Based on observation, record review, resident interviews, staff interviews, and policy review the facility failed to follow a resident's Care Plan for transfers and to assess a resident immediately after a fall for 1 of 3 residents reviewed (Resident #6). The resident required a mechanical lift with the assistance of 2 staff for transfers. The facility failed to provide assistance of 2 while the resident was transferred in the shower room which resulted in the resident sliding out of the mechanical lift sling. The facility further failed to conduct an assessment of the resident prior to getting her up from the shower room floor. The facility reported a census of 74 residents. Findings include: The Minimum Data Set (MDS) for Resident #6 dated 5/23/24 documented a Brief Interview for Mental Status (BIMS) score of 14/15 which indicated intact cognition. Diagnoses included other acute paralytic poliomyelitis (polio, disease of motor neurons of the spinal cord and brain), repeated falls, and fracture (vertebra). The MDS documented the resident used a wheelchair for mobility and required substantial/maximal assistance for showering and bathing. The resident was dependent on staff for all transfers. Resident #6's Care Plan, with a focus area for ADL self-care performance deficits revised 9/20/23, included bathing and transfer interventions revised 4/12/24. At that time the resident required extensive assistance by 1 staff with showering twice a week and as needed, and transfer assistance of 2 staff with a Sara lift (standing mechanical lift) to shower. On 8/12/24 the bathing section was updated to change the Sara lift to a Hoyer lift (full body mechanical lift), and the resident remained an assist of 2. A Late Entry Progress Note titled Nursing Progress Note, dated 8/10/2024 at 15:02, was entered in Resident #6's electronic health record (EHR) on 8/11/24 at 16:06. It documented the following encounter with the resident and Staff C, Certified Nurses Aide, (CNA): This nurse (Staff B, Registered Nurse (RN)) was sitting in the nurses station when notified by (Staff C) as she was wheeling patient past the nurses station back to her room that the resident did not fall in the shower. (Staff C) stated that (the resident) was supported as her legs were already giving out and it was not possible to lift her even further, she was transferred to her wheelchair using the gait belt. This nurse followed them to her room and did vital signs and an assessment. 120/70, 80, 14, 97.8, 96 RA. Patient denied having pain. Patient stated that she did not fall and that she was ok. A Progress Note dated 8/10/24 at 17:07 titled Nursing Progress Note indicated Staff B was called into the resident's room for two skin tears on her right forearm that needed dressing. One measured 5 mm by 5 mm and the other 20 mm by 10 mm. The note indicated the provider was faxed for an order. The cause of the skin tears was not documented. A form titled Skin Condition Record, initiated 8/10/24, documented the skin tears as they measured in the Progress Note. It indicated the plan of care was updated. The physician and family were notified on 8/11/24. The resident was not experiencing pain related to the wounds. The cause of the skin tears was not documented. The Progress Notes and the EHR lacked an incident report, full resident assessment, family notification, provider notification, or Director of Nursing (DON) and/or Administrator communication completed on 8/10/24 regarding the resident's assisted fall in the shower room. A Progress Note dated 8/11/24 at 9:30 AM documented the resident reported to Staff E, RN that she was in the Sara lift the day before during the 2 PM to 10 PM shift for a shower and fell. The note documented dry dressings on the resident's arm and complaints of increased back and right foot pain without bruising or deformity. Vitals were taken, feet were floated, and pain cream was applied to the resident's back. A Progress Note dated 8/11/24 at 11:36 noted the resident's daughter was in the facility and was aware of the situation. A Progress Note dated 8/11/24 at 12:04 titled Communication - with Physician reported the resident fell out of the Sara lift on 8/10/24 while being transferred for a shower. The resident complained of increased right shoulder/right upper arm and back pain. The note indicated the resident's daughter requested x-rays of the right upper arm, right shoulder, and back. A Progress Note dated 8/11/24 at 15:12 titled Nursing Progress Note reflected an order from the resident's doctor for a one time dose of 800 milligrams oral ibuprofen. A note dated 8/12/2024 at 08:04 titled Nursing Progress Note revealed the resident complained of pain in her right arm, right hip, across chest, and anterior shoulder, especially with ROM (range of motion). She rated her pain at 7/10 and requested to stay in bed that morning. Documentation of the facility investigation dated 8/12/24 at 8:30 AM included an interview with Resident #6 who confirmed Staff C did not have a second helper during the transfer and indicated her arm hurt when she was transferred from the floor. The resident interview documented the nurse did not complete an assessment and it was a long time before she came to bandage her arm. At least an hour. At 10:00 AM, the DON and Administrator interviewed Staff C who revealed she did not have a second person during