**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 41 residents. The sample included 14 residents with five reviewed for pressure ulcers. Based on observation, record review, and interview the facility failed to provide interventions to prevent the development of pressure ulcers for two of five sampled residents, Resident (R) 33, who developed a Stage 3 pressure ulcer (full thickness skin loss potentially extending into the subcutaneous tissue layer, just under the skin), and R11, who developed one unstageable pressure ulcer (wound bed covered with slough,dead tissue that may be white, tan, or yellow or eschar,a dry dark scab). Findings included: - R33's Physician Order Sheet, dated 12/06/20, documented diagnoses of diarrhea, history of rectal or anal cancer, stasis dermatitis (skin inflammation in the lower legs caused by fluid buildup), and tinea cruris (fungal infection in the skin of the genitals, inner thighs, and buttocks). R33's Admission/5-Day Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. The MDS documented the resident required extensive assistance of two staff for transfers and toilet use, extensive assistance of one staff for bed mobility and personal hygiene, and supervision with one staff assistance for eating. The MDS documented R33 was frequently incontinent of urine and always incontinent of bowel. The MDS documented R33 had a Stage 2 pressure ulcer (partial thickness skin loss into but no deeper than the dermis, outer layer of skin) present on admission. The MDS documented the resident had pressure reducing devices for his chair and bed, required nutrition or hydration program interventions for skin problems, was not on a turning/repositioning program, and required no pressure ulcer/injury care. The Pressure Ulcer Care Area Assessment (CAA), dated 12/20/20, documented the resident was at risk for pressure related skin breakdown related to decreased functioning with activities of daily living (ADLs) and incontinent of bladder and bowel. The Basic Care Plan, dated 12/16/20, documented R33 was dependent for meeting his emotional, intellectual, physical, and social needs related to cognitive deficits and was focused on the activities that R33 enjoyed. The care plan lacked interventions for prevention of pressure ulcers. The Braden Scale, (predicts risk for pressure ulcers) dated 12/14/20, documented a score of 11 (high risk). The Skin Integrity Care Plan, dated 01/06/21, directed staff to educate the resident, resident's family, and caregivers to the causes of skin breakdown including transfer/positioning requirements, good nutrition, and frequent repositioning. The care plan further directed staff to avoid positioning R33 on his left buttock, to monitor nutritional status, and obtain lab work. The care plan documented a Stage 3 pressure ulcer to left buttock and directed staff to apply treatment as ordered. The ADL Assistance Care Plan, dated 01/06/21, recorded the resident required extensive staff assistance with bed mobility, and directed staff to turn and reposition the resident every two hours and as necessary. The admission Skin Assessment dated 12/14/20, documented R33 had a healing sore to the left gluteal fold measuring 1 centimeter (cm) x 0.5 cm. The Skin/Wound Note, dated 12/18/20, documented redness and an open area to inner left buttocks area. Staff cleaned, dried, and applied A&D ointment (ointment to treat minor skin irritations). No measurements documented in the note. The Weekly Skin Assessment Note, dated 12/23/20, documented no new areas of concern. The Nurse's Note, dated 12/24/20, documented a pea sized open area to left buttock and staff applied a foam dressing to the area. No measurements documented in the note. The Weekly Skin Assessment, dated 12/28/20, documented skin intact and no new skin areas identified. The Weekly Skin Assessment, dated 01/04/21, documented redness to left buttock. The Skin/Wound Note, dated 01/05/21 at 02:47 PM, documented R33 had a declining area to his left buttock, treatments were not effective due to loose stools. Staff informed the Director of Nursing (DON) and the resident's family of area. Air mattress placed to bed, Roho cushion (pressure relieving cushion) placed in wheelchair, and repositioning program implemented. Staff called R33's physician and requested a multivitamin with minerals, Prostat (protein supplement), and Vitamin C and awaited a return call. The Wound Note, dated 01/05/21 at 03:13 PM, documented a Stage 3 pressure ulcer to left gluteal fold that measured 1.76 cm x 0.7 cm x 0.2 cm with 70% epithelial (the thin tissue layer forming the outer layer of the body's surface) and 30% slough. Staff notified the primary care