Based on observations, interviews, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment in accordance with professional standards. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI- intact skin with localized area of persistence non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to a Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) six times larger with eschar/necrotic tissue (dead/devitalized tissue). Findings include: Review of the Lippincott Manual of Nursing Practice, 11th Ed. (2019) indicated: Scope of Practice, Licensure, and Certification: The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. The National Council of State Boards of Nursing and the National League of Nursing have developed standards that guide each State Board in the development of their licensure requirements and scope of practice rules. Review of the Massachusetts Board of Registration in Nursing Advisory Ruling on Nursing Practice dated as revised April 11, 2018 indicated: Nurse's Responsibility and Accountability: Licensed nurses accept, verify, transcribe, and implement orders from duly authorized prescribers that are received by a variety of methods (i.e., written, verbal/telephone, standing orders/protocols, pre-printed order sets, electronic) in emergent and non-emergent situations. Licensed nurses in a management role must ensure an infrastructure is in place, consistent with current standards of care, to minimize error. Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised 11/2017, indicated but was not limited to the following: -Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. -Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any change in condition. -Conduct a comprehensive skin assessment upon admission, including skin integrity-any evidence of existing or developing pressure ulcers or injuries. -Inspect the skin on a daily basis and identify any signs of developing pressure injuries (i.e., non-blanchable erythema) and inspect pressure points (sacrum, heels, buttocks, and coccyx, etc.) -Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. -Evaluate, report and document potential changes in the skin. -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: -The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can immediately be addressed, and which will take time to modify. -Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk for pressure ulcers/injuries. -The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. -Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. -Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool -Conduct a comprehensive skin assessment with every risk assessment. -If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of skin alteration in skin. -Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if the current interventions are deemed inadequate. -The following information should be recorded in the resident's medical record utilizing facility forms: a. The type of assessment(s) conducted. b. The date and time and type of skin care provided. c. Any change in condition of identified. d. The condition of the resident's skin. e. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration is noted. f. Documentation in medical record addressing MD notification if new skin alteration noted with change of plan of care, if indicated. g. Notify attending MD if new skin alteration noted. Review of the facility's policy titled Dressings, Dry/Clean, dated as last revised 4/2018, indicated but was not limited to the following: -Verify that there is a physician's order for this procedure. -Review the resident's care plan, current orders, and diagnoses to determine if there are any special resident needs. -The following equipment and supplies will be necessary when performing this procedure: clean dressing, cleaning solution as ordered, and personal protective equipment (PPE). Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 11/2017, indicated but was not limited to the following: -A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. -The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Incorporate identified problem areas. d. Incorporate risk factors associated with identified problems. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. -Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. -The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS assessment). -Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. -The Interdisciplinary Team must review and update the care plan when there has been a significant change in the residents' condition and when the desired outcome is not met. Resident #30 was admitted to the facility in June 2023 with diagnoses including dementia, diabetes mellitus, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/23, indicated Resident #30 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. Review of the admission Nursing Evaluation V16, dated 6/27/23, indicated Resident #30 was totally dependent on staff for bed mobility, eating, toileting, and required a mechanical lift for transfers. Further review of the evaluation indicated Resident #30 had a pressure injury to the sacrum (bottom of spine above tailbone) measuring 1 centimeter (cm) in length x 0.5 cm in width x 0 cm in depth. The pressure injury was staged as a Suspected Deep Tissue Injury. The evaluation was signed by the nurse on 7/7/23, 10 days after the resident was admitted to the facility. Section C: Skin Integrity was signed by nurse on 8/11/23, 45 days after the resident was admitted to the facility. Review of the admission Physician Order Summary, dated 6/28/23, failed to indicate a treatment order for the pressure injury to Resident #30's sacrum. Review of the care plans for Resident #30 failed to indicate a Pressure Ulcer/Injury care plan had been initiated upon admission. Review of the Weekly Skin evaluation, dated 7/4/23, indicated Resident #30 had a pressure area to the right buttock, no measurements were documented. The evaluation was signed by the nurse on 7/8/23. Review of the