**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was admitted with pressure ulcers received appropriate treatment/services to prevent deterioration, infection and additional wounds. (Resident J) The immediate jeopardy began on 1/10/23 when the facility did not follow the Nurse Practitioner treatment orders to prevent the deterioration of the of pressure ulcers, a hospitalization, additional wounds discovered in emergency room and passed away 2 days later due to complications, one being pressure ulcers. The Administrator, the Director of Nursing (DON), an Assistant Director of Nursing (ADON), a Regional Nurse and a Registered Nurse (RN) were notified of the immediate jeopardy, at 4:28 P.M. on 2/28/23. The immediate jeopardy was removed, and the deficient practice corrected, on 3/2/23. Finding includes: On 2/23/23 at 2:28 P.M., a review of the clinical record for Resident J was conducted. The record indicated the resident was admitted on [DATE], as a full code, and discharge to a local hospital on 1/27/23. The resident's diagnoses included, but were not limited to: multiple sclerosis, neuromuscular dysfunction of the bladder, history of urinary tract infections and pressure ulcer of sacral region-Stage III (pressure injury with full-thickness lose of skin). A Braden score, dated 12/30/22, indicated the resident was at high risk for developing pressure ulcers. A pressure ulcer care plan, dated 12/30/22, indicated the resident had pressure ulcers present on admission and was at risk for developing pressure ulcers related to his impaired mobility and bowel incontinence The interventions included but were not limited to: assist with repositioning, observe/report signs & symptoms of infection, provide thorough skin care after incontinent episodes and treatments as ordered. A Physician Assistant Progress Note, dated 12/30/22 indicated .Patient found to be resting comfortably in bed in no acute distress. He states he has a baclofen pump for his MS [multiple sclerosis] that has essentially left him paralyzed from the waste down. The original one that he had become infected and he became septic. He was sent to Indianapolis for surgery on the infected pump area . He spent 6 weeks until he was able to be placed in our facility for further treatment and evaluation .He is unable to voluntary move his lower extremities but does have feeling in his legs The Assessment/Plan indicated the following: .1. Pressure ulcer of sacral region: Did not visualize wound today. Most likely from being bedridden for almost 6 weeks. Wound [Nurse Practitioner] is following and we will follow their recommendations The Treatment Administration Record (TAR) for, December of 2022, had no pressure wound treatments documented. A General Note, documented by the Wound Nurse Practitioner, dated 1/15/23, with a date of service of 1/3/23, indicated .Will debride pressure ulcer with medical grade honey for autolytic debridement and softening of slough; anticipate sharp debridement in follow up. Patient is at increased risk for infection. Recommend specialty bed. Recommend offloading of bony prominence's while out of bed and heels offloaded The Note indicated to see the Tissue Analytic form in miscellaneous section of resident's chart. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/3/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 1.43 x 2.59 x 0.3 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage and no odor. Treatment: wound cleanser then medihoney with bordered gauze TID (three times a day) 2. Left buttock, unstageable wound, measured 6.30 x 4.05 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A moderate amount of drainage. Treatment: wound cleanser then medihoney and bordered gauze BID (twice a day). 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 11.6 x 13.26 x 0.20 cm and was present on admission with scant drainage. Treatment: wound cleanser and then calmoseptine daily and as need for soilage. The admission Minimum Data Set (MDS) Assessment, dated 1/6/23, indicated the resident was cognitively intact, required extensive assistance of two people for bed mobility and transfers. The assessment indicated the resident had an impairment of lower extremities on one side, had a Foley Catheter (a thin tube inserted into the bladder to drain urine into a drainage bag) was always incontinent of bowels and was admitted with two Stage 3 pressure ulcers. A Physician Progress Note, dated 1/6/23, indicated the Medical Director had examined and reviewed the resident's history. The examination indicated the skin was very dry in the lower extremities. The Assessment portion of the Note, indicated .Pressure ulcer of sacral region, stage 3 The treatment portion of the note indicated .Pressure ulcer of sacral region, stage 3 Notes: Wound care underway A General Note, documented by the Wound Nurse Practitioner, dated 1/28/23, with a date of service of 1/10/23, indicated .Unstageable wound to the left and right buttock with surrounding MASD; sharp debridement performed today to the left buttock eschar and curette debredement to right buttock biofilm. Will optimize dressing treatment The Note indicated to see the Tissue Analytic form for full wound assessment. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/10/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 1.89 x 2.22 x 0.3 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage and no odor. Treatment: wound cleanser then calcium alginate medihoney with bordered gauze TID (three times a day) 2. Left buttock, unstageable wound, measured 6.12 x 4.12 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A moderate amount of drainage. Treatment: wound cleanser then calcium alginate, medical-grade honey and cover with bordered foam daily 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 6.86 x 7.97 x 0.10 cm and was present on admission with scant drainage. Treatment: wound cleanser and then thin layer of calmoseptine daily and as need for soilage. Treatment documentation for the left buttock wound: The TAR for January 2023, indicated an order was received, on 1/4/23, for the treatment of the left buttock, stage III, pressure ulcer, which consisted of cleansing the wound with wound cleanser, pat dry and apply Medihoney TID (6:00 A.M., 2:00 P.M. & 10:00 P.M.). This was first documented as completed, on 1/4/23 at 10:00 P.M., and continued, until 1/11/23 at 2:00 P.M. Then the TAR indicated a new order was received, on 1/11/23, which stated .Left Buttock: Pressure Ulcer Stage 3 every day shift .Cleanse with wound cleanser, pat dry, apply Medi-honey TID [three times a day] and PRN [as needed], cover with bordered gauze. Offload with pillow. This treatment documentation started, on 1/12/23 but had been documented, once a day through to 1/27/23 even though the treatment order changed on 1/10/23 (see above) Treatment documentation for the right buttock wound: The TAR, for January 2023, indicated an order was received on 1/11/23 for the treatment of a .Right Buttock: Pressure Ulcer Stage 3 every day shift .Cleanse with wound cleanser, pat dry, apply Medihoney BID [twice a day] and PRN [as needed], cover with bordered gauze. Offload with pillow The first documented right buttock treatment was on 1/12/23 and continued daily, until 1/27/23, even though the treatment order changed on 1/10/23 (see above) Treatment documentation for the MASD: The TAR, for January 2023, indicated an order was received on 1/4/23 for the treatment of .Buttocks: MASD every day shift .Cleanse with wound cleanse, pat dry, apply Calmoseptine/Calazine daily and PRN [as needed] for soilage. The first documented treatment was on 1/5/23 and continued daily until 1/11/23. Then the TAR indicated a new order was received, on 1/11/23, which stated .Buttock: MASD three times a day .Cleans with wound cleanse, pat dry, apply Calmoseptine/Calazime daily and PRN [as needed] for soilage The treatment documentation started on 1/11/23 at 10:00 P.M. and continued TID through, to 1/26/23, even though the treatment order had changed on 1/17/23 (see below) The TAR for January 2023, indicated .Staff to monitor all resident's wounds for both shifts for any changes and signs of infection. Document and report to provider for any changes This was first documented as completed on 1/6/23 at 8:00 P.M. and continued twice a day, until 1/27/23. A General Note, documented by the Wound Nurse Practitioner, dated 1/18/23, with a date of service of 1/3/23 (per DON the date of service corresponded with 1/17/23, Tissue Analytics), indicated no new information and repeated the 1/10/23 General Note. A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/17/23 the resident had the following wounds: 1. Right buttock, Stage 3 pressure ulcer, measured 2.53 x 1.39 x 1.0 centimeters (cm) and was present on admission. The ulcer had a moderate amount of drainage with no odor. Treatment: cleanse wound with Dakins (antiseptic) then collagen with bordered foam daily. 2. Left buttock, unstageable wound, measured 4.46 x 3.77 cm and had 70% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A heavy amount of drainage with malodorous odor. Treatment: cleanse wound with Dakins (antiseptic) then Silver alginate and cover with bordered foam daily 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 8.17 x 6.83 cm with 30 % slough and was present on admission. Wound bed bleeding. Treatment: wound cleanser and then thin layer of Zinc HD to periwound only three times a daily and as needed. A General Note, documented by the Wound Nurse Practitioner, dated 1/24/23, with a date of service of 1/24/23, indicated skin dry/flaky.There is an unstagable wound to the left and right buttock with surrounding MASD; sharp debridement performed today. Will optimize dressing treatment. Alginate to be applied to wound base then fill wound cavity with lightly moistened fluff gauze then apply zinc HD to peri wound A Wound Nurse Practitioner Tissue Analytic form indicated, on 1/17/23 the resident had the following wounds: 1. Right buttock, Stage 3-now an unstageable pressure ulcer, measured 4.29 x 2.37 centimeters (cm) and was present on admission. The ulcer had a heavy amount of drainage with no odor. Treatment: cleanse wound with wound cleanser, apply silver alginate to wound bed then fill wound cavity with lightly-moistened fluff gauze; cover with bordered foam daily. 