physician of the wound and he gave orders to apply skin prep (protective solution to protect good skin from adhesive) to peri wound, silver alginate (natural fiber dressing that absorbs drainage and forms a gel-like covering over the wound) to wound bed, cover with foam dressing, and change dressing daily. Staff would request orders for Prostat, Vitamin C, and multivitamin for wound healing. Staff would place the resident on a turning and repositioning program and air mattress. The note documented staff educated the resident about repositioning program to be implemented and placed a Roho cushion in the resident's wheelchair. The note documented staff continued to monitor area with cares and would reassess. Awaited return call for nutritional supplements. The Skin/Wound Note, dated 01/12/21, documented the Stage 3 pressure ulcer was 100% closed. On 01/07/21 at 01:30 PM, observation revealed Licensed Nurse (LN) removed the old foam wound dressing revealing a moderate amount of bright bloody drainage. Observation revealed the wound tear drop shaped and open, with a red, beefy wound bed. LN H cleansed the wound with wound cleaning solution, applied skin prep to the peri-wound, applied Silver alginate to the wound bed, and covered with a new foam dressing. On 01/07/21 at 01:45 PM, LN H stated R33 was very incontinent of stool. When R33 came to this facility he had no appetite and had an area to his left buttock that had just healed, but no open areas. After he obtained the pressure ulcer, the facility placed a Roho cushion in his wheelchair, started a turning/repositioning schedule when he was in bed, obtained a new mattress with a special overlay, and started him on Prostat, Vitamin C, and a multivitamin for wound healing . On 01/11/21 at 09:02 AM, LN I stated R33 did not have any pressure relieving interventions prior to developing the pressure ulcer. Staff were going in and checking and changing his incontinent brief, so he had been repositioned some, and R33 was able to reposition himself if he wanted to. On 01/12/21 at 09:56 AM, LN HH stated that she had performed the admission skin assessment and R33 had no open areas to his buttocks. He did have an area of newly healed skin to his right buttock that measure 1 cm x 0.5 cm. It was healthy pink skin but fragile. On 01/12/21 at 01:48 PM, CNA P stated she and another CNA toileted and showered R33 on 12/24/20. CNA P stated when she wiped the resident's buttocks the wipe was bloody and there was an open area. CNA P stated she informed the nurse and the nurse placed a foam dressing to the open area. On 01/12/21 at 03:46 PM, LN K stated her regional nurse consultant performed the admission MDS and documented a Stage 2 pressure ulcer. LN K contacted the regional nurse consultant by email and was told she got her information from the hospital's admission packet. The packet documented a Stage 2 pressure ulcer to the right superior buttock. On 01/12/21 at 03:50 PM, LN H stated if she would have known R33 had a pressure ulcer on admission she would have ensured pressure relieving measures were in place. LN H stated the usual protocol for any open areas was to report them to her upon finding them, document the measurements, and implement interventions. LN H stated she did not know why the nurses who documented the previous open areas did not inform her of them or document them better and did not know how the Weekly Skin Assessments did not show that there were any areas of concern. On 01/12/21 at 04:28 PM, LN L stated she was informed on 12/24/20 that the resident had an open area to his left buttock. LN L stated she did not measure the area and did not inform the wound care nurse about the area. On 01/12/21 at 10:12 PM, LN GG stated she found an open area to the left buttock on 12/18/20 at 04:39 AM that measured 2.0 cm x 0.5 cm. LN GG stated she notified the charge nurse the next morning by leaving her night sheet on the charge nurse's desk and also gave verbal report about the open area to the morning nurse that was taking over for her. On 01/12/21 at 04:04 PM, Administrative Nurse D stated R33 did not have a Stage 2 pressure ulcer prior to his admission to the facility. After reviewing the resident's admission documentation Administrative Nurse D stated the facility missed it and if she had known she would have ensured that interventions were in place to ensure R33 did not obtain any pressure ulcers. Administrative Nurse D stated the nurses that found the open areas to R33's left buttock should have notified her or the wound care nurse about them and documented the measurements and interventions in the nurse's notes. The facilities Pressure Injury Prevention and Management