Pressure Ulcer Evaluation, dated 7/4/23, indicated Resident #30 had an Unstageable Pressure Ulcer to the sacrum, measuring 1.7 cm x 0.9 cm x 0 cm. Wound description included: -Date first observed: 7/14/23 (sic) -Exudate/Drainage: Moderate Serous -Wound Bed: Eschar -Notes: cleanse, apply calcium alginate and cover with foam dressing daily -Type of Evaluation: Weekly Evaluation of Existing Skin Condition -Signed by the nurse on 8/11/23 Review of the June 2023 and July 2023 Treatment Administration Record (TAR) failed to indicate a treatment for the pressure ulcer from 6/27/23 through 7/7/23. The Resident had gone 10 days with no treatment in place for the pressure ulcer; during that time, the wound had progressed from an intact DTI measuring 1 cm x 0.5 cm x 0 cm on 6/27/23 to an Unstageable pressure ulcer with moderate serous drainage and eschar measuring 1.7 cm x 0.9 cm x 0 cm on 7/4/23. Further review of the TAR indicated a treatment order as follows: -Apply House Barrier on buttocks twice daily skin protection/redness. (7/7/23). Review of additional Weekly Skin Evaluations for July 2023, indicated the following: -7/11/23, no documentation of the pressure ulcer, Signed by the nurse 7/18/23. -7/18/23, no documentation of the pressure ulcer, Signed by the nurse 7/23/23. -7/25/23, Weekly Skin Evaluation was not completed. Review of additional Pressure Ulcer Evaluations for July 2023, indicated the following: -7/11/23, Pressure Ulcer Evaluation was not completed. -7/18/23, indicated Resident #30 had a resolved pressure area. -Date first observed: 7/18/23, Signed by nurse on 7/20/23 No additional Pressure Ulcer Evaluations were completed in July 2023. Review of the Wound Consultant Progress Note, dated 7/20/23, indicated the Resident was not seen. No further Wound Consultant visits were completed in July 2023. Review of the Nurse's notes from 6/27/23 - 7/30/23 failed to indicate the pressure ulcer had been assessed and monitored for changes. Further review of a Nurse's Note, dated 7/31/23, indicated the Resident's skin was intact, the Resident did not have any ulcers, and wound care was provided in between buttock cheeks near the rectum. No further description or assessment of the wound or wound care provided was documented. Further review of the TAR indicated Resident #30 did not have any orders for wound care to the pressure ulcer on his/her sacrum. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse, who is also the Unit Manager and Assistant Director of Nurses (ADON), said Resident #30 was admitted with the wound and she was not made aware of it until weeks later. Additionally, she said there was no treatment ordered on admission and there should have been. She said the Barrier cream treatment ordered on 7/7/23 was not appropriate for a pressure ulcer as that is for prevention, and this wound should have had a dressing on it. She also said there was no care plan initiated on admission and that it was not done until she re-opened the Nursing admission Evaluation V16 on 8/11/23 to fix it (45 days after admission). She said on the Pressure Ulcer Evaluation, dated 7/4/23, the date first observed should have been the admission date and not 7/14/23, that was wrong, and that she should not have written the treatment memo in the notes section of the Pressure Ulcer Evaluation because she was backdating the evaluation, and that dressing recommendation was from the 8/10/23 Wound Doctor visit. Additionally, she said when she and the Wound Physician did rounds on 7/20/23 they did not see Resident #30 because the wound was not visible, probably because of poor lighting, but it had to have been there as it was a big deep open wound the next time. She said they must have missed it. She said the usual process is: On admission after the Nursing admission Evaluation V16 is done, an order is obtained for a treatment, the care plan is initiated directly from the Nursing admission Evaluation V16, the nurse then notifies me and the Director of Nurses, the Wound Doctor is added to the Resident profile so the Resident would be seen on weekly wound rounds and weekly Pressure Ulcer Evaluations should be done. She said in this case none of those things happened. She said she was not made aware of the wound until weeks later when it was much bigger and that is when the wound care physician was added to the profile and the Resident was added to weekly wound rounds. She said adding the Wound Doctor to the Resident profile is our fail safe because it triggers the Wound Doctor to see the Resident, but in this case that did not happen for several weeks. She said Resident #30 should have had weekly Pressure Ulcer Evaluations done from admission and he/she did not. During an interview on 12/4/23 at 11:27 A.M., the Director of Nurse (DON) said a treatment should have been ordered on admission and it was not. She said her expectation is if there is no order from the hospital, the nurse calls the primary care physician to obtain an appropriate order. She said a care plan should have been initiated and it was not, and the wound doctor should have been added to the Resident's profile and added to weekly rounds and that did not happen either. Additionally, the DON said the order written on 7/7/23 for House Barrier Cream was not an appropriate order for a pressure injury, the area should have had a dressing on it for protection. The DON said usually she or the Wound Nurse will review the Nursing admission Evaluations V16 for completion and to ensure any wounds have orders, care plans, and are added to wounds rounds; however, in this case none of those things were done and Resident #30's wound got worse and much larger. AUGUST 2023 Review of the Weekly Skin Evaluations for August 2023 indicated the following: -8/29/23, no documentation of the pressure ulcer. Review of the Pressure Ulcer Evaluations for August 2023, indicated the following: -8/3/23, Pressure Ulcer Evaluation was not completed. -8/10/23, Resident #30 had a Stage 3 Pressure Ulcer (full thickness loss of skin, in which subcutaneous fat mat be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present), measuring 6.3 cm x 4.4 cm x 0 cm. Notes: Cleanse, apply calcium alginate and cover with border dressing daily. -8/18/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6 cm x 3.6 cm x 0.1 cm. