7/21, 12/19/21, and 12/27/21. Review of the 12/2/21 Weekly Skin Assessment revealed the pressure wound to the resident's left buttock measured 1.5 x 1.5 x 0.1 cm and was a stage 2 wound. Review of the 12/7/21 Weekly Skin Assessment for R#101 revealed the location of the resident's pressure wound was now identified as the sacrum. The wound measured 1.5 x 1 x 0.1 cm and was a stage 2. A review of a Progress Note, dated 12/7/21, revealed the resident was assessed by a nurse following a staff request. The note indicated R#101 had a wound on the sacrum with a red skin base and peri-skin alteration with suspected deep tissue injury to the peri-skin. The nurse indicated the Nurse Practitioner (NP) was made aware and a new order was obtained for a foam dressing change weekly. A review of Progress Notes revealed on 12/7/21, the NP's assessment and plan for R#101 indicated there was a sacral wound and to continue to monitor. The note further indicated that treatments were in progress and to encourage the resident to turn and reposition. Review of a Progress Note, dated 12/19/22 by the treatment nurse, revealed a draw sheet was utilized for R#101. The note indicated other interventions included a wheelchair cushion; the head of the bed maintained at less than or equal to 30 degrees elevation, with the knees elevated; and turning and repositioning at least every two hours while in bed. The treatment nurse documented a semi-occlusive dressing was applied over the ulcer, affected by incontinence. A review of a skin assessment completed by the treatment nurse and signed on 12/22/21 indicated R#101 had a stage 2 pressure area to the sacrum measuring 1.5 cm x 1 cm x 0.1 cm. The date of onset was entered as 12/7/21, and the treatment was listed as a foam dressing. On the same day (12/22/21) the treatment nurse had completed another assessment of R#101's sacral pressure ulcer and documented the measurements as 1 cm x 0.8 cm x 0 cm and identified the wound as a stage 2. A review of the 12/27/21 weekly skin assessment completed by a licensed nurse for R#101 revealed the pressure injury was identified as a sacral pressure injury measuring 0.2 cm x 0.2 cm with the stage identified as not applicable (N/A). The treatment nurse completed a weekly skin assessment as well and entered the same information, with N/A for the stage. The treatment nurse identified the treatment for the sacral wound as skin barrier. A review of a Progress Note, dated 12/27/21 and written by the treatment nurse, indicated R#101 continued to receive skin care for a stage 2 wound to the sacrum. The pressure ulcer was described as pale pink epithelial tissue with no drainage or signs of infection. There were no more assessments of the sacral pressure ulcer found in R#101's medical record. A review of R#101's December 2021 TAR indicated multiple treatments. These treatments included: - A treatment dated as initiated 11/26/21 and discontinued 12/3/21 indicated to wash the left buttock with soap and water and pat dry, then apply a foam dressing. The dressing was to be changed as needed every Monday and Friday. The treatment was signed as completed on 12/3/21. - A treatment dated as initiated 12/3/21 and discontinued 12/7/21 indicated to wash the left buttock with soap and water and pat dry, then apply skin barrier every shift for a skin alteration. Seven scheduled treatments were signed as completed and four scheduled treatments were not signed as completed. - A treatment dated as initiated on 12/14/21 and discontinued 12/27/21 indicated to clean the sacral wound with saline, pat dry, and cover with a foam dressing, which was to be changed weekly and as needed every Tuesday on day shift. This treatment was signed as completed on Tuesday 12/14/21 and Tuesday 12/21/21. - A treatment dated as initiated 12/27/21 and discontinued 1/15/22 indicated to clean the sacrum with soap and water, pat dry, and apply skin barrier protection every shift. The area was to be left open to air. Four of the scheduled treatments were not signed as completed. The review of the January 2022 TAR for R#101 indicated the following treatments for the sacral wound: - A treatment dated as initiated 12/27/21 and discontinued 1/15/21 indicated to wash the sacrum with soap and water, pat dry, and apply skin barrier protection every shift. The area was then to be left open to air. Fourteen of the 43 opportunities to provide this treatment were not signed as completed for the resident. - A treatment dated as initiated 1/15/22 and discontinued 2/4/22 indicated to cleanse the sacrum with normal saline, pat dry, and apply skin prep and a dry dressing every shift until healed. Fourteen of the 47 