**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 39 residents, with five residents reviewed for skin issues. Based on observation, interview, and record review the facility failed to order and provide four days (11/01/21-11/04/21) of continued intravenous antibiotic treatment as ordered for Resident (R)7, who was continuing post-surgical recovery for osteomyelitis and gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection) treatment to his left foot. On 11/01/21 R7's Infectious Disease Provider prescribed Zosyn (antibiotic) intravenously (IV, through the vein) three times a day for an additional two weeks. The interruption in the IV antibiotic treatment for R7 resulted in worsening of wound and the potential for regrowth of the infection, osteomyelitis, and gangrene. Furthermore the facility failed to ensure necessary treatment and care, in accordance with professional standards of practice, for Resident (R) 4, who had multiple wounds. Findings included: - Review of R7's diagnoses from the 10/06/21 Physician's Orders in the Electronic Medical Record (EMR) revealed gangrene, osteomyelitis (local or generalized infection of the bone and bone marrow), and absence of toes on the left foot. The 10/13/21 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. R7 had a surgical wound with foot infection and received antibiotics for seven days out of the seven-day observation period. The Pressure Ulcer/Injury Care Area Assessment (CAA), dated 10/13/21, documented R7 was at risk for skin breakdown with a surgical wound to the left foot measuring 19.9 centimeters (cm) by 4.5 cm by 6.2 cm. The 10/20/21 Care Plan directed staff to administer IV medication and antibiotics per the physician order using R7's peripherally inserted central catheter (PICC) line, complete weekly wound assessments, and observe for any signs and symptoms of infection, which included swelling, redness, warmth, discharge, and odor. The 10/06/21 Physician Orders documented an order for Zosyn (injectable broad-spectrum antibiotic, combination of two antibiotics) 4.5 grams (GM) intravenously every eight hours for gangrene that completed on 11/01/21 at 00:00 AM (midnight). The 10/10/21 Wound Assessment documented Nurse Practitioner (NP) KK ordered the IV antibiotic for R7's osteomyelitis infection. The IV antibiotic was to be given for two weeks and then reevaluated. The 10/17/21 Wound Note lacked documentation of the left foot surgical site measurements. The chart lacked the next scheduled wound care assessment note (per order) on 10/24/21. The 10/2021 through 11/2021 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented staff administered Zosyn to R7 between 10/06/21 and 10/31/21. The 11/01/21 Infectious Disease Consultants IV Order signed by NP KK documented an order for Zosyn 4.5 GM IV every eight hours for one week, with an extension of two weeks to end on 11/15/21. The 11/02/21 Wound Assessment documented completion of the IV antibiotic and noted the resident had a tele-med (virtual appointment using the computer or handheld device) visit with Physician HH on 11/01/21. (The assessment lacked mention of the 11/01/21 re-ordered Zosyn) The Wound Note dated 11/02/21 documented the left foot surgical wound measured 3.9 cm long by 1.7 cm wide by 5.9 cm deep. The 11/02/21 picture of R7's left foot wound revealed the partial amputation with a scabbed area that ran across the end of the residual foot. The skin around the scab looked light pink and non-edematous, the incision scab looked healing as it was intact, dark, and dry. The 11/04/21 Physician Progress Note written by NP GG documented Administrative Nurse D completed a tele-med visit with NP KK on 11/01/21. Administrative Nurse D stated NP KK wanted to continue the IV antibiotic due to the persistence of the wound infection. NP GG documented that no staff placed the IV antibiotic order into R7's chart and Administrative Nurse D was to follow up with the Infectious Disease Team to determine continued antibiotic treatment. The MAR/TAR lacked documentation of the administration of Zosyn from 11/01/21 through 11/04/21 (a total of 4 days). The 11/05/21 Physician Orders documented an order for Zosyn 4.5 GM intravenously every eight hours, to treat osteomyelitis, and to continue until Physician HH gave new orders. The Infectious Disease Consultants IV Order dated 11/08/21 signed by NP KK documented Zosyn 4.5 GM IV every eight hours for one week to end on 11/15/21. The 11/08/21 Physician Orders included an order to administer Zosyn 4.5 GM, intravenously three times a day for osteomyelitis until 11/19/21 at 11:59 PM. The physician discontinued (stopped) the order on 11/16/21. The 11/08/21 Physician Progress Note written by NP GG documented NP KK ordered Zosyn to continue for R7 on 11/01/21 for two weeks, but staff failed to administer it on 11/01/21, 11/02/21, 11/03/21, and 11/04/21. The 11/09/21 wound picture revealed R7's left foot incisional wound revealed the partial amputation with a scabbed area that ran across the end of the residual foot. The skin around the top side of the scabbed incision looked pink and very edematous. The residual foot area looked over twice the size (due to tissue swelling) from the 11/02/21 picture. The bottom side of the foot near the outer areas of the incision was very reddened and the skin was pulling away from the scabbed area. The outer area of the scabbed incisional wound was cracked open across the incision, revealing beefy red tissue underneath. The top area around the incisional wound near the inside top of the foot revealed a round darkened area. The 11/09/21 Wound Assessment documented R7 received IV antibiotics per the physician order and had an [undated] tele-med visit with Physician HH, during which Physician HH noted concerns about the eschar (dead tissue) covering the incision. The Wound Note dated 11/09/21 documented the left