the transfer but knew she should have. After Staff C lowered the resident to the floor, she got Staff I, Agency CNA to help her. Staff C stated she couldn't find the nurse and that was why she didn't have her do the assessment. The investigation included a statement from Staff C: Resident was given a shower alone and was lifted on the Sara lift and was transferred on her own to her wheelchair. The resident's legs gave out and while it gave out, I supported her shoulder and back while gently lowering her to the floor. I called another CNA and he put a gait belt to help her lift and transfer to the wheelchair. I reported to the nurse what had happened and insisted on giving her an assessment and check her vitals. Investigation documentation also included a statement from Staff I that he went to answer the call light while Resident #6's shower was taking place at around 3:00 PM. When he left that resident's room, Staff C informed him Resident #6 was on the floor. He asked if the nurse knew because he was not going to get her up. Staff C told him no and they could get her up. They lifted her using the gait belt. He saw a skin tear on the resident's right arm. He reported they took her to the nurses station and there was not a nurse there, so they took the resident to her room. 15 minutes later he saw the nurse was assessing her. He reported never transferring a resident alone if they were an EZ Stand (another name for a Sara lift or standing mechanical lift). A Progress Note dated 8/12/2024 at 08:55 AM titled Nursing Progress Note revealed an order was received for spinal, lumbar thoracic, 2 view right hip et 2 view right shoulder X-ray. Order noted in queue. (X-ray company) notified. The resident's power of attorney was notified at 09:04. A note titled Nursing Progress Note on 8/12/24 at 12:48 revealed the X-ray results were negative for fracture and faxed to the resident's provider. A Progress Note dated 8/12/2024 at 13:58 titled Nursing Progress Note indicated she continued to have widespread pain, especially with movement and repositioning. She had not been out of bed during the shift due to her pain. A document from the resident's provider titled ICF Progress Note with an 8/12/24 date of service documented the resident's legs gave out on her when staff transferred her. The resident had increased pain and discomfort. The provider noted a history of chronic pain due to a T12 compression fracture and chronic pain medication, scheduled and as needed. There were no acute findings on the X-rays. The provider added a pain patch to her regimen that would be replaced weekly and ice as needed. A Progress Note dated 8/13/2024 at 12:06 titled Nursing Progress for a follow up on a staff assisted incident revealed the resident continued to complain of right shoulder and right anterior chest wall discomfort. She was able to move her right upper extremities with some discomfort but stated that it felt better. On 8/16/24 at 1:24 PM, during an observation and interview with Resident #6, she stated that on Saturday (8/10/24) she changed from a Sara lift to a Hoyer lift after her legs gave out on her. She pointed to her left arm and said she hurt her right shoulder, arm, knee, and hip and had been spending more time resting. She reported no breaks but that she had pain, and it felt better lying down. She thought the knee and hip pain was from hitting the floor and the arm and shoulder pain from holding on to the stand. Resident #6 was not exhibiting any signs or symptoms of pain at the time of the observation, no grimacing, jerky movements, or holding on to her arm or shoulder. She believed the facility was managing her pain. The following day, 8/17/24 at 12:26 PM, the resident's daughter and the resident offered additional information. Observed skin tears bandaged near the resident's right wrist. Her daughter stated the resident's skin is very fragile and this happened often. Resident #6 stated it felt like a long time to get them wrapped by the nurse the day of the fall, and the CNA had to ask multiple times. The resident confirmed she refused imaging beyond the x-ray and added she was not interested in therapy. Both the resident and daughter endorsed a long history of chronic pain and pain medication. The resident stated the patch the doctor prescribed was helping, and she had both scheduled and as needed pain medication. The resident's daughter mentioned an incident a couple of months prior where an agency CNA transferred the resident without checking her transfer status. They felt the facility handled that well and the resident felt safe. In the most recent incident on 8/10/24, they both mentioned that the lack of a thorough assessment and that the information was not passed between shifts was concerning. On 8/17/24 at 1:58 PM Staff F, Agency CNA, confirmed he worked with Resident #6 and she used a Sara lift. He reported being trained that any time a resident went to the floor it was a fall, and a CNA might have to write a statement about what happened before the fall as part of the investigation. The CNA should make sure the resident was safe, and get a nurse to complete an assessment before a resident was moved. He reported staff on one shift were responsible for reporting resident changes, including falls, to the next shift. He stated he learned about this incident from the resident when he returned to