**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review, resident interview, and staff interview the facility failed to assure a complete and thorough initial assessment and weekly follow up assessments were completed for 1 of 2 residents reviewed (Resident #128) with impaired skin. Resident #128 admitted to the facility from the hospital on 6/24/22. The facility failed to complete a full skin assessment for Resident #128, including the abdominal wound, present on admission to the facility, until 7/8/22. The facility failed to complete an assessment of an additional skin impairment identified on 7/9/22, until 7/17/22 when deterioration of the area noted and revealed 2 open areas. The facility reported a census of 26 residents. Findings Include: Resident #128's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS coded that Resident #128 required extensive physical assistance of one to two persons for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS included diagnoses of renal insufficiency, hypertension, renal insufficiency, diabetes, malnutrition, rash/other nonspecific skin eruption, and disorder of calcium metabolism. The MDS identified Resident #128 as a risk for developing pressure ulcers. She used a pressure reducing device for her bed and her chair. The MDS documented that Resident #128 received an application of nonsurgical dressings and an ointment/medications for skin and ulcer/injury treatment. The facility failed to develop a comprehensive care plan for Resident #128, that included a Focus area, a Goal and/or Interventions related to her risk for impaired skin integrity and/or actual skin impairment. On 7/25/22 at 2:00 PM, Resident #128 sat in her recliner with her feet elevated wearing a hospital gown on. Staff E, Licensed Practical Nurse (LPN), informed Resident #128 that they would change the dressing on her abdomen. Resident #128 removed the old dressing dated 7/24/22 and revealed a large necrotic (dark black) area surrounded with redness along the bottom of her abdominal fold. Noted an open area with a red base along the bottom side, the length of the necrotic area that measured approximately 1 cm wide. Resident #128 stated that the area started as two scratches and bruises that developed into the large black scabbed area. Resident #128 said that dialysis told her the cause of the area happened by calcification under the skin. Resident #128 stated the wound deteriorated at home, as she did not go out for dialysis, and eventually got admitted to the hospital due to the pain of the wound. On 7/26/22 at 10:37 AM, Resident #128 sat in her recliner with her feet elevated. Resident #128 stated that she just did not feel well that day and that she had pain. Resident #128 reported that she spoke with the nurse about it and she had received all the pain medications she could have. Resident #128 explained that she did not feel up to an interview at the time. On 7/26/22 at 3:20 PM, Resident #128 sat in her recliner, with feet elevated and covered with a blanket. Resident #128 reported that she just took a bunch of medication and would like to take a nap, and did not feel like being interviewed. The Progress Notes for Resident #128 revealed: a. On 6/24/22 at 7:30 PM, the admission Nursing Note documented that Resident #128 arrived at the facility via family care from the hospital. b. On 6/24/22 at 12:00 AM, the Health Status Note (HSN) recorded that Resident #128 arrived at the facility from the hospital with family. The note indicated that Resident #128 able to make her needs known due to being alert and oriented. The resident had triple lumen to the upper right arm, a bruise noted across the abdominal area and fistula to the right upper arm with several bruises observed c. On 6/28/22 at 10:10 AM, HSN documented Resident #128 as alert and oriented to person, place, time, and able to make her needs known. Resident #128's skin appeared pale, warm, and dry as her baseline. The wound noted to her abdomen appeared without signs or symptoms of infection. Resident #128's left arm fistula with bruit and thrill, her port appeared to have no signs or symptoms of infection d. On 7/6/22 at 3:02 PM, HSN indicated that Resident #128 continued with her abdominal treatment. The wound contained an intact scab that appeared to be tender to the touch. No new skin issues identified. e. On 7/8/22 at 9:47 AM, HSN recorded a new