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Wound Cleanser and Calcium Alginate secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 milligrams (mg) twice daily, Prevalon Boots. -Signed by nurse on 8/21/23 Review of the Wound Consultant Physician Evaluation and Management Summary, dated 8/3/23, indicated but was not limited to the following: -Resident #30 had an Unstageable Deep Tissue Injury (DTI) to the sacrum. -Wound Etiology: Pressure -Duration: greater than 7 days Wound Size: 7.6 cm x 5.5 cm x not measurable cm (Depth is immeasurable due to the presence of tissue overgrowth.) -Dressing Treatment Plan: Primary Dressing: Silver Sulfadiazine (antibiotic cream used to treat and/or prevent infection) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound (relieve pressure); Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days (vitamins to aid in wound healing); Pre-Albumin (blood test to determine if your body is getting enough protein which aids in wound healing). Review of the medical record including Medication Administration Record (MAR), TAR, and physician's orders failed to indicate the treatment order was obtained for the Silver Sulfadiazine and foam dressing to the sacrum or any other new order for wound care. Additionally, the medical record failed to indicate the additional recommendations to off-load the wound, Vitamin C and Zinc Sulfate, or the lab work were ordered. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/10/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 6.3 cm x 4.4 cm x not measurable cm (Depth is immeasurable due to the presence of nonviable tissue and necrosis.) -Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate (promotes formation of granulation tissue, re-epithelialization (cell growth to help healing), and helps to minimize bacterial infections) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots (heel booties with a heel cut out used to float heels off the mattress and relieve pressure to prevent pressure ulcers). -Surgical Excisional Debridement to remove necrotic tissue and establish the margins of visible tissue. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record failed to indicate an order was obtained for the antimicrobial cleanser and foam dressing. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/18/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 6 cm x 3.6 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record indicated the wound care order was changed on 8/22/23 with a start date of 8/23/23 as follows: Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. This was 12 days after the recommendations were made on 8/10/23 and the antimicrobial cleanser was still not ordered as recommended. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/24/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 5.9 cm x 3.2 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) (cleanser that creates a moist environment and loosens contaminated exudate within the wound bed to allow natural healing to take place) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (8/24/23; Discontinued 8/25/23) -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) -Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate the recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/31/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 5.5 cm x 3.5 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe). Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) -Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. A care plan titled Pressure Ulcer was initiated on 8/11/23, 45 days after admission. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the Pressure Ulcer Evaluation on 8/3/23 should have been done and it was not. Additionally, she said the recommendations from the Wound Doctor on 8/3/23 should have been addressed and they were not, and the Resident continued to have a progressing wound without an appropriate treatment. She said she does wound rounds and usually writes the orders, but these were missed. Additionally, she said the order written on 8/11/23 for Calcium Alginate should have had the recommended cleanser and the foam dressing as part of the order and it did not and the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed and they were not. She also said the orders should be written with the specific cleanser recommended as Wound Cleanser, Antimicrobial Wound Cleanser and Vashe Wound Cleaner are all different cleansers. She also said she took over doing wound rounds because things like this were not getting done. During an interview on 12/4/23 at 11:27 A.M., the DON said the Pressure Ulcer Evaluation should be done weekly and it was not. She also said the order on 8/11/23 should have had the appropriate cleanser and foam dressing as part of the order and she missed that, therefore the order was incorrect. The DON said the type of cleanser needs to be specific as Wound Cleanser, Antimicrobial Wound Cleanser, and Vashe are all different cleansers. Additionally, she said all the recommendations made by the wound doctor should have been addressed and they were not. SEPTEMBER 2023 Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/7/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7.5 cm x 3.3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR, physician's orders, and care plan failed to indicate off-load wound or Prevalon Boots had been addressed. Further review of the medical record including MAR, TAR and physician's orders indicated the following: -Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23; Discontinued 9/4/23) -Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (9/4/23). -Ascorbic Acid (Vitamin C) 500 mg twice daily (9/5/23) -Pre-Albumin blood test was