opportunities to provide this treatment for R#101 were not signed as completed. Review of a nurse's Progress Note, dated 1/15/22, indicated the dressing to R#101's sacrum was changed. The nurse documented the area was a dime-sized opening. There were no sacral wound assessments found in R#101's chart that indicated if the sacral wound improved or declined during the month of January 2022. A review of a Registered Dietitian's (RD) Progress Note, dated 2/7/22, indicated the resident received a liquid supplement twice daily that was well accepted most of the time. The RD noted R#101's skin was intact, with no skin breakdown, and the resident was off the wound care caseload. Review of the February 2022 TAR for R#101 indicated the sacral wound was cleansed with normal saline and a skin prep was applied. This was to continue every shift until the wound was healed. The treatment started on 1/15/22 and ended on 2/4/22. Ten treatment opportunities were identified for R#101, with only five of the treatments signed as completed. No further treatments were documented for R #101's sacral pressure ulcer. There were no treatment notes that included measurements or descriptions of the resident's wound. A review of the weekly skin assessment listing indicated that after 12/27/21, the next weekly skin assessment for R#101 was completed three months later, on 3/29/22. Review of the results of the 3/29/22 skin assessment, completed by a licensed nurse, revealed R#101 had a stage 2 left buttock pressure ulcer measuring 1.5 cm x 1.5 cm x 0 cm. Additionally, the assessment indicated the resident had a stage 2 right buttock pressure ulcer measuring 2 cm x 2 cm x 0 cm. The assessment indicated R#101 had a wound on the right heel measuring 3 cm x 3 cm x 0 cm with the stage identified as N/A. This was not identified as a pressure wound. The onset date for the wounds was indicated to be 3/29/22. The description of the right heel wound was black tissue (indicating the tissue was dead) with no granulation (healthy) tissue. The treatment was to apply Betadine, a dry dressing, and kerlix (a gauze product that can be wrapped around an extremity to secure a dressing in place). Review of a Progress Note, dated 3/29/22 and written by a licensed nurse, indicated R#101 had two new wounds. The nurse noted R#101 had superficial wounds to the right and left buttock and a blister to the right heel. There were no further weekly skin assessments completed by the nurses for R#101 after 3/29/22. Review of the March 2022 TAR for R#101 indicated that on 3/30/22, treatments were initiated for R#101's right heel blister and right and left buttock wounds. The treatments were documented as completed on 3/30/22 and 3/31/22. Review of the RD's quarterly assessment, dated 4/5/22, indicated there were no wounds documented for R#101. Review of a Skin/Wound progress note, dated 4/11/22, revealed the resident's representative (RR) was notified the wound nurse would be assessing R#101. The RR requested a wedge for positioning and boots for the resident's feet. The nurse indicated the boots had already been ordered. A review of a consultant wound care note, dated 4/25/22, indicated R#101 had two pressure injuries. The first wound was a stage 2 on the buttock. The NP did not identify which buttock. Measurements were documented as 1.5 cm x 0.9 cm x 0.1 cm, with no drainage or odor. The wound was identified as improving. Wound #2 was identified as an unstageable pressure injury on the right heel, measuring 4 cm x 4 cm with no measurable depth. The NP indicated the wound bed was 76%-100% eschar. The NP indicated a recommendation to off-load the resident's heels per facility protocol. The NP also indicated under, Lower Extremity Assessment that there was no off-loading device in use for the resident's right heel and that there had been poor wound progression. A review of the April 2022 TAR for R#101 indicated the following treatments: - A treatment dated as initiated 3/30/22 and discontinued 4/6/22 indicated to cleanse the resident's right and left buttock wounds with normal saline and apply betadine and a dry dressing daily. Out of six opportunities to provide the treatment for R#101, only three were signed as completed. - A treatment dated as initiated 3/30/22 and discontinued 6/7/22 indicated to apply Betadine and kerlix daily to the resident's right heel blister. Of 30 opportunities to complete the heel treatment for R#101 in April 2022, five were not signed as completed. - A treatment dated as initiated 4/18/22 and discontinued 5/29/22 indicated to cleanse the resident's right and left buttock wounds with normal saline and apply hydrocolloid (an occlusive