work 2 days later, and she told him she fell out of the lift and hurt her arm and shoulder. During an interview with Staff E, RN on 8/17/24 at 2:16 PM she stated a fall was when a resident landed on the ground. Nurses were expected to complete incident reports immediately, document in the EHR, notify the physician and the family, and report to the next shift. They should notify the provider by phone if the resident was on a blood thinner or was injured and could make the notification by fax if there were no immediate concerns. She stated nothing was reported to her when she arrived the day after Resident #6's fall, and there was no incident report, assessment note, or documentation in the EHR other than a record of 2 skin tears. She learned of the incident from the resident who told her an assessment hadn't been done. Staff E added that this resident had also been transferred in June without a mechanical lift by an agency CNA who had not looked at the resident's transfer status before moving her. That CNA has not been back to the facility. At 2:32 PM on 8/17/24 Staff G, CNA, stated she was not there the day Resident #6 fell but the resident always used a Sara lift and was supposed to have two staff helping her. Staff H, CNA stated on 8/17/24 at 3:59 PM that staff got to know residents and their needs. She reported if a resident fell then CNAs should make sure they were okay and not move them until a nurse completed an assessment. She stated if they were safe she would look out the door for help. If no one was visible she would pull that call light to send a signal that she needed help. During Staff C's initial interview on 8/18/24 at 8:14 AM she stated mechanical lift decisions and changes came from the doctor and the nurse. She confirmed there were no changes for Resident #6 the day she fell. Staff C reported she had fall training when she started and was paired up with another staff who trained her about expectations. She explained a fall happened when a resident landed on the floor. When asked about the incident on 8/10/24 with this resident, she stated she finished the resident's shower and began moving her to her wheelchair with the lift when the resident's legs gave out. She first stated the resident didn't fall on the floor because she supported the resident's back and arm. Staff C later stated the other CNA put a gait belt on the resident and they lifted her from the floor to the wheelchair. She was standing on the resident's right side and he was on the left side, and the resident's arms remained up. Staff C first said the resident didn't have any pain, then stated she complained that her arms were sore. Staff C first stated she had to insist the nurse do an assessment, then admitted to getting the resident up without getting the nurse first. She stated she did not notice skin tears during the shower, and did not notice them until the resident called her in before dinner. Staff C thought the shower was around 3:00 PM, vitals between 3:30 and 4:00 PM, and the wound dressing around 5:00. She didn't think the nurse completed a full body assessment if she missed the skin tears. On 8/18/24 at 1:43 PM the DON, when asked about the facility process when staff do not follow a resident's Care Plan, stated they investigated, determined what led to it, and provided education and/or initiated disciplinary action. She reported Staff C was not following the Care Plan by not having a second staff with her and the expectation was always for 2 staff. When asked about the interventions the facility put in place after this incident to keep residents safe during transfers, she stated the facility re-educated all CNAs regarding the facility's two person transfer requirement when using mechanical lifts and making sure a resident was assessed before they were moved. She provided documentation of that training as well as training for the nursing staff regarding completing full assessments prior to moving a resident after a fall. She provided the disciplinary action that included suspension of both the CNA and the nurse involved. The DON stated staff had access to the most updated transfer information on their tablets and/or nurses report sheets daily. When asked if this incident was preventable, the DON stated upon staff interviews they knew to use two people. She also felt staff had not communicated with her or the MDS coordinator to let them know the resident was getting weaker. That communication would have been helpful to prevent this incident. During an interview on 8/18/24 at 2:37 PM the Administrator stated she was not made aware of the resident's fall until the following day. The DON called and explained the incident stating the family and the nurse were upset. The nurse on duty did not complete an incident report because she was told it was not a fall. They initiated an investigation with in house interviews and the information they were getting was not consistent. She reported she can't honestly say what happened because of the inconsistencies. The Administrator, when asked about the resident's transfer status, did confirm that the resident should have been assisted with the transfer by 2 staff and the resident should have been assessed prior to being moved. At 10:23 AM on 8/19/24 Staff B, RN, confirmed she was the nurse on duty when Resident #6 had her fall and stated it was a very busy day. She