Based on record review, staff and resident interviews, review of the facility policy titled, Incidents and Accidents, facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, and Operational Manual, the facility failed to ensure three of 19 sampled residents (R) (R14, R15, R30) were free of accidents and hazards. Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an electrical stimulation (e-stim) treatment (a device that sends electrical impulses through electrodes attached to the skin to help with physical therapy and fitness) treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Additionally, the facility failed to ensure resident's (R) (R14), (R15), and (R30) safety by having power strips maintained on the floor and bedside table while being utilized with medical equipment. Findings include: A review of the facility's undated policy titled Incidents and Accidents, revealed it is the policy of the facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. Compliance guidelines: 6. In the event of an incident or accident, immediate assistance will be provided, or securement of the area will be initiated unless it places one at risks or harm. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. 8. The supervisor or other designee will be notified of the incident/accident. 9. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated. 12. The nurse will enter the incident/accident information into the appropriate form/system within 24 hours of occurrence and will document all pertinent information. 13. Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications and orders obtained or follow-interventions. A review of the facility's tool titled Electrical Stimulation Prep, Precautions, and Contraindications, indicated electrical stimulation can be used in an adjunctive treatment in managing many disorders. Contraindications and Precautions: Over areas with diagnosed pathology (e.g., diabetic neuropathy). A review of the facility's tool titled _____ Operational Manual, Warning: Do not use this device under these conditions - On open wounds or rashes, or over swollen, red, infected, or inflamed areas or skin eruptions, or on top of, or in proximity to cancerous lesions; over areas of skin that lack normal sensation. Never apply the electrodes to - If the patient experiences any skin irritation or redness after a session, do not continue stimulation in that area of the skin. General Warnings - Before administering any treatment to a patient you should become acquainted with the operating procedures for each mode of treatment available, as well as the indications, contraindications, warnings, and precautions. Consult other resources for additional information regarding the application of electrotherapy and ultrasound. General precautions - If a patient is injured during treatment discontinue use immediately and contact your dealer about the injury. 1. Review of the Electronic Medical Record (EMR) for R14 revealed a diagnosis that included Type 2 diabetes mellitus with diabetic neuropathy and generalized muscle weakness. Review of the Quarterly Minimum Data Set (MDS) assessment for R14 dated 6/12/2024 revealed a Brief Interview for Mental Status Score (BIMS) of 14, indicating little or no cognitive impairment. Review of the EMR for R14 revealed a physician order dated 5/10/2024 for physical therapy to address the therex, theract, neuro re-ed and electrical stimulation (e-stim) and or ultrasound (U.S.) for right knee pain 1-5 times per week for 30 days. Further review of physician orders revealed an order to wash right lower extremity with soap and water, pat dry, apply Silvadene cream/non-stick dressing daily and as needed with a start date of 6/26/2024. Review of the Physical therapy Evaluation and Plan of Treatment for R14 dated 5/10/2024 revealed a plan of treatment that included Modality application, electric stimulation, manual and modality application, ultrasound, and constant attendance. Goal -Patient will exhibit a decrease in pain at rest to 4/10 in the right knee to increase patient's ability to perform functional transfers with supervision. Record review of the Physical Therapy Treatment Encounter Note for R14 revealed that on 6/5/2024, upon therapist entering R14's room, resident presented with sores around right lower leg appearing to be from e-stim machine. Resident denying two sores origin being e-stim, stating sore on the right inner knee from e-stim the previous day and he has been treating it with antibiotic ointment. E-stim held this day, will follow up. Further review of therapy notes revealed there were not any follow -up notes related to the burns. Record review of the EMR for R14 revealed there was no evidence that the physician or nurse practitioner had been notified related to his burn until 6/16/2024 (11 days later). Review of the therapy progress notes revealed R14 received an e-stim treatment on 6/13/2024 for 20 minutes after the therapy staff were aware of the burn sustained and identified on 6/5/2024. Record review revealed a progress note dated 6/16/2024 that indicated R14's right lower leg was observed to be red and warm to touch, resident verbalized some tenderness to the area. R14 was also