dressing) every three days. However, the TAR also indicated this treatment was to be completed on Mondays and Fridays. The treatments were signed as completed on Mondays and Fridays but not every three days. A review of a consultant wound care note, dated 5/3/22, indicated the right buttock wound had resolved. There was another right buttock pressure ulcer identified that was a stage 2, measuring 2.5 cm x 1 cm x 0.2 cm. A left buttock, stage 2 pressure ulcer measured 1.2 cm x 3 cm x 0.3 cm. The NP documented there was a moderate amount of drainage from the left buttock wound with no odor. The NP recommended a gel treatment that provided nutrients for new tissue growth and a calcium alginate (an absorbent fiber) treatment three times a week. The right heel wound for R#101 continued to be unstageable and measured 4.5 cm x 4.5 cm. There was no drainage or odor noted. The NP documented the recommendation of an off-loading device for the lower extremities and again noted there were no devices for off-loading in place. Further review of notes from the consultant wound care NP revealed the NP saw R#101 on 5/9/2022 and 5/16/22 and noted little change in the wound status. For both visits, the NP recommended offloading of the lower extremities and noted there were no off-loading devices in use for R#101's feet. A review of RD nutrition progress notes dated 5/9/22 indicated the resident had stage 2 pressure injuries to the right and left buttock and an unstageable wound to the right heel that had improved. The RD requested the current diet be continued and recommended encouraging intake and protein rich foods, continuing the frozen nutritional supplement, monitoring the resident's intake, diet status, and tolerance, and adding liquid protein 30 milliliters (ml) per day to help aid in wound healing. A review of the May 2022 Medication Administration Record (MAR) for R#101 revealed the RD's 5/9/22 recommendation for added protein for wound healing was not initiated. Review of a consultant wound care note, dated 6/6/22, revealed the right heel remained unstageable, with measurements of 3.5 cm x 6 cm. The wound was described as 76% to 100% eschar. A sacral wound was identified as stage 3, and no left or right buttock wounds were noted. The note indicated there was poor progression of the wounds. The NP again recommended off-loading of R#101's lower extremities and again noted there were no off-loading devices in place. Review of a RD nutrition progress note dated 6/13/22 indicated the RD again recommended adding 30 ml of liquid protein for R#101 to aid in wound healing. A review of a consultant wound care NP note, dated 6/13/22, indicated Resident #101's right heel remained unstageable and measured 4.2 cm x 5 cm with no drainage or odor. The NP noted there had been no change in the wound progression. The sacral wound was measured as 11 cm x 4 cm x 0.2 cm, with a moderate amount of drainage and a strong odor. The NP stated the peri-wound exhibited maceration (a term used to describe the softening and breaking down of skin because of prolonged exposure to moisture). The NP again noted there were no off-loading devices being used for R#101's feet. A review of Progress Notes, dated 6/14/22, indicated R#101's RR was notified to get consent for debridement (the surgical removal of non-viable tissue) of the sacral wound. Later that day, the progress notes indicated a midline intravenous catheter was placed in R#101's left upper arm. A review of Progress Notes, dated 6/14/22 and written by the facility NP, revealed R#101's sacral wound assessment was performed with the assistance of the treatment nurse. The NP indicated a strong odor was noted from the wound, along with necrotic tissue around the wound bed with a foul odor. The NP noted there was yellowish-green drainage oozing from the center of the wound bed and added that the wound NP had scheduled debridement for the following week. The NP indicated wound infection prophylaxis would be initiated, consisting of intravenous (IV) cefepime (an antibiotic) and Flagyl (an antibiotic) for 10 days. A review of the June 2022 MAR for R#101 revealed the liquid protein was added on 6/14/22. Review of Progress Notes, dated 6/20/22 by the facility NP, revealed R#101 had a wound infection/deterioration and was receiving IV hydration and continued antibiotic therapy. The NP noted the family was aware of R#101's health decline. A review of Progress Notes, dated 6/22/22, indicated R#101 was sent to the hospital per the RR's request. Licensed Practical Nurse (LPN) #1 was interviewed on 12/14/22 at 1:46 p.m. The LPN stated that when a pressure injury was found, the nurse was expected to start a