foot surgical wound measured 5.4 cm long by 3.0 cm wide by 3.7 cm deep. The Wound Note dated 11/14/21 documented the left foot surgical wound measures 5.6 cm long by 2.7 cm wide by 4.9 cm deep. (During this time, the antibiotic was being given.) Observation on 01/04/22 at 02:00 PM of R7 revealed Licensed Nurse J completed a dressing change of the resident's surgical amputation wound on the midfoot area. The skin was pink and intact with one open area where his toes would have been. Observation on 01/05/22 at 01:36 PM revealed R7 lying in bed, with his left foot wrapped up with a dressing labeled 01/04/22, when the staff last changed the dressing. Observation revealed a small amount of dried blood at the area where R7's big toe would have been. Interview on 01/05/22 at 01:35 PM with R7 revealed he had an amputation of his toes on his left foot and received IV antibiotics for about a month. R7 stated he received the IV antibiotics multiple times a day but could not remember if there were problems with receiving the antibiotic. Interview on 01/05/22 at 06:00 PM with NP GG revealed R7 had a tele-med visit on 11/01/21 with Physician HH. Administrative Nurse D received a verbal order from NP KK during the tele-med visit to extend the Zosyn 4.5 GM IV three times a day and a fax of the order would be sent to the facility. On 11/04/21, NP GG visited R7 and noted R7 had a PICC line, but it was not being used. NP GG called Administrative Nurse D and found the Zosyn order from 11/01/21 was never placed into R7's chart and was not given to R7 for a total of four days. NP GG restarted the Zosyn order for 11/05/21 and notified Administrative Nurse D that Physician HH needed to be notified of the medication error and to have Administrative Nurse D ask for clarification of the Zosyn order continuing. NP GG stated that during her visitations with R7, the appearance of R7's wound from 11/04/21 to 11/08/21 became worse (more gangrenous and needing debridement; medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue). Interview on 01/06/22 at 02:19 PM with Consultant Pharmacist LL revealed Zosyn must be given for the ordered duration from the Physician. Having an interruption in the medication would not be ideal and could cause the gangrene or other bacteria to come back within the four days the Zosyn was not given to R7. By giving the Zosyn properly the bacteria would be prevented from re-growing and the expected result would be to see the wound decrease and ultimately heal. Interview on 01/10/22 at 02:15 PM with Licensed Nurse (LN) G revealed she completed the weekly assessment of R7's foot and tracked the progress of the wound healing. R7 received IV antibiotics for his gangrenous foot wound, that was ordered by the Infectious Disease Team. LN G stated the ID team had concerns about the way R7's wound looked, and the Infectious Disease Team chose to continue the IV antibiotic using the PICC line. LN G stated the antibiotic order was never placed into R7's chart and was ultimately noted to be missing from the chart by NP GG. From what LN G remembered, Administrative Nurse D should have placed the IV antibiotic order into R7's chart as the tele-med order was given to Administrative Nurse D. Interview on 01/10/22 at 07:00 PM with LN H revealed Administrative Nurse D received a verbal order from the Infectious Disease Team to continue the IV antibiotic. She did not place the order into R7's chart but told LN H to place the order once the faxed orders arrived from the Infectious Disease Team. LN H stated that because Administrative Nurse D received the verbal order, Administrative Nurse D should have placed the order in the resident's chart. LN H did not feel comfortable placing an order for a medication another nurse verbally received from the physician. Interview on 01/10/22 at 08:00 PM with LN I revealed R7 received IV antibiotics for a left foot wound. LN I stated there was a mix up with the IV antibiotic order and staff never placed it in the chart. She stated that R7's foot looked worse during that time and was covered with eschar. Interview on 01/11/22 at 08:43 AM with Administrative Nurse D revealed R7 admitted to the facility receiving IV antibiotics per Physician HH's order. R7 was on Zosyn for about a month after admission and was eventually switched to the PO (by mouth) version. Administrative Nurse D stated the Infectious Disease Team was to fax an order for the Zosyn to the facility on [DATE], but the facility never received the fax. On 11/05/21 Administrative Nurse D stated she discovered the Zosyn order was never placed into R7's chart, so she notified the Infectious Disease Team via telephone of the issue. Administrative Nurse D stated the Infectious Disease Team decided to switch R7 to the PO form of antibiotic at that time. An interview on 01/13/21 at 02:30 PM with NP KK revealed she documented a note stating on 11/01/21 she wanted R7's Zosyn continued for two weeks. NP KK stated the Infectious Disease Team had no documentation of R7 missing doses of the Zosyn until 11/10/21. NP KK stated she gave verbal orders during the tele-med appointment and then faxed all orders to the facility. She stated she expected the nurse would place the order into the resident chart with the verification of the faxed order(s). NP KK did not remember which nurse was present during the 11/01/21 tele-med visit but stated that Administrative Nurse D had taken charge of the tele-med visits. The facility, undated Physician's Telephone Orders policy stated the physician's verbal and telephone orders would be entered into the resident chart by the licensed nurse accepting the order, and would document the date, time, physician name, and order provided. The order would then be validated for accuracy by the licensed nurse and the order would be printed, signed, and placed into the resident's paper chart under the Physician's