drawn on 9/11/23, results were critically low. The Vashe cleanser was ordered 11 days after it was recommended. The Vitamin C was ordered 33 days after it was recommended. The Pre-Albumin blood test was drawn 39 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/14/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7.5 cm x 3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the medical record including MAR, TAR, and physician's orders indicated the following: -Bootie/Heel Protectors on as tolerated every shift. (8/25/23; Discontinued 9/13/23) -Prevalon Boots in place at all times (9/13/23) Review of the care plan indicated the following: -Off-load wound was added to the care plan (9/15/23) The Bootie/Heel Protectors were ordered 15 days after the Prevalon Boots were recommended. The Prevalon Boots were ordered 34 days after they were recommended. Off-load wound was added to the care plan 43 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/21/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7 cm x 3 cm x 0.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/28/23, indicated but was not limited to the following: -Resident #30 had Stage 3 Pressure wound to the sacrum. -Wound Size: 7 cm x 3 cm x 0.3 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the Physician's Orders indicated the recommendations for Zinc Sulfate had still not been addressed since first recommended on 8/3/23. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed when recommended and they were not. The expectation is the orders are obtained within a day or two and they were not. and they were not. During an interview on 12/4/23 at 11:27 A.M., the DON said all the recommendations made by the wound doctor should have been addressed by the day after the Wound Doctor visit and they were not. OCTOBER 2023 Review of the Weekly Skin Evaluations for October 2023 indicated the following: -10/17/23, no documentation of the pressure ulcer. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 10/5/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 6.6 cm x 2.8 cm x 1.1 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. Review of the Physician's Orders failed to indicate the recommendation for Pre-Albumin lab work was addressed. -10/12/23 no visit note - Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 10/19/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 3.9 cm x 1.4 cm x 0.8 cm -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply twice daily and as needed; Hypochlorous acid solution (Vashe) apply twice daily and as needed. Secondary Dressing: Silicone Bordered Foam apply twice daily and as needed. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. -Sharp debridement refused by family. Review of the medical record including MAR, TAR, and physician's orders failed to indicate the recommendation to increase frequency of dressing change from once daily to twice daily and for the Pre-Albumin lab work were addressed. - Review of the Wound Consultant Physician Evaluation and Management Summary, dated 10/26/23, indicated but was not limited to the following: -Resident #30 had Stage 4 Pressure wound to the sacrum. -Wound Size: 3.9 cm x 1.5 cm x 1 cm with undermining: 1.4 cm at 1 o'clock -Dressing Treatment Plan: Primary Dressing: Calcium alginate apply twice daily and as needed; Hypochlorous acid solution (Vashe) apply twice daily and as needed. Secondary Dressing: Silicone Bordered Foam apply twice daily and as needed. -Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots, Pre-Albumin blood test. -Sharp debridement refused by family. Review of the Physician's Orders results failed to indicate an order for the Pre-Albumin blood test was obtained since recommended on 10/5/23. Further review of the medical record including TAR and physician's orders failed to indicate the treatment was changed from once daily to twice daily as recommended on 10/19/23. The order to change the treatment from once a day to twice a day was obtained on 10/27/23 after it was recommended again by the wound physician on 10/26/23 (8 days after it was initially recommended). During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the recommendation to increase the dressing change from once to twice daily and the Pre-Albumin lab work should have been addressed when recommended and they were not. During an interview on 12/4/23 at 11:27 A.M., the DON said all the recommendations made by the wound doctor should have been addressed by the day after the Wound Doctor visit and they were not. She said recommendations for lab work should be ordered for the next lab day as the lab comes a couple times a week. NOVEMBER 2023 -Review of the Wound Consultant Physician Evaluation and Management Summary, date

Based on observation, interviews, policy review, and record review, the facility failed to ensure one Resident (#30), out of a total sample of 20 residents, received care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed for Resident #30, to obtain a physician's order for wound care on admission, develop and implement a pressure ulcer care plan on admission, to assess and monitor a pressure ulcer, to obtain orders for wound consultant recommendations-including medications, treatments and lab work, to transcribe orders for wound care accurately, and to provide wound care per physician's orders resulting in the progression of a deep tissue injury (DTI-intact skin with localized area of persistence non-blanchable deep red, maroon, or purple discoloration due to damage of underlying soft tissue from intense and/or prolonged pressure and shear forces at the bone-muscle interface) to a Stage 4 pressure ulcer (full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) six times larger with eschar/necrotic tissue (dead/devitalized tissue). Findings include: Review of the facility's policy titled Prevention of Pressure Ulcers/Injuries, dated as last revised 11/2017, indicated but was not limited to the following: - Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. - Assess the resident