reported Staff C wheeled the resident by the nurses station after her shower and told her the resident didn't fall. Staff B indicated she went to the resident's room and took her vitals, which were okay. She wasn't sure why the CNA said the resident didn't fall, and reported the resident had a smile on her face. Staff C again said the resident didn't fall. She said the resident appeared fine, and that was the last she knew until the DON called her. Staff B stated everything surfaced the next day, and Staff C lied to the DON about what happened with the resident's transfer. Staff C reported there had been another CNA with her and that she had to ask 3 times for the nurse to do an assessment. Staff B also stated Staff E told her the next morning she should have filled out an incident report, and called the family and provider, but Staff B was confused because Staff C said the resident didn't fall. She stated she didn't know there was an issue to call about. She clarified Staff C told her they assisted the resident from the lift to the wheelchair, not from the floor to the wheelchair. Staff B then stated she panicked and called the DON. She confirmed she entered the incident report, and notified the POA and provider on 8/11/24 as late entries. Staff B reported that Staff C eventually admitted she was alone during the transfer, apologized for not telling the truth, and told her she did it because she didn't want to get into trouble. Staff B said she resigned when approached with a disciplinary report because of how accusing ' they ' were and because the report was the same as the CNA's even though Staff C lied. She said she couldn't work there like that and there were too many residents for one nurse to be responsible for anyway. On 8/21/24 at 4:07 PM, during an interview with Staff C, she verified she received fall training during her orientation and Resident #6 was an assist of two staff at the time of the fall. She acknowledged the facility requirement was for a 2 person transfer for mechanical lifts and that the resident was not assessed by a nurse prior to getting her up from the floor. She confirmed she chose to transfer the resident alone and stated she felt pressured to move the resident so she didn't get cold. She clarified the resident didn't say she was cold, she just knew it could happen. Staff C stated again that she was on the right side and Staff I was on the left side, and reported not being sure how the resident got the skin tears on her right arm. She avoided the question asking which one of them decided to get the resident up without being assessed. She was aware of the resident's prior incidents of weakness and back pain. Staff C believed this incident could have happened with two people because of that. She reported not knowing why the resident had arm and shoulder pain, and denied the resident reported pain to her at the time of the fall. She stated the resident was never left alone even when she looked for another CNA. She repeated she told the nurse as they walked by the nurses station that the resident needed to be assessed. She didn't know why Staff I said the nurse wasn't there. Staff C stated the resident told the nurse she didn't fall, and the nurse said it wasn't a fall. She denied the nurse's claim that she said the skin tears were there before the fall. At the end of the interview, when asked about staffing, the CNA stated there was a lot of work but they could usually get it done. At 5:02 PM Staff C shared that she wanted to add something about staffing. She stated staffing was actually a big concern of hers. She felt there were not enough staff who actually knew the residents that day, and felt like she had to do everything herself. She did not think 3 CNAs was enough for 70 residents when so many require 2 staff to transfer. In an email dated 8/17/24 at 2:36 PM the Administrator documented the facility did not have a policy or procedure related to resident transfers (technique, training, decision making, etc.). They also did not have a policy related to assessments. The facility's policy titled Nursing Facility Abuse Prevention, Identification, Investigation, and Reporting Policy, dated only as October, documented that all residents had the right to be free from abuse and neglect. Page 3 noted the facility would provide a supportive and safe environment for all residents to the extent possible through the deployment of trained and qualified staff to meet resident needs as identified in both the individual resident care plans and the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility investigation report, and staff interviews, the facility failed to supervise 1 of 6 residents reviewed in order to prevent a fall with injury (Resident #4). The facility reported a census of 78 residents. Findings include: The MDS (Minimum Data Set) dated 12/14/2023 revealed Resident #4 had severely impaired cognitive abilities, required extensive assistance to transfer from one surface to another, and had a fall that resulted in a major injury. The resident had diagnoses including weakness, depression, and dementia. Resident #4's Care Plan identified she had a a risk for falls due to confusion, deconditioning, gait/balance problems, incontinence, poor communication, unaware of safety needs, and history of syncope initiated on 10/18/2019. The Care Plan directed staff to provide