observed with an open area below his right knee which he reported occurred with the therapy treatment. Nurse Practitioner (NP) was called, and new orders were received for Bactrim DS, one tablet by mouth twice a day for ten days. Record review revealed a progress note dated 6/18/2024 which indicated a treatment order for the burn sustained for e-stim on 6/5/2024 was not received until 6/16/2024. An order was received for Bactroban and Santyl to the area. Further review revealed the burn was covered and an order was received for Bactroban and Santyl to site. Further review of R14's record revealed a weekly wound observation tool dated 6/18/2024, which indicated the resident had a burn; this was the first observation, and the burn had 100% slough in the wound bed. The burn measured 05 x 05 x 01 millimeters(mm). Record review revealed a progress note dated 6/18/2024 which indicated the e-stim has been discontinued at this time. During an observation and interview on 8/9/2024 at 8:40 am with R14, he stated that he sustained a burn on his right leg at the facility. He further revealed the therapy department had received a new machine that was supposed to stimulate his muscles and nerves in his leg. R14 further stated the girl from therapy entered his room, applied the device to three different areas on his leg, and left the room. R14 was observed to still have brown marks on his leg and a white bandage. R14 further stated that after about 15 or 20 minutes, the areas where the device was applied began to burn him like crazy, so he removed the pads from his leg. The resident stated after removing the device, he noticed, he had three burn marks on his leg. He stated two of the areas on the outer aspect of his right leg were really superficial and eventually left two brown marks, but the area on the inner aspect just below the knee was really bad, deep, and very tender. R14 further revealed that he informed the therapist when she returned to the room, but she just took the machine and left the room. Observations of the room revealed an electrical surge protector on the resident's bedside table with the red indicator light illuminated. There were three cords plugged into the surge protector with a container of clear liquid alongside the surge protector. During an interview on 8/9/2024 at 3:06 pm with the Physical Therapy Assistant (PTA) DD stated that she noticed the two brown areas and an open area on the right lower leg of R14. She further stated that R14 informed her that the e-stim had gotten too hot, and he removed the device from his leg, and the resident informed her not to worry about it. PTA DD stated she documented her observations in the progress notes and informed the Therapy Manager on the day of her observations. She revealed that she always remained with the resident during treatment, which lasted between 15 and 20 minutes. PTA DD further revealed whenever she implemented the e-stim treatment, she monitored the resident for complications, and he never voiced any concerns to her during or after the treatment. PTA DD further stated she failed to communicate her observations to the nursing staff or Administrator. During an interview on 8/9/2024 at 3:49 pm with the Assistant Director of Nursing (ADON) revealed no one from physical therapy alerted the staff about the burn that R14 received during treatment. The ADON reviewed the EMR and verified there was not any documentation in the record to include an event report or change in condition report related to the burn until 8/16/2024. The ADON further stated the nurses should have completed a Situation Background Assessment Recommendation (SBAR) and contacted the physician or NP after learning of the areas. During an interview on 8/9/2024 at 3:54 pm with Licensed Practical Nurse (LPN) BB, who stated that she learned of R14 having a burn when he informed her and notified the Registered Nurse (RN) Supervisor on 6/16/2024. LPN BB stated no one from the physical therapy department informed her of the incident with the e-stim device. During an interview on 8/9/2024 at 4:05 pm with the Administrator revealed she was aware R14 was receiving treatment for a burn, but she was not aware the burn was sustained during an e-stim treatment with physical therapy. The Administrator further stated she was under the impression that the burn was discovered shortly after his admission to the facility, and he had prior to coming to the facility. During a telephone interview on 8/9/2024 at 4:10 pm with the Regional Rehabilitation Manager revealed she was made aware of the resident sustaining a burn during e-stim treatment, a performance improvement plan (PIP) was put in place, education for e-stim training with the physical therapy staff was provided. The Regional Rehab Manager stated she couldn't change what happened, but she reinforced the education and the training after learning of the incident. Observation on 8/10/2024 at 8:51 am revealed R14 lying in bed with his head covered. The surge protector remains on the bedside table, unsecured, with a red indicator light on and two cords plugged into the device. A follow-up interview on 8/10/2024 at 9:23 am with the Physical Therapy Manager stated