2. Left buttock, unstageable wound, measured 5.90 x 3.74 cm and had 50% slough (dead skin tissue that may have a yellow appearance) covering the wound bed. Present at admission. A heavy amount of drainage with no odor. Treatment: cleanse wound cleanser then Silver alginate to wound bed then fill wound cavity with lightly- moistened fluff gauze; cover with bordered foam. Change daily and as needed. 3. MASD (Moisture-Associated Skin Damage) to the buttocks, which measured 6.02 x 6.65 cm with 30 % slough and was present on admission. Wound bed bleeding. Treatment: wound cleanser and then thin layer of Zinc HD to peri wound only three times a daily and as needed. A Weekly Skin Review, dated 1/7/23 indicated pre-existing open area-pressure area noted to right buttock. No other information was documented. A Weekly Skin Review, dated 1/14/23, indicated pre-existing surgical wound to right abdomen. Wound vac in place. Coccyx-pre-existing open area. A Weekly Skin Review, dated 1/23/23, indicated pre-existing surgical wound to right abdomen. Coccyx-pre-existing open area. A General Note by LPN2, dated 1/23/23 at 7:16 P.M., indicated .Resident's wounds show no worse symptoms. Moderate drainage observed. Wounds were cleaned up and covered with bordered dressing. No s/s [signs/symptoms] infection observed. Will continue to monitor Follow by another General Note, dated 1/23/23 at the same time, indicated .Residents wounds show no unusual appearance. Copious drainage observed as usual. Wound has both eschar and slough. Skin around wounds red and peeling A General Note, dated 1/27/23 at 4:46 A.M., indicated .911 notified of need for resident to be transferred to [name of hospital] for TX [treatment] and evaluation An emergency room (ER) Physician Report, dated 1/27/23, indicated on exam the patient presented with concerns of altered mental status and fever. The patient's skin was warm and dry. There was a right lower quadrant abdominal wall wound VAC in place with what appeared to be a yellow-white material in the wound VAC. There were multiple areas of unstageable pressure ulcerations throughout bilateral lower extremities on the calves and heels., the ulceration on the right heel, measured approximately 3.0 centimeters, consistent with pressure ulceration. There was a large 2 to 3 deep pressure ulceration over the sacrum with a visible granulation tissue, tenderness surrounding it, surrounding erythema and extreme odor. Patient's skin is extremely dry on the extremities and flaking. The right lower quadrant abdominal wall incision had signs of cellulitis and tenderness with palpation. The ER Medical Decision Making indicated the resident's emergency contact was updated on the patient's condition and was explained that the patient had a .significant risk for morbidity and mortality given his septic shock, severe sepsis, dehydration, unstable a fib [atrial fibrillation], lactic acidosis [body produces to much lactic acid and is produced when oxygen levels become low in the cells], UTI [Urinary Tract Infection], sacral decubitus ulcer with cellulitis, wound VAC site with infection, lower extremity decubitus ulcers The ER Medical Decision Making indicated the physician had contacted APS [Adult Protective Services] regarding the resident's wounds. The hospital CT (Computed Toomography-diagnostic imaging exam) of the Abdomen and Pelvis with Contrast included the following: .4. Soft tissue stranding [term applied to injury of skin, the fat and layers beneath the skin] and locules of gas likely reflecting developing decubitus ulcer subcutaneous soft tissues posterior to the lower sacrum and coccyx with soft tissue stranding and edema extending to the dorsal aspect of the sacrum and coccyx . The following Wound Care Notes & Pictures, dated 1/27/23, provided by the hospital, indicated the following: .Purulent drainage from penis, erosion from Foley catheter. Negative Pressure wound therapy dressing removed. Exudate canister is full of purulent drainage with foul odor. Surrounding skin is moist erythremia, foam dressing was placed directly on skin. No date or time on dressing to indicate when it was changed last. Left medial foot, deep tissue injury, 1.0 x 1.5 cm, surrounding skin blanchable. Right posterior ankle, 4.0 x 2.0 cm, deep tissue injury, wound base purple, surrounding skin is blanchable. Right plantar medial heel, 4.5 x 6. cm, Stage 2 pressure injury intact fluid filled blister. Right plantar lateral heel 0.5 x 1 cm deep tissue injury. Surrounding skin is blanchable. Left anterior medial foot deep tissue injury 5 x 3 cm purple, surrounding skin dry, flakey blanchable. Right lateral foot deep tissue injury 1 x 0.5 cm surrounding tissue is blanchable. Left Sacrum unstageable pressure injury 5 x 4.5 x 2 cm 10% yellow/90% brown slough Left buttock stage 2 pressure injury 4 x 3 deep red to pale pink Medical Sacrum unstageable pressure injury 4 x 2 cm 30% yellow/70% brown slough Right coccyx to buttock unstageable pressure injury 7 x 3 cm 80% pale yellow/20% brown. Surrounding skin is nonblanchable red to purple in color During an interview, on 2/28/23 at 11:40 A.M., the DON indicated the General Notes were completed, by the Wound NP, and were scanned into the facility's system, at a later