assistance with all transfers and ambulation initiated on 12/12/2023. The Care Plan identified the resident had an ADL (Activities of Daily Living) self-care performance deficit initiated 10/16/2019. It directed staff to transfer with the assistance of one staff and a 4 wheeled walker initiated 10/18/2019. The MAR (Medication Administration Record) revealed the resident received Tylenol 650 mg on [DATE] at 7:00 A.M. The physician ordered Tylenol 650 mg four times a day for pain control on 12/13/2023. The resident continued to receive Tylenol 650 mg four times a day. The X-ray report dated 12/12/2023 revealed Resident #4 had an acute complete oblique (broken at an angle) fracture of the distal radius (one of the forearm bones) extending to the distal radial ulnar joint (left wrist) with minimal dorsal angulation of the distal fracture fragment. On 12/12/2023 the physician ordered a wrist splint to be worn at all times, except for bathing or showers, Tylenol 650 mg (milligrams) four times a day and repeat X-ray in four weeks. The X-ray report dated 1/15/2024 revealed a healing non-displaced fracture. In a Progress Note dated 12/12/2023 at 1:00 P.M., Staff G, RN documented the resident ambulated with the CNA, lost her balance and fell onto the floor towards the right side. The resident did not hit her head, and she complained of left wrist pain with no swelling or bruising noted at this time. Ice pack applied. The facility Incident/Accident Report dated 12/12/2023 at 1:00 P.M. completed by Staff G, RN revealed Resident #4 ambulated with a CNA, lost her balance and fell onto the floor on her right side without hitting her head. The resident complained of left wrist pain. Additional comments and/or steps to prevent recurrence: Use walker with ambulating. An additional comment added later stated: Gait belt for all transfers. The facility Self Report, submitted to DIA (Department of Inspections and Appeals) on 12/12/2023 by Staff M, the former DON (Director of Nursing) included: Accident with major injury in the main dining room. The resident ambulated in the main dining room with Staff I, CNA. The resident lost her balance and fell toward her right side. She did not hit her head. She complained of left wrist pain without bruising or swelling. The right middle finer had a light purple bruise. Corrective Action Description: Resident will use walker with ambulation. Staff I, CNA Witness Statement Summary: was ambulating with resident when resident lost her balance and fell toward her right side. Staff G, RN Witness Statement Summary: Resident was ambulating in dining room with CNA. Resident lost balance and fell forward toward her right side. She did not hit her head but complained of left wrist pain. No swelling or bruising to wrist. Light bruise to middle finger of right hand. Staff H, Care Plan Coordinator statement dated 4/10/2024: Gait belt education was provided by Staff right away through the communication binder (5 minute binder), through facility postings at nurses area, and covered in a subsequent nursing meeting. Staff L, Interim DON submitted a copy of communication from Staff M to all staff to read. Gait belts are a part of your uniform. They must be used or reprimand will happen. Staff L indicated Staff M wrote the communication after Resident #4's fall. Staff M also posted a sign at the nurse's stations that read: Attention all nursing staff. Gait belts are required as part of your uniform. You must have a gait belt on you at all times. Observation on 4/8/2024 at 12:13 P.M. revealed Staff N, CNA, assisted Resident #4 to the edge of her bed and applied a gait belt around her waist. Staff N assisted the resident to stand with the gait belt and the wheeled walker. Staff N held the gait belt and the resident used the wheeled walker to ambulate with a slow and steady gait to the dining room. The resident was cooperative and alert. On 4/10/2024 at 11:30 A.M., Staff A, Administrator reported working at the facility since January, 2024, and did not work at the facility when Resident #4 fell. She could only provide information that the previous administration reported on line since many of the investigative files were empty. On 4/10/2024 at 8:30 A.M., Staff G reported working on 12/12/2024 when Resident #4 fell. Staff I, CNA walked with the resident and Staff G did not see her in time to correct her. Staff G did not know the resident used a walker, and thought the resident required light contact assistance with ambulation. Staff G said the resident fell in the dining room and she did the investigation. Staff G did not recall seeing the resident with a gait belt on when she fell. All staff were educated to use gait belts. Signs were placed at the nurse's stations reminding staff they are to have gait belts as a part of the uniform and should be worn at all times. Staff G wrote use walker with ambulating. Staff H updates the Care Plans. Staff need to use a gait belt with any resident that requires assistance with transfers or ambulation. Staff I had worked at the facility prior to that day. The facility provides new staff with cheat sheets telling them how each resident transfers. Everyone knows the gait belt policy, it is standard nursing practice. On 4/10/2024 at 8:56 A.M., Staff H, Care Plan Coordinator indicated any resident who transfers or ambulates with assistance requires the use of a gait