policy, dated 01/01/20, documented in order to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries that facility will implement evidence-based interventions by implementing individualized interventions that will address specific factors identified in the resident's risk assessment and skin assessment; prevention devices will be utilized in accordance with manufacturer's recommendations; interventions will be documented in the care plan and communicated to all staff; licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on resident's upon admission/readmission, weekly times four weeks, then quarterly; and licensed nurses will perform assessments of pressure injuries and ensure the assessments are documented in wound rounds or in Skin/Wound Portal in Point Click Care. The staging of pressure injuries will be clearly identified. The facility failed to implement individualized interventions for R33 to prevent pressure ulcers, failed to adequately monitor the resident's skin condition, and failed to document and communicate R33's open areas to his left buttocks, placing the resident at risk for worsening pressure areas. - R11's Physician's Order Sheet, dated 12/08/20, documented diagnoses of degenerative changes to one or many joints characterized by swelling and pain, vascular dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by decreased blood flow to the brain), anemia (condition without enough healthy red blood cells to carry adequate oxygen to body tissues), and cerebrovascular disease (disorder that affect the blood vessels and blood supply to the brain). R11's Annual MDS, dated 03/26/20 documented a BIMS of three, indicating severe cognitive impairment. The MDS documented R11 required two staff extensive assistance with transfers and toileting, extensive assistance of one staff for bed mobility, dressing, personal hygiene, and bathing, and independent with staff supervision for eating. The MDS documented the resident had no weight loss or difficulty eating, and no pressure ulcers. R11's Quarterly MDS, dated 12/09/20, documented the resident had severe cognitive impairment. The MDS recorded R11 had long and short-term memory problems and severely impaired decision-making process. R11 required extensive assistance of two staff for bed mobility, transfers, toilet use, personal hygiene, and bathing, supervision of one staff for eating and locomotion on the unit, no weight loss, no difficulty eating, and at risk for pressure ulcers. The MDS documented the resident had no pressure ulcers, and had a pressure relieving devices for the bed and chair. The Pressure Ulcer/Injury CAA, dated 03/26/20, documented R11 was at risk for pressure related skin breakdown and required extensive assistance with bed mobility, dressing, hygiene, and bathing, total staff assistance with toileting and transfers. The CAA documented R11 was non-ambulatory, required limited assistance with locomotion, and used a wheelchair for mobility. The CAA documented R11 was incontinent of bowel and bladder and unable to voice the need for elimination. The CAA directed staff to turn and reposition R11 with rounds if needed, monitor skin condition as needed, and perform weekly skin checks. The 01/07/21 update directed staff to apply an air mattress to the resident's bed and Roho (pressure cushion) to the resident's wheelchair. The Skin Integrity Care Plan, dated 01/03/21 documented R11 was at risk for alterations in skin integrity related to decreased mobility and fragile skin. The care plan directed staff to educate R11, family, and caregivers as to causes of skin breakdown including transfer/repositioning requirements, good nutrition, and frequent repositioning. The care plan directed staff to ensure use of pressure redistribution surface to bed and chair, to assess skin during routine cares, and encourage repositioning assisting if R11 was unable to himself. The Skin Integrity Care Plan, dated 01/07/21 documented R11 had an unstageable pressure ulcer to the left inner buttock and directed staff to follow treatment as ordered. The Braden Scale, dated 06/26/20 and 09/26/20 , documented a score of 12 (high risk). The Weekly Skin Check, dated 12/28/20, documented no new skin concerns, various bruises, and skin tears in various stages of healing. The Weekly Skin Check, dated 01/05/21, documented no new skin areas of concern. The Skin/Wound Assessment, dated 01/07/21 documented an unstageable pressure ulcer to the right buttock that measured 1.16 cm x 0.65 cm x 0.1 cm. The Skin/Wound Note, dated 01/07/21, documented the resident had an open area to the right inner buttock that measured 1.2 cm x 0.6 cm x 0.1 cm. The note documented R11 was incontinent