date. However, the date of service was in the body of the assessment and represented the day the wound care was completed. The DON indicated the Tissue Analytics form was the date the wounds were assessed, treatments were ordered and were available to the unit managers/nurses. On 2/28/23 at 12:12 P.M. an interview was conducted with the DON and LPN/Unit Manager. The Unit Manager indicated on 1/14/23 & 1/23/23 she had completed the form titled Weekly Skin Review. The Unit Manager indicated if there had been any other skin problems or ulcers she would have documented them. The DON explained the Weekly Skin Reviews were when the nurse observes all of the skin and documents on all skin issues. On 2/24/23 at 9:57 A.M., the DON provided a policy titled, Pressure Injury Prevention Guidelines, dated 2021, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: to prevent the formation of avoidable pressure injuries and too promote healing of existing pressure injuries, it is the policy of this facility to implement evidence-based interventions for all residents who are assessed at risk or who have a pressure injury present .Policy Explanation and Compliance Guidelines: 1. Individualized interventions will address specific factors identified in the resident's risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging wound characteristics) .8. Compliance with interventions will be documented in the medical record .b. For residents who have a pressure injury present: treatment or medication administration records; weekly wound summary charting. 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include: a. Development of a new pressure ulcer. b. Lack of progression towards healing or changes in wound characteristics On 2/28/23 at 11:50 A.M., the DON provided a policy titled, Skin Assessment, dated October 2022, and indicated the policy was the one currently used by the facility. The policy indicated .Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy included the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury The immediate jeopardy that began on 12/30/22 was removed and the deficient practice corrected on 3/2/23 when the facility completed a facility wide skin sweep with Braden scale completed on all residents, care plans updated/revised for any residents identified to be at risk for a pressure ulcer, nursing staff in-serviced on the Pressure Injury Prevention and Management & Weekly Skin Assessment policies, with audits instituted to ensure compliance. This Federal tag relates to complaint IN00400925. 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure thorough assessments and care was provided for the use of a Foley catheter in 1 of 3 residents. And failed to identify a change in condition which resulted in sepsis and death . (Resident J) The Immediate jeopardy began on [DATE] when the resident entered the facility with a Foley catheter, and the facility did not document catheter care for 8 days and had no documentation of resident's output from the catheter. The resident was sent to a local hospital where he was diagnosed with Sepsis and an Urinary Tract Infection due to the Foley catheter. The resident deceased on [DATE]. The Administrator, the Director of Nursing (DON), Assistant Director of Nursing (ADON), a Regional Nurse and a Registered Nurse (RN) were notified of the immediate jeopardy at 4:28 P.M., on [DATE]. The immediate jeopardy was removed, and the deficient practice corrected, on [DATE]. Finding includes: On [DATE] at 2:28 P.M., a review of the clinical record for Resident J was conducted. The record indicated the resident was admitted to the facility, on [DATE], as a full code and discharged to a local hospital on [DATE]. The resident's diagnoses included, but were not limited to: multiple sclerosis, neuromuscular dysfunction of the bladder, history of urinary tract infections (UTI) and pressure ulcers of the sacral region-Stage III (pressure injury with full-thickness loss of skin). The discharging hospital form titled, Document Review Report, dated [DATE], indicated a baclofen pump replacement had occurred on [DATE], the resident had a history of UTIs, the resident performed self-catheterized on himself once a day, and an indwelling Foley catheter was inserted on [DATE]. The form indicated a CT scan was completed, on [DATE], which indicated the resident had bilateral renal staghorn calculi with a partial obstruction. The Hospital Discharge Report/orders, dated [DATE], indicated .right lower quadrant .wound vac to right lower quadrant, change every other day until wound closure .pt [patient] has neurogenic bladder. Currently with Foley in place. D/c [discontinue] on [DATE] and change to intermittent catheterization BID [twice a day] The admission Minimum Data Set (MDS) Assessment, dated [DATE], indicated the resident was cognitively intact, required extensive assistance of two people for bed mobility and transfers. The assessment indicated the resident had an impairment of his lower extremity on one side, had an indwelling Catheter (a thin tube inserted into the bladder to drain urine into a drainage bag) was always incontinent of his bowels and was admitted with two Stage 3 pressure ulcers. A care