treatment plan. She stated the facility had no wound care protocols in place, so the physician had to be called to order the needed treatments. The LPN stated skin checks for residents were completed weekly, either by the nurse on the hall or the treatment nurse. She stated that when a resident was due to have their skin checked, the information popped up on the electronic MAR. The LPN stated the danger of missing skin checks would be unrecognized skin breakdown. The LPN stated if an entry on the MAR or TAR lacked initials, that meant the treatment was not done or the medication was not given. The LPN stated she remembered R#101, adding the resident had been on hospice but the family dropped hospice due to wanting more aggressive treatment for the resident. During a telephone interview on 12/14/22 at 4:08 p.m., the Hospice Registered Nurse (HRN) stated R#101 was discharged from hospice sometime in late 2021. The HRN stated that right before R#101 was discharged from hospice, the resident had reddened skin on the buttocks but no skin breakdown. During an interview on 12/15/22 at 9:00 a.m., the Administrator stated that the treatment nurse who cared for R#101 had not worked in the building for over a year and indicated she had no contact number for the nurse. A telephone interview with the consultant wound nurse practitioner (WNP) was conducted on 12/15/22 at 9:21 a.m. The WNP stated she was only able to remember R#101's sacral wound. The WNP stated R#101 had limited mobility due to their size and had been difficult to position side to side. She stated she remembered the facility using a wedge to help position the resident, but the resident's feet were not off-loaded. She stated that even when staff used a pillow, R#101's heels were not off-loaded and just sat on the pillow. The WNP added that the initial sacral stage 2 wound could have been avoided, but the progressive decline of the sacral wound could not have been prevented due to the resident's poor intake and overall decline. The WNP stated missing treatments to the sacral wound did not help the wound healing. A telephone interview was conducted with the hospice case manager (HCM) on 12/15/22 at 9:45 a.m. The HCM had been R#101's first hospice nurse. She stated that during the time she had seen R#101, the resident had no injuries related to pressure. An interview was conducted with the facility NP on 12/15/22 at 10:08 a.m. The NP stated she consulted for all wounds, in addition to having the WNP see the residents. She stated staff made her aware of the wounds and she also reviewed wound care notes. The NP stated that when she was informed of R#101's sacral wound, the wound was already a stage 3. The NP stated she had a difficult conversation with R#101's family about the wound and the need for the wound care specialist to look at the resident's sacrum. The NP stated any missed treatments would increase the deterioration of the wound, especially in the condition R#101 had been in, adding the resident had co-morbidities that included diabetes, hypertension, recovering from COVID-19, blood clots in the resident's bilateral legs, seizures, hypothyroidism, and dementia. The NP reviewed the 4/25/22 WNP note for R#101 and stated the nursing assistants should have seen some type of impairment prior to R#101's heel wound becoming an unstageable wound. The NP stated she would have expected the staff to assess and measure the wounds weekly. The NP reviewed the list of skin assessments completed by the licensed staff and stated the nurses had done a poor job with skin assessments. The NP stated that during the months when no skin assessments were completed, R#101's wounds may have become worse with no one noticing. The RD was interviewed on 12/15/22 at 10:52 a.m. The RD stated she saw high-risk residents with weight loss or wounds monthly. The RD stated she usually was in the facility on Monday and expected recommendations to be implemented at the latest by Friday. She reviewed the recommendations for a frozen nutritional supplement and the liquid protein she had made and saw the delay in implementation. The RD added that between March 2022 and April 2022, and in May 2022 and June 2022, there had been several turnovers in the facility's Director of Nursing (DON). She stated one DON refused to initiate the recommendations, and it was left for other staff to complete. The RD stated the negative outcomes in delaying dietary recommendations for R#101 were delayed wound healing and weight loss. LPN#5 was interviewed on 12/15/22 at 11:41 a.m. LPN #5 had cared for R#101 during the resident's stay. The LPN stated R#101 had a pressure ulcer on the sacrum but she was unsure