of bowel and bladder, staff provided incontinence care every 2-3 hours, and repositioned every 2-3 hours while in bed at night and as needed. The note documented R11 was combative with staff at times and had numerous bruises in different stages of healing to bilateral arms. Therapy gave the resident a new wheelchair with a new cushion this week. The Nurses Note, dated 01/07/21, documented the facility had placed a Roho cushion to R11's wheelchair and had ordered an air mattress. The air mattress was put in place on 01/11/21. The facility placed R11 on a turning/repositioning schedule of being laid down after meals and the every 2 hours while in bed on 01/07/21. The Nurses Note, dated 01/07/21, documented R11's physician assessed the resident and recommended discussion with resident's family to admit to hospice care. Family would like R11 to finish his skilled days, then reassess, and proceed with hospice after re-evaluating. The Nurse's Note, dated 01/07/21, documented the physician ordered dressing changes to the right inner buttock every three days, cleanse area to right inner buttock with wound cleanser, apply skin prep, cover with Duoderm (foam dressing) and administer liquid protein 30 milliliters (ml) twice a day, Thera tablet (multi vitamin) 1 tablet daily, and Vitamin C 500 milligrams (mg) daily. On 01/07/21 at 01:50 PM, observation revealed CNA O and CNA P checked R11's incontinent brief. After CNA O cleaned resident buttocks observed a pressure ulcer on the right buttock. Staff notified LN H who came to R11's room, cleaned the area, applied skin prep to the peri wound, and covered the wound with a foam dressing. The wound measured 1.16 cm x 0.65 cm x 0.1 cm, wound covered with yellow slough and peri wound purplish/red in color all the way around the wound. On 01/11/21 at 08:51 AM, LN I stated the facility performed weekly skin assessments and assessed the skin during showers two times a week. R11 was able to turn and reposition some in the bed, once up in the wheelchair he stayed up from breakfast until after lunch and then will lay down after lunch. LN I stated R11 had a pressure relieving mattress and a Roho (pressure relieving cushion) cushion in his wheelchair. On 01/11/21 at 01:50 PM, CNA O stated she previously reported the skin area to LN Land stated she always reported any bumps, rashes, bruises, or open areas to her nurse, the charge nurse, or the wound care nurse. CNA O stated she should have notified the wound care nurse when she found the area. On 01/11/21 at 04:30 PM, LN H stated she felt the pressure ulcer came from him constantly scooching around in his wheelchair. R11 had a foam cushion in his wheelchair and we have since changed it to a Roho cushion. On 01/12/21 at 04:15 PM, LN L stated she saw the wound to R11's right buttocks on 01/04/21. LN L stated she told LN H about it and LN H said she would go later and look at it and put a patch on it. LN L stated she did not measure the wound because she thought LN H wound do that when she looked at it. On 01/12/21 at 03:21 PM, Administrative Nurse D stated she heard R11 had an open area to his buttocks and supposedly the nurse who found it said she told me about it the same day, but I don't recall her telling me. The nurse should have documented the area, told the wound nurse about the area so interventions could have been put in place the same day. The facilities Pressure Injury Prevention and Management policy, dated 01/01/20, documented in order to prevent the formation of avoidable pressure injuries and to promote healing of existing pressure injuries that facility will implement evidence-based interventions by implementing individualized interventions that will address specific factors identified in the resident's risk assessment and skin assessment; prevention devices will be utilized in accordance with manufacturer's recommendations; interventions will be documented in the care plan and communicated to all staff; licensed nurses will conduct a pressure injury risk assessment, using the Braden Scale, on resident's upon admission/readmission, weekly times four weeks, then quarterly; and licensed nurses will perform assessments of pressure injuries and ensure the assessments are documented in wound rounds or in Skin/Wound Portal in Point Click Care. The staging of pressure injuries will be clearly identified. The facility failed to implement individualized interventions for R11 to prevent pressure ulcers, failed to adequately monitor the resident's skin condition, and failed to document and communicate R11's open areas to his left buttocks, placing the resident at risk for worsening pressure areas. R11 developed an unstageable pressure ulcer.