plan, dated [DATE], for the elimination of bowel and bladder indicated the use of an indwelling urinary catheter related to diagnoses of multiple sclerosis with neurogenic bladder with frequent urinary tract infections. The interventions included, but were not limited to: encourage fluids, catheter care every shift, keep drainage bag below level of the bladder at all times, labs as ordered and monitor for signs & symptoms of UTI such as change in color, odor, consistency of urine, fever and pain. There was no documentation regarding the catheter use, discontinuing the indwelling catheter or any urine output results from [DATE] through [DATE]. A Physician's Order, dated [DATE], indicated the Foley catheter use was related to neuromuscular dysfunction of the resident's bladder and for staff to provide catheter care every shift and as needed. Catheter care included the following directions: to cleanse with soap and water, rinse and pat dry as needed and to change Foley drainage bag weekly and as needed. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident J, for [DATE], indicated the catheter type, size and diagnosis supporting the use of the catheter was to be documented every shift. The documentation was initiated on [DATE]. In addition, the Foley catheter care every shift was initiated on [DATE] The facility had documented the drainage bag changes on 1/8, 1/13 and [DATE]. During an interview, on [DATE] at 9:36 A.M., the DON indicated the drainage bag for a Foley catheter was changed once a week. She did not know if Foley was removed on the [DATE] as ordered. She provided an order for the Foley on [DATE] but did not know if it was the same Foley which was already in place at admission. During an interview, on [DATE] at 2:00 P.M., the DON indicated the facility does not document a resident's output of urine unless there was a specific order to do so. Therefore there was no documentation to indicate when the Foley catheter collection bag was emptied and how much urine was removed from the collection bag. The ER (Emergency) Physician Report, dated [DATE], indicated .the skin of the penis and scrotum is erythematous [abnormal redness] without induration. There is an extensive amount of crusting .His Foley catheter was replaced and new urine taken off of new Foley catheter was sent with with evidence of UTI [Urinary Tract Infection] . The Hospital History & Physical (H&P) , dated [DATE], indicated .Foley catheter appears to be very old, it was replaced .Foley in place with purulent urine The H&P Impression and Plan indicated the patient had a fever, septic shock, pleural effusion and had a UTI associated with chronic indwelling Foley catheter. The H&P indicated .the source of sepsis was not clear however, the UTI or pleural effusion could be causing the septic shock The resident was admitted to the ICU (intensive care unit) and passed away on [DATE]. On [DATE] at 9:26 A.M., the DON provide a policy titled, Catheter Care, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .1. Catheter Care will be performed every shift and as needed by nursing personal .8. Empty drainage bags when bag is half-full or every 3 to 6 hours On [DATE] at 9:30 A.M., the DON provided a policy titled, Notification of Changes, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .Policy: The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification .Circumstances requiring notification include: .2. Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial staus. This may include: a. Life-threatening conditions, or b. Clinical complications On [DATE] at 11:16 A.M., the Regional Nurse provided a policy titled, Indwelling Catheter Use and Removal, dated [DATE], and indicated the policy was the one currently used by the facility. The policy indicated .It is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Policy Explanation: Indwelling urinary catheters are catheters that remain in the bladder to assist with urinary elimination .Compliance Guidelines .2. Residents that admit with an indwelling catheter or subsequently receives one will be assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that the catheter is necessa [necessary]. 3. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to .f. Ongoing monitoring for changes in condition related too potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes .6. Additional care practices include: a. Recognition and assessment for complications and their causes, and maintaining a record of any catheter-related problems .d. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter .7. Catheters and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system is compromised. Routine, fixed intervals is not recommended The immediate jeopardy that began, on [DATE], was removed and the deficient practice corrected, on [DATE], when the facility assessed all residents with indwelling catheters; to ensure no signs or symptoms of infection, nursing staff were in-serviced on the Catheter Care Policy and the Change of Condition policy, which included documentation required, and instituted on-going audits of residents with Foley catheters to ensure compliance. This Federal tag relates to complaint IN00400925. 3.1-41(a)(2)