on admission (within 8 hours) for existing pressure ulcer/injury risk factors. Repeat the risk assessment weekly and upon any change in condition. - Conduct a comprehensive skin assessment upon admission, including skin integrity, any evidence of existing or developing pressure ulcers or injuries. - Inspect the skin on a daily basis and identify any signs of developing pressure injuries (i.e., non-blanchable erythema) and inspect pressure points (sacrum, heels, buttocks, and coccyx, etc.) - Include nutritional supplements in the resident's diet to increase calories and protein, as indicated in the care plan. - Evaluate, report and document potential changes in the skin. - Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's policy titled Pressure Ulcer/Injury Risk Assessment, dated as last revised 4/2018, indicated but was not limited to the following: - The purpose of a structured risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can immediately be addressed, and which will take time to modify. - Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risk for pressure ulcers/injuries. - The risk assessment should be conducted as soon as possible after admission, but no later than eight hours after admission is completed. - Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. - Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool - Conduct a comprehensive skin assessment with every risk assessment. - If a new skin alteration is noted, initiate a pressure or non-pressure form related to the type of skin alteration in skin. - Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if the current interventions are deemed inadequate. - The following information should be recorded in the resident's medical record utilizing facility forms: a. The type of assessment(s) conducted. b. The date and time and type of skin care provided. c. Any change in condition of identified. d. The condition of the resident's skin. e. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration is noted. f. Documentation in medical record addressing MD notification id new skin alteration noted with change of plan of care, if indicated. g. Notify attending MD if new skin alteration noted. Review of the facility's policy titled Dressings, Dry/Clean, dated as last revised 4/2018, indicated but was not limited to the following: - Verify that there is a physician's order for this procedure. - Review the resident's care plan, current orders, and diagnoses to determine if there are any special resident needs. - The following equipment and supplies will be necessary when performing this procedure: clean dressing, cleaning solution as ordered, and personal protective equipment (PPE). Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated as last revised 11/2017, indicated but was not limited to the following: - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. - The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Incorporate identified problem areas. d. Incorporate risk factors associated with identified problems. e. Reflect treatment goals, timetables, and objectives in measurable outcomes. f. Identify the professional services that are responsible for each element of care. - Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. - The comprehensive, person-centered care plan is developed within seven days of the completion of the required comprehensive assessment (MDS assessment). - Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition changes. - The Interdisciplinary Team must review and update the care plan when there has been a significant change in the residents' condition and when the desired outcome is not met. Resident #30 was admitted to the facility in June 2023 with diagnoses including dementia, diabetes mellitus, and muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 9/30/23, indicated Resident #30 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. JUNE 2023 Review of the admission Nursing Evaluation V16, dated 6/27/23, indicated Resident #30 was totally dependent on staff for bed mobility, eating, toileting, and required a mechanical lift for transfers. Further review of the evaluation indicated Resident #30 had a pressure injury to the sacrum (bottom of spine above tailbone) measuring 1 centimeter (cm) in length x 0.5 cm in width x 0 cm in depth. The pressure injury was staged as a Suspected Deep Tissue Injury. The evaluation was signed by the nurse on 7/7/23, 10 days after the Resident was admitted to the facility. Section C: Skin Integrity was signed by nurse on 8/11/23, 45 days after the Resident was admitted to the facility. Review of the admission Physician's Order Summary, dated 6/28/23, failed to indicate a treatment order for the pressure injury to Resident #30's sacrum. Review of the care plans for Resident #30 failed to indicate a Pressure Ulcer/Injury care plan had been initiated upon admission. JULY 2023 Review of the Weekly Skin evaluation, dated 7/4/23, indicated Resident #30 had a pressure area to the right buttock, no measurements were documented. The evaluation was signed by the nurse on 7/8/23. Review of the Pressure Ulcer Evaluation, dated 7/4/23, indicated Resident #30 had an Unstageable Pressure Ulcer to the sacrum, measuring 1.7 cm x 0.9 cm x 0 cm. Wound description includes: - Date first observed: 7/14/23 (sic) - Exudate/Drainage: Moderate Serous [watery, clear, or slightly yellow/tan/pink fluid that has separated from the blood and presents as drainage] - Wound Bed: Eschar [dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color and may appear scab-like] - Notes: cleanse, apply calcium alginate and cover with foam dressing daily - Type of Evaluation: Weekly Evaluation of Existing Skin Condition - Signed by the nurse on 8/11/23 Review of the June 2023 and July 2023 Treatment Administration Record (TAR) failed to indicate a treatment for the pressure ulcer from 6/27/23 through 7/7/23. The Resident had gone 10 days with no treatment in place for the pressure ulcer; during that time, the wound had progressed