order received from the Wound Center to apply iodine 10% (antimicrobial used to treat wounds) via a swab stick to the scabbed area on the abdominal wound. Continue the medi-honey (gel used for hard to dress wounds and dry to moderate draining wounds) to the open area below the scabbed area on the abdomen. f. On 7/8/22 at 9:48 AM, HSN documented a scabbed wound to Resident #128's abdomen that measured 17.5 centimeters (cm) in length x 5.4 cm in width x 0 cm in depth. The open area below the scabbed area measured 6.7 cm x 1.5 cm x 0.5 cm. g. On 7/10/22 at 1:02 PM, HSN indicated that during Resident #128's shower, the staff observed a superficial area on her right buttock. The nurse cleaned the area, applied calmoseptine (ointment to prevent and heal minor skin irritations), and covered the wound with mepilex (foam dressing). The nurse sent a fax to Resident #128's primary care provider (PCP). Resident #128 continued with her wound treatment. h. On 7/17/22 at 2:15 PM, HSN indicated that while performing the treatment to Resident #128's abdomen, Resident #128 said that she had a patch to her right hip area. The nurse noted a large bordered foam dressing dated 7/9/22. The nurse removed the dressing, then cleaned the area revealing two open wounds. Wound #1 (closest to the coccyx) measured 4 cm x 2.5 cm x 0.1 cm. Wound #2 measured 4.6 cm x 3.4 cm x 0.1 cm. The nurse applied Bactroban (ointment used to treat skin infections) to both of the areas and covered them with a bordered foam dressing. The nurse sent a fax to Resident #128's PCP. Resident #128's Nursing Daily Skilled assessment dated [DATE] - 7/27/22 lacked documentation of an assessment related to the abdominal wound and/or the skin impairment to the right buttock or hip area. Resident #128's Weekly Skin Assessments revealed one assessment dated [DATE]. The assessment identified intact dressings to her lower abdomen and her right buttock. The assessment lacked documentation of the open areas including measurements. Resident #128's Resident Bath/Skin Observation documented the following: 1. On 6/25/22 - identified an abdominal area while applying betadine. 2. On 6/29/22 - no skin impairments identified. 3. On 7/6/22 - an open area to her lower abdomen, the nurse treated the wound. 4. On 7/10/22 - lower abdomen dressing intact and new area to her right buttock. 5. On 7/16/22 - lower abdomen dressing intact and no documentation related to the area on her right buttock Resident #128's Wound Healing Center documentation included the following: 1. On 7/6/22 - midline abdomen, lower quadrant caused by calciphylaxis (serious uncommon disease where calcium accumulates in the small blood vessels of the fat and skin tissues, causing painful skin ulcers). Date acquired 5/1/22, 5 weeks of treatment. Measurements: 7 cm x 15 cm x 0.8 cm. Small amount of yellow, brown, and green purulent drainage. Large amount of eschar (black) tissue. 2. On 7/27/22 midline abdomen, lower quadrant measured 6 cm x 18 cm x 0.8 cm. Right gluteus caused by calciphylaxis acquired on 7/1/22. Measured 2.5 cm x 6 cm x 0.1 cm. small amount of granulation with medium amount of slough. The paper and electronic clinical record lacked weekly skin assessments of Resident #128's abdominal wound from her admission on [DATE] until 7/8/22. Resident #128's paper and electronic clinical record lacked a thorough assessment of the areas identified on the right buttock on 7/9/22 until the identification of two areas on 7/17/22. The facility failed to develop a comprehensive care for Resident #128. The Skin Care and Wound Management policy dated 6/15, identified the components of the program to include: weekly monitoring of Resident #128 skin status, daily monitoring of existing wounds, and the interdisciplinary team (IDT) to review the identified skin impairments. 1. Procedure: a. Complete admission skin sweep and the admission clinical information/readmission data collection and initial care plan on admission. Initiate weekly skin sweep thereafter. Identify areas of skin impairment and any pre-existing signs. b. Develop a care plan with input from the IDT and Resident #128 and family. Document individualized goals and interventions to manage risk factors. c. Communicate risk factors and interventions to the caregiving team, resident/family. d. Evaluate for consistent implementation of the interventions and evaluate effectiveness of the interventions during care management meetings. 