of any other skin breakdown. The LPN stated that when she first saw R#101's sacral pressure injury, it was considered a stage 2 and was not bad. She added the resident was followed by the wound consultant. LPN#5 stated interventions in place to help heal the sacral pressure injury and prevent more wounds included liquid supplements, vitamins, and frequent turning when in bed. The LPN stated R#101's feet were elevated on pillows. LPN#5 stated if a treatment was not signed as completed, it meant the nurse either forgot to sign the treatment or failed to do the treatment. She added if wound care treatments were not completed then the wound would get worse. The nurse stated weekly assessments and measuring wounds was the responsibility of the treatment nurse. Weekly skin checks for residents were the responsibility of the treatment nurse and the nurse on the halls. LPN#5 stated if skin checks were not done weekly, something could be missed. The nurse stated skin assessments for the residents were done on bath days and popped up on the MAR when they were due. The nurse reviewed the weekly skin checks and stated she was unaware there had been that many skin checks missed and could not explain why there had been a period of four months without skin checks and another period of three months without skin checks. She could not explain why treatments were missed. She indicated that at the time of discharge, R#101's wound was worse, and the family wanted the resident transferred to the hospital. CNA#13 was interviewed on 12/15/22 at 12:22 p.m. CNA#13 stated she was familiar with R#101. The CNA stated she remembered R#101 had a dressing on the buttock and had a bandage on the heels, but she had not seen the resident's wounds. The CNA stated R#101's position was changed every two hours, the heels were up on a pillow, and pillows were used for positioning. The DON was interviewed on 12/15/22 at 2:50 p.m. The DON stated the treatment nurse who had been responsible for R#101 left before she had arrived on 7/14/22. The DON stated if a treatment had no signature of completion, that treatment had to be counted as omitted since one could not be sure the treatment had been completed. The DON reviewed the December 2021 and January 2022 treatment sheets and stated with that many missed treatments, there had to be a negative effect on R#101's wounds. The DON stated her expectation was for all residents' skin to be inspected at least weekly and added if a resident failed to have a weekly skin check, then wounds could develop without anyone's knowledge. The DON reviewed the skin checks for R#101 and stated going three or four months without skin checks could result in wounds not being found until they were unstageable wounds. The DON stated she was unaware there were issues with skin checks being completed. The DON stated she expected wounds to be assessed weekly to include measurements and the condition of the wound. The DON stated she was unaware skin assessments, to include descriptions and measurements, were not being done weekly. The DON stated she thought no skin inspections between December 2021 and March 2022 had something to do with R#101's right heel wound not being found until it was an unstageable pressure injury. The DON stated it was the responsibility of the treatment nurse to teach staff how to offload and teach other preventative measures. The Administrator was interviewed on 12/14/22 at 4:20 p.m. The Administrator stated the treatment nurse was expected to provide treatments the way they were ordered, make rounds with the wound nurse, and communicate any wound changes to the DON. The Administrator stated treatments and weekly measurements of the wounds was the responsibility of the treatment nurse, and in her absence, the DON. The Administrator stated she expected skin checks to occur as scheduled. The Administrator stated any blank on the treatment sheet meant the treatment was not done. The Administrator stated if treatments were not completed as ordered, wounds could deteriorate, and omitted skin checks would delay identification of new areas of breakdown. The Administrator stated the negative outcome of not measuring wounds would be no knowledge of the progression of the wound. The Administrator stated she had changed DONs three times since November 2021, and there may have been problems with implementation of dietary recommendations. The Administrator stated she had expected the DON at the time R#101 was in the facility to make sure the assessments, skin checks, and treatments had been completed and added she was not aware of the problems with skin checks, wound assessments, and completion of treatments.