from an intact DTI measuring 1 cm x 0.5 cm x 0.0 cm on 6/27/23 to an Unstageable pressure ulcer with moderate serous drainage and eschar measuring 1.7 cm x 0.9 cm x 0.0 cm on 7/4/23. Further review of the TAR indicated a treatment order as follows: - Apply House Barrier on buttocks twice daily skin protection/redness. (7/7/23). Review of the Physician's Orders for Resident #30 indicated: - Weekly Skin Check every Tuesday (7/20/23). Review of additional Weekly Skin Evaluations for July 2023 indicated the following: - 7/11/23, no documentation of the pressure ulcer, Signed by the nurse 7/18/23. - 7/18/23, no documentation of the pressure ulcer, Signed by the nurse 7/23/23. - 7/25/23, Weekly Skin Evaluation was not completed. Review of additional Pressure Ulcer Evaluations for July 2023 indicated the following: - 7/11/23, Pressure Ulcer Evaluation was not completed. - 7/18/23, indicated Resident #30 had a resolved pressure area. Wound description included: a. Date first observed: 7/18/23 b. Type of Evaluation: Weekly Evaluation of Existing Skin Condition c. Signed by nurse on 7/20/23 No additional Pressure Ulcer Evaluations were completed in July 2023. Review of the Wound Consultant Progress Note, dated 7/20/23, indicated the Resident was not seen. No further Wound Consultant visits were completed in July 2023. Review of the Nurses' Notes from 6/27/23 - 7/30/23 failed to indicate the pressure ulcer had been assessed and monitored for changes. Further review of a Nurse's Note, dated 7/31/23, indicated the Resident's skin was intact, the Resident did not have any ulcers, and wound care was provided in between buttock cheeks near the rectum. No further description or assessment of the wound or wound care provided was documented. Further review of the TAR indicated Resident #30 did not have any orders for wound care. The Resident had an order for House Barrier Cream to buttocks twice daily for skin protection/redness. During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse, who is also the Unit Manager and Assistant Director of Nurses (ADON), said Resident #30 was admitted with the wound and she was not made aware of it until weeks later. Additionally, she said there was no treatment ordered on admission and there should have been. She said the Barrier cream treatment ordered on 7/7/23 was not appropriate for a pressure ulcer as that is for prevention, and this wound should have had a dressing on it. She also said there was no care plan initiated on admission and that it was not done until she re-opened the Nursing admission Evaluation V16 on 8/11/23 to fix it (45 days after admission). She said on the Pressure Ulcer Evaluation, dated 7/4/23, the date first observed should have been the admission date and not 7/14/23 that was wrong and that she should not have written the treatment memo in the notes section of the Pressure Ulcer Evaluation because she was backdating the evaluation and that dressing recommendation was from the 8/10/23 Wound Doctor visit. Additionally, she said when she and the Wound Physician did rounds on 7/20/23 they did not see Resident #30 because the wound was not visible, probably because of poor lighting, but it had to have been there as it was a big, deep, open wound the next time. She said they must have missed it. She said the usual process is: On admission after the Nursing admission Evaluation V16 is done, an order is obtained for a treatment, the care plan is initiated directly from the Nursing admission Evaluation V16, the nurse then notifies me and the Director of Nurses, the Wound Doctor is added to the Resident profile so the Resident would be seen on weekly wound rounds and weekly Pressure Ulcer Evaluations should be done. She said in this case none of those things happened. She said she was not made aware of the wound until weeks later when it was much bigger and that is when the wound care physician was added to the profile and the Resident was added to weekly wound rounds. She said adding the Wound Doctor to the Resident profile is our fail safe because it triggers the Wound Doctor to see the Resident, but in this case that did not happen for several weeks. She said Resident #30 should have had weekly Pressure Ulcer Evaluations done from admission and he/she did not. During an interview on 12/4/23 at 11:27 A.M., the Director of Nursing (DON) said a treatment should have been ordered on admission and it was not. She said her expectation is if there is no order from the hospital, the nurse calls the primary care physician to obtain an appropriate order. She said a care plan should have been initiated and it was not, and the wound doctor should have been added to the Resident's profile and added to weekly rounds and that did not happen either. Additionally, the DON said the order written on 7/7/23 for House Barrier Cream was not an appropriate order for a pressure injury, the area should have had a dressing on it for protection. The DON said usually she or the Wound Nurse will review the Nursing admission Evaluations V16 for completion and to ensure any wounds have orders, care plans, and are added to wounds rounds; however, in this case none of those things were done and Resident #30's wound got worse and much larger. AUGUST 2023 Review of the Weekly Skin Evaluations for August 2023 indicated the following: - 8/29/23, no documentation of the pressure ulcer. Review of the Pressure Ulcer Evaluations for August 2023, indicated the following: - 8/3/23, Pressure Ulcer Evaluation was not completed. - 8/10/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6.3 cm x 4.4 cm x 0 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Cleanse, apply calcium alginate and cover with border dressing daily. - 8/18/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 6 cm x 3.6 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Wound Cleanser and Calcium Alginate secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 milligrams (mg) twice daily, Prevalon Boots. d. Signed by nurse on 8/21/23 Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/3/23, indicated but was not limited to the following: - Resident #30 had an Unstageable Deep Tissue Injury (DTI) to the sacrum. - Wound Etiology: Pressure - Duration: greater than 7 days - Wound Size: 7.6 cm x 5.5 cm x not measurable cm (depth is immeasurable due to the presence of tissue overgrowth). - Exudate: light serous - Granulation tissue: 100% - Dressing Treatment Plan: Primary Dressing: Silver Sulfadiazine (antibiotic cream used to treat and/or prevent infection) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound (relieve pressure); Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days (vitamins to aid in wound healing); Pre-Albumin (blood test to determine if your body is getting enough protein which aids in wound healing.) Review of the medical record including Medication Administration Record (MAR), TAR, and physician's orders failed to indicate the treatment order was obtained for the Silver Sulfadiazine and foam dressing to the sacrum or any other new order for wound care. Additionally, the medical record failed to indicate the additional recommendations to off-load the wound, Vitamin C and Zinc Sulfate, or the lab work were ordered. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/10/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound (appears as full thickness loss of skin, in which subcutaneous fat mat be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) to the sacrum. - Wound Size: 6.3 cm x 4.4 cm x not measurable cm, (depth is immeasurable due to the presence of nonviable tissue and necrosis). - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 100% - Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate (promotes formation of granulation tissue, re-epithelialization (cell growth to help healing), and helps to minimize bacterial infections) apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Reposition per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots (heel booties with a heel cut out used to float heels off the mattress and relieve pressure to prevent pressure ulcers). - Surgical Excisional Debridement to remove necrotic tissue and establish the margins of visible tissue. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record failed to indicate an order was obtained for the antimicrobial cleanser and foam dressing. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/18/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 6 cm x 3.6 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Dressing Treatment Plan: Primary Dressing: Antimicrobial wound cleanser, calcium alginate apply once daily; Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Zinc Sulfate 20mg once daily for 14 days; Prevalon Boots. Review of the medical record including MAR, TAR, and physician's orders indicated an order for Calcium alginate pad-apply to sacrum once daily (8/11/23). Further review of the medical record indicated the wound care order was changed on 8/22/23 with a start date of 8/23/23 as follows: Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. This was 12 days after the recommendations were made on 8/10/23 and the antimicrobial cleanser was still not ordered as recommended. Additionally, the recommendations repeated from 8/3/23, to off-load wound, Vitamin C, Zinc Sulfate, and Pre-Albumin lab test had not been ordered, nor had the recommendation from 8/10/23 for Prevalon Boots been addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/24/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 5.9 cm x 3.2 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 30% - Granulation Tissue: 70% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) (cleanser that creates a moist environment and loosens contaminated exudate within the wound bed to allow natural healing to take place) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician's orders indicated the following: - Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (8/24/23; Discontinued 8/25/23) - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) - Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate the recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 8/31/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 5.5 cm x 3.5 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe). Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR and physician orders indicated the following: - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23) - Bootie/Heel Protectors on as tolerated every shift. (8/25/23) Further review of the medical record failed to indicate the correct solution was ordered for wound care and failed to indicate recommendations to off-load wound, Vitamin C, and Pre-Albumin lab work were addressed. Review of the care plan titled Pressure Ulcer was initiated on 8/11/23, 45 days after admission. The care plan indicated but was not limited to the following: - FOCUS: Pressure Ulcer: Ulceration or interference with structural integrity of layers of skin caused by prolonged pressure. - GOAL: Show no signs of infection. - INTERVENTIONS: Follow facility protocol/regime for treating breaks in skin integrity/pressure ulcers, Turn and reposition with skin care every two hours, and use two-person transfer and use turn sheet to avoid friction/shearing of resident skin. (8/11/23) Additional interventions include Air Mattress set at 150, Monitor for changes and update provider as warranted, Treatment as ordered, and Wound MD as needed (8/22/23). During an interview on 12/4/23 at 10:18 A.M., the Wound Nurse/Unit Manager/ADON said the Pressure Ulcer Evaluation on 8/3/23 should have been done and it was not. Additionally, she said the recommendations from the Wound Doctor on 8/3/23 should have been addressed and they were not, and the Resident continued to have a progressing wound without an appropriate treatment. She said she does wound rounds and usually writes the orders, but these were missed. Additionally, she said the order written on 8/11/23 for Calcium Alginate should have had the recommended cleanser