belt. Staff H reviews each incident, makes sure there is an intervention in place and that it is care planned. When Resident #4 fell, the charge nurse's immediate intervention was to use walker with ambulation. Staff H reviewed the incident and added gait belt for all transfers. The former DON interviewed staff and the investigation determined Staff I did not use a gait belt when the resident fell. If Staff I had used a gait belt, she would have been able to grab it when the resident started to lose her balance. On 4/10/2024 at 10:00 A.M., Staff K, CNA reported working on 12/12/2023, however she had no recall of Staff I and no recall of Resident #4's fall. Staff K knew she needed to wear a gait belt at all times and use it with any resident who required assistance of one to transfer and ambulate. During a phone interview on 4/10/2024 at 10:30 A.M., Staff I reported working on 12/12/2023 when Resident #4 fell, That was her second day at the facility and her first with the resident. Staff I had no cheat sheet and did not know the resident. Staff I reported she walked with the resident from the bathroom to the dining room with a wheeled walker and a gait belt. Staff I held the resident's hand, and stood on her left side. Staff I said the resident also had one hand on the walker. The resident lost her balance and her hand slipped away from Staff I. It happened fast and the resident fell. It took awhile for staff to come and assist. On 4/10/2024 at 9:10 A.M., Staff N, an agency CNA, reported working at the facility for awhile. Staff N knew to use a gait belt with any resident who requires assistance to transfer. If she did not know how a resident transferred, she would ask. On 4/10/2024 at 9:00 A.M., Staff C, CNA reported working at the facility through an agency. Staff C knew she needed to use a gait belt if the resident required assistance to transfer, something she learned in CNA training. The facility Gait Belt (Use of ) policy included: Purpose: To ensure the safety of the residents and staff when assisting with a transfer or ambulation a gait belt will be used. Procedure: 2. All residents who require assistance with transfers and do not require and electric lift will utilize a gait belt with all transfers. 10. The staff person will utilize safe transfer technique, moving with the resident, with the knees bent and a strong grasp on the transfer belt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to prevent the development of a facility acquired unstageable (obscured full thickness skin and tissue loss) pressure ulcer and failed to implement a treatment order for the wound for one of two residents reviewed for pressure ulcers (Resident #22). The facility reported a census of 44 residents. Findings Include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 was rarely to never understood. The resident required the extensive assistance of two persons physical assist for bed mobility and transfer. Per the assessment, the resident identified at risk for pressure ulcer development, and had no unhealed pressure ulcers/injuries. Diagnoses for Resident #22 included dysphagia (swallowing difficulty), paroxysmal atrial fibrillation, and chronic kidney disease Stage 3. On 4/20/22, Resident #22's Care Plan did not address alterations in skin integrity or the presence of wounds. The Braden Scale for Predicting Pressure Ulcer Risk dated 2/10/22 revealed the resident scored 13, which identified the resident at high risk. The Progress Note dated 3/1/22 at 4:00 PM, documented, Fax sent regarding a 4 centimeter (cm) x 4 cm black eschar (dead or devitalized tissue) to the left (L) heel. The Visit/Consult Sheet dated 3/1/22 documented, in part, 4 cm x 4 cm Thick black Eschar L heel. No drainage. Heels Floated on pillow. Treatment (Tx?) Bunny boots? - Yes. The New orders/provider response section of the form documented, Wound Clinic Consult please. The Progress Note dated 3/2/22 at 1:00 PM documented, Received return Fax re: Black eschar on L heel and tip of 2nd toe, right foot, Wound Clinic Consult. The Progress Note dated 3/3/22 at 1:20 PM, documented, Call to Power of Attorney (POA) to inform of black eschar on L heel and discuss treatment plan, had to leave message to call facility. The Visit/Consult sheet dated 3/3/22 documented, the POA refuses the Wound Clinic Consult, she would like resident managed at the facility. How would you like to proceed? The New orders/provider response section of the form documented: What is the treatment currently? Bunny boots & float heels. Betadine applied twice a day (BID) to R (right) 2nd toe. I will still have to look at next week. Did she say why? No. The Progress Note dated 3/3/22 at 4:00 PM, documented, POA called; she declines Wound Clinic Consult, would like the resident to be cared for here. Fax sent to notify the Primary Care Provider PCP). Review of the Long Term Care Facility Acute Visit note by the Nurse Practitioner (NP) dated 3/10/22 for a chief complaint of acute visit for wound on left heel documented, the is a [age] year old female who is seen for a wound on her left heel. I had recommended staff for her to see the Wound Clinic for treatment for this but her POA (Durable Power of Attorney) refused this referral. Patient reports that it is painful. No fever or chills. Staff are unsure why the POA refused the referral to the Wound Clinic. Per the Impression