1. Treatment: a. Select and complete the appropriate form: Skin Grid, Pressure or Skin Grid Other (all skin impairment issues that require measurement to indicate healing occurred) b. Monitor and document progress towards goals c. Evaluate effectiveness d. Modify and document goals and interventions On 7/26/22 at 11:15 AM, the Director of Nursing (DON) explained the the weekly wound assessments got documented in Resident #128's progress notes and denied having a separate skin book. The DON stated all of Resident #128's clinical record would be located in the hard chart and/or the electronic health record (EHR). On 7/28/22 at 7:19 AM, Staff A, Nurse Consultant, confirmed in an email that Resident #128 had wound clinic documentation from 7/6/22 and 7/27/22 with measurements. Staff A explained her next scheduled appointment as 8/8/22. Staff A acknowledged that during Resident #128 bath, the bath sheets acknowledged a wound for 6/25/22, 7/6/22, 7/10/22, and 7/16/22; however, the bath sheets lacked measurements. On 7/28/22 at 8:13 AM, the DON stated Resident #128 had a history of open areas with sores to her bottom and to her right hip. The DON explained that he started in the position after Resident #128's admission to the facility. The DON stated he believed that Resident #128 had the areas to abdomen and/or right buttock upon admission. The DON said that Resident #128 received dialysis and she had been in and out of the hospital. The DON reported that he ordered a new commode for Resident #128 due to the new area on her right hip and that he educated the bath aide (a Registered Nurse) about body assessments and measuring open areas. The DON confirmed Resident #128 did not have a complete thorough skin assessment upon admission and/or every week thereafter. The DON confirmed Resident #128 did not have an assessment of her skin impairment identified on 7/9/22 to her right buttock until 7/17/22. The DON added that on a resident's admission to the facility, he expected a full head to toe assessment and initiation of the Care Plan immediately. The DON said the Baseline Care Plan could be a Pocket Care Plan and would expect Resident #128, her family, and the staff to be involved. The DON reported that he expected ongoing weekly skin assessments and an assessment of any new areas identified. The DON explained that he reviewed the facility protocol with the facility nurses on duty related to the skin assessments and expected all residents in the facility to have a skin assessment completed on 7/27/22 and/or 7/28/22. On 8/1/22 at 2:28 PM, Staff B, Licensed Practical Nurse (LPN), explained that the weekly skin assessments were completed under the assessment tab in the resident's EHR. Staff B reported that skin assessments should be done every week, however, they did not get assigned to anyone specifically. For that reason, the assessments do not get completed. Staff B reported that they worked one day a week, and when they arrived to work on Monday mornings the aides would report skin impairments to the agency nurses, who did nothing about them all weekend.

Based on observations, clinical record reviews, and staff interviews the facility failed to adequately supervise, thoroughly investigate falls that occurred, and implement interventions to prevent further falls for 1 of 1 residents (Resident #10) reviewed. Resident #10 sustained falls on 6/1, 6/10, 6/12, and 6/26/22 without a thorough investigation and/or intervention implemented to prevent further falls. On 6/12/22, Resident #10 found on the floor in Resident #10's room with a deep cut to the back of head that required transfer to the emergency room, and resulted in staples being placed. The facility reported a census of 26 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #10 dated 6/2/22, identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed Resident #10 required extensive physical assistance of one staff for bed mobility, transfers, ambulation, toilet use, and personal hygiene. The MDS coded Resident #10 ' s balance during transitions and walking, as not steady and only able to stabilize with staff assistance. The MDS coded Resident #10 as frequently incontinent of bowel and bladder. The MDS included diagnoses of hypertension, diabetes, non-Alzheimer's dementia, and repeated falls. The MDS identified Resident #10 fell since her admission/entry, reentry, or her prior assessment. The MDS coded Resident #10 had two or more falls with no injury, 2 or more falls with injury, and no falls with major injury. The Care Plan with date initiated 1/29/22, identified Resident #10 had an actual fall with no injury related to poor balance and unsteady gait. The Care Plan interventions included: a. Anti-roll back wheelchair to reduce the wheelchair rolling backwards when Resident #10 stands up and sits back down (2/25/22) b. Assist x 1 with ambulation, after toileting, when Resident #10 became restless and attempting to get out of the wheelchair if restlessness continues (6/1/22) c. Back of wheelchair seat to be lowered (4/2/22) d. Continue interventions on the at-risk plan (1/29/22) e. Ensure call light in reach, place on walker/wheelchair or near body (2/3/22) f. Keep frequently used items on right side (3/12/22) g. Keep walker and/or wheelchair in resident's reach for visual cue for safety (2/24/220 h. Anti-tip wheels on wheelchair if indicated (2/15/22) i. Offer snacks and activities when up in wheelchair (4/3/22) j. Pharmacy consult to evaluate medications (3/12/22) k. Provide room in high traffic area (3/14/22) l. Physical therapy consult for strength and mobility (3/12/22) m. Ambulate resident three times a day (2/23/22) n. Encouraged to propel self in wheelchair in hallway, instead of ambulating independently (2/23/22) o. Resident to wear shoes when out of bed and non-skid socks in bed (1/30/22) p. Avoid telling Resident #10 what you don't want her to do (2/18/22) q. When not pushing wheelchair, ensure pedals are locked and to the side (4/29/22) r. Encourage Resident #10 to use a controller to lower the footrest of the recliner (1/30/22) The Care plan for Resident #128 with date initiated 1/29/22, identified Resident #10 mixed bladder incontinent related to dementia. The Care Plan interventions included: a. Ensure unobstructed path to the bathroom (1/29/22) b. Establish voiding patterns (1/29/22) c. Check every 2 hours and as needed for incontinence (1/29/22) On 7/25/22 at 10:22 AM, Resident #10 up in a wheelchair in the hallway, sitting outside of the door to the room. The resident was well-groomed with non-skid footwear on. The resident with hand up on forehead and leaning forward, eyes closed. On 7/25/22 at 11:25 AM, Resident #10 at the dining room table in a wheelchair with nursing staff sitting with Resident #10. On 7/26/22 at 8:52 AM, the nursing staff assisted Resident #10 in the dining room with breakfast. The resident had well-groomed and non-skid footwear on. On 7/26/22 at 3:16 PM, Resident #10 in the hallway in a wheelchair. The resident had well-groomed and non-skid footwear on. The resident attempted to propel the wheelchair back and forth. The Progress notes for Resident #10 revealed: a. On 6/1/22 at 1:45 PM, The Alert Note (AN) identified Resident #10 observed on the floor on the left side in front of the wheelchair by the nurse's station. No sign/symptoms of injuries, bruising, laceration, or redness. The resident denied pain or discomfort. Range of motion (ROM) within normal limits. Assist of 2 for short walk, gait steady. Vitals sign stable and neurological assessment initiated. Family and physician notified. b. On 6/1/22 at 3:46 PM, AN identified an intervention of assist x 1 with ambulation, after toileting, when Resident #10 became restless and attempted to get out of wheelchair if restlessness continued c. On 6/10/22 at 4:08 PM, a health status note (HSN) stated Resident #10 was on the floor, lying on the right side with a wheelchair behind. The resident was unable to explain what occurred. The resident denied pain and was able to demonstrate ROM to all extremities. No bruising or abrasions noted. The resident assisted by standing and in a wheelchair. The resident assisted at the nurse's station and provided. Family and physician notified. d. On 6/12/22 at 11:41 AM, HSN revealed Resident #10 was found on the floor in a room with blood at the back of head, deep cut and bump notes. The resident was transferred to a wheelchair and sent to the emergency room after family and physician notification. e. On 6/12/22 at 2:49 PM, HSN stated the facility received call from the emergency room (ER) and Resident #10 to return to the facility, and Resident #10 CT scan negative f. On 6/12/22 at 4:32 PM, HSN stated Resident #10 