Order tab. The facility failed to provide the ordered antibiotic treatment to R7 for four days and the resident's surgical wound revealed worsening with decline. - The Physician Orders (PO), dated 01/01/22, for R4, included diagnoses of COVID-19, type 2 diabetes mellitus (a form of diabetes that is characterized by high blood sugar, insulin resistance, and relative lack of insulin), pressure ulcer of back, buttock and hip, stage 4, and chronic ulcer of buttock. The Significant Change Minimum Data Set (MDS), dated [DATE], documented R4 with a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition and required extensive assistance with bed mobility, limited assistance with transfer, and total dependence on the staff for toileting. The resident had a non-pressure chronic ulcer of buttock with fat layer exposed and received surgical wound care and application of non-surgical dressings. The Pressure Ulcer/Injury Care Area Assessment, (CAA), dated 07/08/21, indicated the resident had stage three or higher pressure ulcers. The Activities of Daily Living Functional/Rehabilitation CAA, dated 07/08/21, indicated the resident had impaired mobility due to a double lower extremity amputation. The Quarterly MDS, dated 10/08/21, documented R4 with a BIMS score of 15, indicating intact cognition and required supervision with bed mobility, limited assistance with transfer, and extensive assistance of two staff members with toileting. The resident had a non-pressure chronic ulcer of the buttock with fat layer exposed and a surgical wound. He received surgical wound care and applications of non-surgical dressings. The Care Plan, revised 12/14/20, documented the resident had altered skin integrity, non-pressure, related to a surgical wound to left ischial tuberosity, left buttock, ulcer superior to former rectum, ulcer to former rectum tunnel, and coccyx. The staff were to provide treatments as ordered and weekly wound assessments. The resident also had actual impairment to skin integrity of the buttocks and required daily dressing changes until healed as ordered. A PO, dated 12/14/21, documented instructions to the staff to cleanse the resident's right upper back with normal saline/wound cleanser, dry, apply alginate to wound bed, cover with ABD, and secure with Tegaderm to keep intact. Change daily and PRN. Hospice will perform wound care during their visits. Every day shift for wound. Review of the December 2021 Treatment Administration Record (TAR) revealed it lacked documentation to identify the staff provided the ordered wound care as above on December 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. A PO, dated 10/18/21, documented cleanse all open areas to surgical wound (distal) with wound cleanser, dry, apply gauze moistened with petroleum barrier directly to wound bed, Optilock foam, and cover with ABD. Change daily. Hospice performs treatments Monday through Friday. Every day shift for chronic wounds. Review of the December 2021 TAR revealed lack of documentation of wound care for above order on December 7th, 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. A PO, dated 10/18/21, documented ulcer - fistula right lateral inferior buttock: remove old dressing and cleanse with Pure and Clean. Use hydrofera blue as packing, then cover with an ABD as secondary dressing. Treat daily and as needed every day shift for chronic wound. Review of the December 2021 TAR revealed lack of documentation of wound care for above order on December 7th, 15th, 18th, 19th and 23rd, indicating the nurse did not provide treatment as ordered by the physician. The facility lacked evidence that the hospice nurse provided treatment on those dates. Review of weekly Skin and Wound Evaluations revealed for the months of November and December 2021, the nursing staff did not assess or monitor for the healing of the left buttock from 11/20/21 through 12/06/21 (15 days), the next evaluation was eight days later on 12/14. Nine days later the wound was evaluated on 12/23/21. There were no other wound evaluations available after 12/23/21. Review of weekly Skin and Wound Evaluations revealed for the month of December 2021, the nursing staff did not assess or monitor for the healing of the right illiac crest from 12/06/21 through 12/14/21 (eight days), the next evaluation was nine days later on 12/123. There were no other wound evaluations available after 12/23/21. The facility policy Skin Care Guideline, dated July 2018, documented .Process .DNS or designee will be responsible to implement and monitor the skin integrity program .Key Elements .Weekly skin evaluations are completed and documented . Interview, on 12/29/21 at 08:19 AM, with Administrative Staff A, revealed the Director of Nursing (DON) was responsible for the resident's wound care at that point and time and it hadn't been timely. The facility had a wound care nurse who helped once a week, but she had a falling out with the DON. Daily wound care was the responsibility of all the nurses in the facility and they should be documenting accordingly. The DON should be performing the weekly monitoring when nurses aren't available. Interview, on 01/11/22 at 10:45 AM, with Administrative Nurse D, revealed the wound evaluations were to be performed every week, but they haven't been done consistently. The wound care nurse was no longer with the facility and some of the nurses here have helped out with the weekly wound monitoring. Administrative Nurse D stated she did not assess this resident's wounds or perform any evaluations. The facility put a nurse on administrative leave due to not performing her duties which included dressing changes. Wound care not documented on the treatment administration record (TAR), was not done. The facility failed to provide necessary treatment and care to ensure proper monitoring and promote healing for this resident with multiple wounds.