she did not document when she was informed of the burn on R14, nor did PTA DD complete an incident report. The Physical Therapy Manager further stated she assumed the PTA DD reported the burn to nursing. The Physical Therapy Manager verified that R14 received e-stim treatment on 6/13/2024 after the therapy staff was aware of the burn and that the e-stim treatments were not discontinued until 6/18/2024. A telephone interview on 8/10/2024 at 9:45 am with PTA EE revealed she administered e-stim treatment for R14. PTA EE further stated the treatments were supervised; she stated someone would always be in there throughout the treatment, most likely. PTA EE stated that R14 never gave her indications that the treatment was hurting. She further stated the Physical Therapy Manager informed her of the burn, and she went and looked at it and observed a hole burned in his leg. She stated she was not sure when the e-stim treatment burn occurred. PTA EE further revealed if she had documented the treatment on the 13th, then she was not aware of the burn, and e-stim therapy is contraindicated to continue treatment on a resident who had sustained a burn. During a follow-up interview on 8/10/2024 at 10:30 am with R14 he stated that he was never informed that the machine could potentially cause a burn. R14 stated that the nurses told him that he needed to go to the doctor due to a deep hole burned in his leg, but they did not do anything for a long while. R14 revealed when he went to the wound doctor for his left amputation, he had the doctor look at the burn, and he gave him some Silvadene cream to put on it. On 8/10/2024 at 11:25 am, the Administrator and Physical Therapy Manager entered R14's room with the surveyor and stated the education with the physical therapy department began on 6/19/2024. She did not give a reason why the education was delayed. A follow-up interview on 8/10/2024 at 2:34 pm with the Infection Control Preventionist (ICP)/Wound nurse, stated R14 had already received antibiotics for treatment, and he went to the wound doctor for his stump. She revealed the wound doctor gave her an order on 6/26/2024 for the Silvadene cream. She stated that R14 reported the burn was very tender. 2. A review of the EMR for R30 revealed a diagnosis that included but not limited to chronic pulmonary disease, generalized anxiety disorder, and major depressive disorder. Review of the quarterly MDS for R30 dated 6/4/2024 revealed a BIMS of 14, indicating little or no cognitive impairment. Observation on 8/09/2024 at 8:33 am and 3:12 pm revealed an unsecured surge protector on the floor with the red light on, indicating it was in use. The surge protector was on the floor at the foot of R30's bed and had the oxygen concentrator, nebulizer, and electrical bed plugged in at the time of this observation. Observation on 8/10/2024 at 8:46 am revealed R30 sitting up in bed eating breakfast. The surge protector continues to be on the floor, unsecured, with medical equipment plugged into the device. During an interview on 8/10/2024 at 10:12 am with R30 revealed the surge protector has been on the floor for over a week. He further stated the Maintenance Director (MD) placed it there when he was repairing their bathroom and never placed it back on the wall. 3. Record review of EMR for R15 revealed a diagnosis that included but not limited to chronic pulmonary disease, heart failure, shortness of breath, and obstructive sleep apnea. Record review of the quarterly MDS for R15 dated 6/14/2024 revealed a BIMS of 5, indicating severe cognitive impairment. Observation on 8/9/2024 at 8:24 am and 3:19 pm in R15's room revealed an unsecured surge protector on the floor at the head of the bed with the oxygen concentrator and electrical bed plugged into the surge protector. Observation on 8/10/2024 at 8:48 am in R15's room revealed the surge protector remained on the floor unsecured with the oxygen concentrator plugged in and the bed. During an interview on 8/10/2024 at 10:18 am with Certified Nursing Assistant (CNA) AA, revealed she was aware that surge protectors were supposed to be mounted on the wall and off the floor for safety reasons. She further stated all staff were responsible for notifying the maintenance supervisor when they were not properly mounted. During an interview on 8/10/2024 at 10:24 am with LPN AA revealed she was never informed that surge protectors should not be on the floor and were required to be mounted if being utilized by medical equipment. LPN AA further stated she could see that unmounted electrical devices could potentially be a hazard. During an interview on 8/10/2024 at 10:31 am with Housekeeping Aide CC revealed she had visualized surge protectors in resident's rooms on the floor and tables but was not aware that was an issue and it needed to be reported. Interview and walking rounds on 8/10/2024 at 10:41 am with the Director of Nursing (DON) and Maintenance Director (MD) verified the unsecured surge protectors on the floor and resident bedside table being utilized with medical equipment plugged into them. The DON stated the MD was responsible for mounting surge protectors on the wall and that surge protectors should never be