and Plan section of form the following had been documented for the resident's Open wound of left heel; initial encounter: Assessment/Plan: Recommend Wound Consult but POA does not want this at this time Dakin's 0.125% solution; cleanse left heel daily and apply Medihoney with Mepilex cover. Review of signed Physician's Orders sheets active 2/1/22 to 3/31/22 and 4/1/22 to 6/30/22 did not include the treatment order which had been documented in the Long Term Care Facility Acute Visit note dated 3/10/22. The Treatment Administration Record (TAR) for March 2022 and April 2022 for Resident #22 did not address treatment for a heel wound. Bunny boots on while in bed and float heels had been added to the March 2022 TAR following 3/1/22. Review of Weekly Pressure Injury Record for left heel black eschar (date of onset 3/1/22) revealed the following: a. On 3/1/22: Stage II classification had been crossed off, measurements 4 cm x 4 cm, depth documented undeterminable, no exudate or odor, black wound bed, and pink surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented, doctor notified 3/1/22 unstageable. Pressure relieving interventions documented, float heels. b. On 3/9/22: Line present through stage, measurements 4 cm x 3 cm, no depth or exudate, odor left blank, thick black eschar wound bed, and pink surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented: no change. Pressure relieving interventions had been left blank. c. On 3/15/22: Stage documented unstageable, measurements 4 cm x 3.2 cm, depth documented ?, no exudate or odor, thick black eschar wound bed, normal pink surrounding skin color, and dry pale pink surrounding tissue/wound edges. Response to treatment/comments documented: no change. Pressure relieving interventions documented, Bunny boots when in bed. d. On 3/23 (year not documented): Stage had been left blank, measurements 3 cm x 3.5 cm, depth documented ?, no exudate or odor, thick black eschar wound bed, normal surrounding skin color, and pale pink surrounding tissue/wound edges. Response to treatment/comments documented, healing slowly, no drainage noted. Pressure relieving interventions had been left blank. e. On 4/6/22: Stage had been left blank, measurements 4 cm x 2 cm, depth had a line through the box, no exudate or odor, thick eschar wound bed, normal surrounding skin color, and surrounding tissue/wound edges had been left blank. Response to treatment/comments documented: no change. Pressure relieving interventions had been left blank. f. On 4/13/22: Stage had been left blank, measurements 4 cm x 3 cm, depth had a line through the box, no exudate or odor, black eschar wound bed, normal surrounding skin color and surrounding tissue/wound edges. Response to treatment/commends documented: no change, no odor, no drainage. Pressure relieving interventions documented, wears boots in bed. g. On 4/20/22: Stage had been left blank, measurements 3.8 cm x 2.5 cm, depth had a line through the box, no exudate or odor, black eschar wound bed, normal surrounding skin color and surrounding tissue/wound edges. Response to treatment/comments documented: small amount of improvement. Pressure relieving interventions had been left blank. On 4/20/22 at approximately 12:55 PM, an observation of Resident #22's left heel was conducted with Staff B, Licensed Practical Nurse (LPN), and Staff C, LPN. Resident #22 observed in bed with soft boots to the bilateral feet. Observation of the left foot revealed a black area present to the resident's left heel. On 4/19/22 at 9:07 AM, Staff B, LPN, was queried about Resident #22's heel. Per Staff B, they were monitoring and keeping pressure off of it, the edges were loosening up a little bit and it was still pretty firmly attached. Staff B acknowledged the area was black in color, had been going on for a little while, then clarified as at least a month. Per Staff B, there was no treatment now other than just keeping pressure off it. On 4/20/22 at 12:55 PM, Staff C, LPN, who assisted with treatments at the facility, was queried about wounds. Staff C explained they would measure the wounds when they were at the facility, and Staff B would measure in the area they worked as they worked that area all the time. It was noted Resident #22 resided in the area where Staff B worked. Staff C explained she believed at one time the resident had been referred, and the family didn't want to take the resident to the Wound Clinic. When queried about how doctor recommendations for wound care would be implemented, Staff C explained the nurse would call the family, the family would decide, and it would go from there. If the Doctor or NP had a treatment order recommendation, it would be faxed over to them, the orders would be done and the treatment would be started. When queried if Resident #22 had been receiving treatment to the left heel, Staff C responded before we were just leaving it, and were just watching it and putting boots on Resident #22 and being really careful with it. Per Staff C, she did not think they ever had a treatment going to debride it. Staff C acknowledged the wound had been treated like a pressure ulcer as the facility had it on a Pressure Ulcer Sheet. When queried if the wound had been facility acquired, Staff C explained she did not know. On 4/20/22 at 1:06 PM, Staff B, LPN, acknowledged Resident #22's wound was facility acquired. When queried about