and the foam dressing as part of the order and it did not and the recommendation to off-load wound, Vitamin C and Zinc Sulfate, Pre-Albumin lab work and Prevalon Boots all should have been addressed and they were not. She also said the orders should be written with the specific cleanser recommended as Wound Cleanser, Antimicrobial Wound Cleanser and Vashe Wound Cleaner are all different cleansers. She also said she took over doing wound rounds because things like this were not getting done. During an interview on 12/4/23 at 11:27 A.M., the DON said the Pressure Ulcer Evaluation should be done weekly and it was not. She also said the order on 8/11/23 should have had the appropriate cleanser and foam dressing as part of the order and she missed that, therefore the order was incorrect. The DON said the type of cleanser needs to be specific as Wound Cleanser, Antimicrobial Wound Cleanser, and Vashe are all different cleansers. Additionally, she said all the recommendations made by the wound doctor should have been addressed and they were not. SEPTEMBER 2023 Review of the Pressure Ulcer Evaluations for September 2023 indicated the following: - 9/1/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 5.5 cm x 3.5 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. d. Signed by nurse on 9/4/23 - 9/8/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7.5 cm x 3.3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 80% Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/14/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7.5 cm x 3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 60% Granulation 30% Skin 10%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/22/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7 cm x 3 cm x 0.1 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Wound Progress: Improved evidence by decreased surface area Surface Area 21.00cm2 Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 20% Granulation 20% Skin 60%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. -9/28/23, Resident #30 had a Stage 3 Pressure Ulcer, measuring 7 cm x 3 cm x 0.3 cm. Wound description includes: a. Exudate/Drainage: Moderate Serous b. Wound Bed: Eschar c. Notes: Wound Progress: Exacerbated. Increase in depth Surface Area 21.00cm2 Etiology: Pressure Objective: Maintain Healing Phase Exudate: moderate serous, Necrotic tissue 25% Granulation 25% Skin 50%; Primary Dressing: Vashe and Calcium Alginate Secondary Dressing: Silicone Border Foam. Recs: Vitamin C 500 mg twice daily, Prevalon Boots. Review of the Wound Consultant Physician Evaluation and Management Summary, dated 9/7/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7.5 cm x 3.3 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 80% - Wound Progress: Exacerbated due to generalized decline of patient, nutritional compromise, patient non-compliant with wound care. - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the medical record including MAR, TAR, physician's orders, and care plan failed to indicate off-load wound or Prevalon Boots had been addressed. Further review of the medical record including MAR, TAR and physician's orders indicated the following: - Sacrum: Cleanse area with wound cleanser, apply calcium alginate and cover with foam border dressing daily. (8/25/23; Discontinued 9/4/23) - Sacrum: Cleanse area with Vashe, apply calcium alginate and cover with foam border dressing daily. (9/4/23). - Ascorbic Acid (Vitamin C) 500 mg twice daily (9/5/23) - Pre-Albumin blood test was drawn on 9/11/23, results were critically low. The Vashe cleanser was ordered 11 days after it was recommended. The Vitamin C was ordered 33 days after it was recommended. The Pre-Albumin blood test was drawn 39 days after it was recommended. Review of the Nurse's Note, dated 9/11/23, indicated the Nurse Practitioner was notified of the Pre-Albumin lab results and new orders were obtained for a Liquid Protein supplement, Ensure Plus supplement drink three times daily, High Protein/Low Salt Diet. (Protein aids in wound healing). (39 days after the lab work was recommended.) Further review of the medical record including TAR, nurse's notes, physician's progress notes, and care plan failed to indicate Resident #30 was non-compliant with wound care as noted in Wound Summary dated 9/7/23. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/14/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7.5 cm x 3 cm x 0.1 cm - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 60% - Granulation Tissue: 30% - Skin: 10% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots Review of the medical record including MAR, TAR, and physician's orders indicated the following: - Bootie/Heel Protectors on as tolerated every shift. (8/25/23; Discontinued 9/13/23) - Prevalon Boots in place at all times (9/13/23) Review of the care plan indicated the following: - Off-load wound was added to the care plan (9/15/23) The Bootie/Heel Protectors were ordered 15 days after the Prevalon Boots were recommended. The Prevalon Boots were ordered 34 days after they were recommended. Off-load wound was added to the care plan 43 days after it was recommended. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/21/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7 cm x 3 cm x 0.1 cm - Cluster Wound: open ulceration area of 8.4cm2 - Periwound radius: Surrounding DTI (purple/maroon) - Exudate: moderate serous - Thick adherent devitalized necrotic tissue: 20% - Granulation Tissue: 20% - Skin: 60% - Dressing Treatment Plan: Primary Dressing: Calcium alginate apply once daily; Hypochlorous acid solution (Vashe) Secondary Dressing: Silicone Bordered Foam apply once daily. - Recommendations: Off-Load wound; Repositions per facility protocol; Vitamin C 500 mg twice daily; Prevalon Boots. Review of the Wound Consultant Physician's Evaluation and Management Summary, dated 9/28/23, indicated but was not limited to the following: - Resident #30 had Stage 3 Pressure wound to the sacrum. - Wound Size: 7 cm x 3 cm x 0.3