on the floor. The MD stated he thought surge protectors should be mounted on the wall because it was a trip hazard. The MD further stated he walks around and checks surge protectors weekly, and they were last checked last Friday. The MD revealed further staff informed him yesterday morning (8/9/2024) that there were some surge protectors on the floor, but he didn't have time to mount the surge protectors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and a review of the facility's Facility Assessment, the facility failed to ensure the physical therapy staff were informed or educated prior to applying an electronic medical device for electrical stimulation treatment (also known as e-stim, which is a treatment method often used in physical therapy and pain management to deliver mild electrical currents through the patient's skin to either target the muscles to stimulate quicker recovery or the nerves to reduce pain) for one of one resident (R) (R 14). Actual harm occurred on 6/5/2024, when physical therapy staff failed to oversee an e-stim treatment for R14, resulting in a burn to the right leg with 100% slough in the wound bed. Findings include: A review of the Facility Assessment, dated 8/8/2024, revealed Purpose Statement: The purpose of this assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Information About Our Staff Training/Education and Competencies: Our facility's training program includes an orientation process and ongoing training for all new and existing staff, including managers, nursing, and other direct care staff, and other individuals consistent with their expected roles. The training content at a minimum includes Effective communication, special needs of residents, and identification of resident changes in condition. Record review of the quarterly Minimum Data Set (MDS) for R14 dated 6/12/2024 revealed a Brief Interview of Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. During an observation and interview on 8/09/2024 at 8:40 am with R14, he stated that he sustained a burn on his right leg at the facility after a girl from physical therapy applied the device in three different areas and left the room. R14 stated the device started burning him like crazy and he removed the device. Once he removed the device R14 stated he saw three burn marks on his leg. R14 revealed that staff should not be allowed to use them as [NAME] pigs to try out new equipment without the proper training. R14 stated the staff did not have any training on the machine and that the Physical Therapy Assistant (PTA) DD informed him she had to go home and look up the operation of the device online. During an interview on 8/9/2024 at 3:01 pm with the Physical Therapy Manager, she revealed that R14 was the only resident with a treatment plan to include e-stim treatment in the last couple of years. The Therapy Manager stated she was not credentialed to administer the treatment, but it was her understanding that once the e-stim treatment started, the staff member applying the device was required to remain with the resident throughout the entire treatment. The Therapy Manager further stated that the therapy staff were not trained nor received education in the facility to ensure they were competent before initiating the e-stim treatment because it is a part of their schooling. During an interview on 8/9/2024 at 3:06 pm with the Physical Therapy Assistant (PTA) DD stated the facility did not provide her with any training on the e-stim device before initiating treatments for R14. PTA DD stated she received modality training while in school, and she can apply the e-stim, but we don't get a certification for it. During an interview on 8/9/2024 at 4:05 pm with the Administrator revealed she believes the therapy staff should have some type of skill checkoff to ensure that they are competent. The Administrator revealed that she was aware R14 was receiving treatment for a burn, but she was not aware the burn was sustained during an e-stim treatment with physical therapy. During a telephone interview on 8/9/2024 at 4:10 pm with the Regional Rehabilitation Manager revealed that there was no training provided to the therapy staff related to the e-stim device before the burn occurred. She stated the therapy staff are trained through their certification on e-stim. She further stated the therapy department has made it a practice from that point forward that the staff will be trained to ensure they are appropriately applying the treatment. During a follow-up interview on 8/10/2024 at 9:23 am with the Physical Therapy Manager, she stated she assumed the Physical Therapy Assistants (PTA)s had more experience as clinicians. During a telephone interview on 8/10/2024 at 9:45 am with the Physical Therapy Assistant (PTA) EE revealed the facility did not provide any formal training on e-stim. PTA EE stated she applied the device on herself to figure it out before she used it on the R14. On 8/10/2024 at 11:25 am the Administrator and Physical Therapy Manager entered R14's room with the surveyor and stated the education with the physical therapy department began on 6/19/2024. She did not give a reason why the education was delayed. Cross Reference F689