whether they knew of any treatment order to the heel, Staff B explained the resident had bunny boots while in bed to keep pressure off it. Per Staff B, reported the Primary Care Physician had wanted to send the resident to the Wound Clinic and the family did not want to do all of that considering the resident's age and general condition. Per Staff B, the wound was not open. Staff B explained the wound did not seem to hurt the resident much, and medication was effective. Per Staff B, the resident got the boots right after the heel wound had been discovered. When queried about weekly skin assessments Staff B explained that there were the sheets that they measured on. Per Staff B, there were not scheduled skin assessments, and the aides would report when giving showers and getting resident up if they saw anything that they had not seen before. Then, it would be reported, assessed and the doctor and family would be notified. Staff B acknowledged the area for Resident #22 was a pressure wound. When queried if the doctor had a recommendation for treatment how this would be put in an order, Staff B explained that they would Fax or write the order out if they were here, or would verbally give the order and then the order would be written as a verbal order. Staff B acknowledged if there were treatment orders they would go on the TAR. When queried the treatment order on the Long Term Care Facility Acute Visit note by the Nurse Practitioner (NP) dated 3/10/22, Staff B explained she did not know that it had been there, and how it had got in the chart and she did not know about it. Per Staff B, generally when the Visit Progress Report was faxed over it went to another staff member so that she could log in that she got a Progress Note, and generally she would say there was a new order. On 4/20/22 at 1:17 PM, Staff D, MDS Coordinator, acknowledged that she would write the Care Plans. When queried about Wound Care Plans for Resident #22, Staff D responded she did not have the resident Care Planned for her vascular issues, and the resident needed an At Risk Pressure Ulcer Care Plan. When queried if Resident #22 had any pressure ulcers, Staff D responded she was pretty sure they were calling the one on her toe vascular. When queried if she was aware of any heel sites for Resident #22, Staff D responded no. Per Staff D, when the provider came in generally if there were new orders that day, telephone orders were written, and were signed on the spot. Then the Charge Nurse would take care of the telephone order and implement it. Per Staff D, a week later the Progress Notes would get sent over in a big group for whoever they saw that week. Staff D acknowledged sometimes it took a week before the notes were Faxed to the facility. When queried about the treatment recommendation included in the 3/10/22 note, Staff D explained the sheet had been faxed to the facility 3/20/22. Per Staff D, staff did not round with the NP who had authored the note for Resident #22 when the provider was in the facility. On 4/20/22 at 1:36 PM, the Director of Nursing (DON) explained typically orders were not written on the notes, and usually if (the provider) was in for a visit, they would write it on the Telephone Orders so that the nurse was aware of it right away. Per the DON, sometimes they write it on a Fax Sheet, and typically a Telephone Order would be written. When queried what should have occurred in this situation, the DON explained ideally the order should have been written on a Telephone Order. When the visit notes come in, the DON explained she was not sure if the nurses looked at them or if they would go to other staff first. The DON acknowledged she did not normally see the Visit Notes, and further explained it should have been looked over either by the Charge Nurse or another staff member and should have been caught. When queried about implementation of Pressure Ulcer Care Plans, the DON acknowledged the MDS Coordinator usually did the Care Plans. Per the DON, the facility had been using boots to keep the resident's heels off of the bed. When queried as to what had been done prior to prevent a wound, the DON acknowledged this would ideally be in the Care Plan. When queried if there was a process for nurses to check skin at a set frequency, the DON explained this would occur on admission, and aides would come to the nurses if they noticed red areas or something like that. The DON explained that they did not have something in place for before, and acknowledged after a Wound Development Assessment would occur weekly. Review of the Facility Policy titled Skin Care: Risk Assessment and Treatment, dated 9/30/04, revealed, it is the policy of the facility that a resident with any type of skin condition (i.e. any red areas, skin tears, decubitus ulcers) shall receive appropriate treatment. The treatment will have as its aim to promote healing, prevent infection, and prevent new conditions from arising. The policy also documented, A Pressure Ulcer Progress Report will be initiated when observed by the Charge Nurse. Progress Reports on all pressure ulcers are to be documented weekly. Included in the report will be date, location, stage of ulcer, size, depth, any drainage, any odors, color of site and surrounding tissues, date of doctor notification and subsequent orders. (i.e. Cultures, treatment, new medications, or change in diet.)