returned to the facility with family, 3 staples placed to the left parietal scalp and to be removed on 6/19/22. g. On 6/19/22 at 4:41 PM, HSN identified 3 staples removed from the back of Resident #10's head, area clean, dry, and intact. The resident denied pain or discomfort. h. On 6/26/22 at 8:31 AM, HSN identified Resident #10 found on the floor of the room, on the left side with legs extended. The resident incontinent and briefly saturated, with yellow stain on bedding. The resident self-transferred from the bed. Neurological assessment initiated and Resident #10 denied pain or discomfort. The Fall Investigation dated 6/1/22 at 1:45 PM, identified Resident #10 found lying on the left side in front of the wheelchair by the nurses station. a. Immediate action: Intervention: assist of one with ambulation after using the toilet when Resident #10 became restless and attempted to get out of her wheelchair. b. Predisposing environmental factors: furniture c. Predisposing physiological factors: gait imbalance and impaired memory d. Predisposing situation: wanderer and ambulated without assist The Fall Investigation dated 6/10/22 at 4:03 PM, identified Resident #10 found in the hallway lying on the floor with a wheelchair behind Resident #10. a. Immediate action: Resident #10 assessed and vital signs obtained. ROM assessed Resident #10 assisted to wheelchair b. Mental status: oriented to person c. Predisposing physiological factors: gait imbalance and impaired memory The Fall Investigation dated 6/12/22 at 11:27 AM, identified Resident #10 found on the floor in the room with blood at the back of head, deep cut and bump noted. a. Immediate action: Resident #10 sent to the hospital b. No injuries observed at time of the incident c. Predisposing environmental factors: other d. Predisposing physiological factors: confused, gait imbalance and impaired memory e. Predisposing situation factors: used wheeled walker The Fall Investigation dated 6/26/22 at 8:25 AM, identified Resident #10 found on the floor in the room on the left side with legs extended. The resident incontinent with saturated briefs and yellow stains on bedding. The resident self-transferred. a. Immediate action: neurological assessment b. No injuries observed at time of the incident c. Mental Status: oriented to person and place d. Predisposing environmental factors: other, detail in note e. Predisposing physiological factors: confused, incontinent, gait imbalance and impaired memory f. Predisposing situation factors: ambulated without assist and improper footwear g. Other information: intervention gripper socks and check and change every two hours The emergency room Provider Report dated 6/12/22 at 11:37 AM, identified Resident #10 ' s chief complaint as a fall with a head injury. Resident #10 presented to the ER by ambulance for a head injury associated with a fall. Resident #10 appeared at her baseline of confusion. The facility staff assumed Resident #10 fell out of bed onto the hard floor, approximately one to two feet. Resident #10 hit her head when she fell, resulting in an injury to the left occipital part of her head. Resident #10 had a history of recurrent falls. The section labeled Additional Documentation indicated that Resident #10 received three staples, antibiotic ointment, and a bulky dressing. The Radiology Impression identified a closed head injury with concussion, left parietal scalp hematoma, and laceration of the occipital scalp. On 8/1/22 at 9:23 AM, the Director of Nursing (DON) said the facility staff asked about Resident #10 falls when he started at the facility at the end of June 2022. The DON stated he inquired about a scooped mattress. The DON explained that Resident #10 did not have any further falls from her bed since placing the scoop mattress. The DON denied knowing the date of the placement of the scooped mattress on Resident #10's bed. The DON reported that he knew Resident #10 had a lot of falls from her bed. The DON explained that he did not have the chance to look into Resident #10's falls. The DON said he expected the falls to be looked into, to determine if the previous interventions implemented were sufficient. The DON added that within 24 to 48 hours he expected an intervention to be put in place following a fall and additional interventions to follow as needed. The DON acknowledged that falls needed to be looked at facility wide.