**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who required the use of a splint to secure a fracture he/she sustained to his/her right arm, the Facility failed to ensure he/she was provided care and treatment that met professional standards of practice, when after a follow-up appointment, Resident #1's orthopedist recommended that Nursing remove the splint daily for hygiene. However, the recommendation were not implemented by Nursing and he/she developed a pressure injury and osteomyelitis in his/her right elbow, and required surgical intervention. Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Resident #1 was admitted to the Facility in November 2022, diagnoses included Fracture of shaft (a break of the thigh bone between the hip and the knee) of left femur, Dementia, severe, with other behavioral disturbances, Hypertension, Gastro-esophageal reflux disease, Osteoarthritis, Iron deficiency anemia, Hypothyroidism, Hyperlipidemia, and Bilateral Sensorineural hearing loss. Review of Resident #1's Norton Scale Predicting Risk of Pressure Ulcer, dated, 11/16/22, indicated he/she was assessed by nursing to be at high risk for the development of pressure injuries. Review of Resident #1's admission Minimum Data Set (MDS) Assessment, dated 11/23/22, indicated that Resident #1 had severe cognitive impairments and he/she was at increased risk for developing pressure injuries. Review of Resident #1's Orthopedic Report of Consultation, dated 1/10/23, indicated he/she had recommendations for the following: -No skin issues were noted -Active Range of Motion (AROM) and Passive Range of Motion (PROM) right shoulder -Elbow splint removal for hygiene -Weight bearing with assisted transitions only with splint on -Should use right arm to feed him/herself Review of Resident #1's Weekly Skin Audit dated, 1/14/23, indicated that nursing documented that he/she did not have any skin impairments. Review of the Report submitted by the Facility via Health Care Reporting System (HCFRS), dated 1/18/23, indicated that on 1/17/23 upon removal of Resident #1's posterior (back side) splint to his/her right arm he/she had an open area to his/her elbow which was red, warm, and swollen. The Report indicated the Nurse Practitioner ordered Resident #1 to be seen at the Hospital for evaluation and he/she was diagnosed with cellulitis of his/her right elbow, placed on antibiotics and an anterior (front side) splint was applied to the right elbow. Review of Resident #1's Nurse Progress Note, dated 1/17/23, indicated that the writer (identified as Nurse #1) and the Unit Manager removed Resident #1's splint from his/her right upper extremity (RUE)/elbow and there was an approximate area 2.0 centimeters (cm) x 2.0 cm x 0.5 cm noted with pocketing, odor, moderate drainage at the site and his/her skin was red and warm. The Note indicated Nurse #1 notified the Nurse Practitioner and ordered Resident #1 to be sent to the Emergency Department (ED) for evaluation. Review of Resident #1's Nurse Progress Note, dated 1/18/23, indicated that he/she returned from the ED and was diagnosed with Cellulitis of his/her right upper limb, Keflex (antibiotic to treat bacterial infection) and Bactrim (antibiotic to treat bacterial infection) were ordered, change dressing daily to his/her right elbow and return to ED for worsening of infection. The Note indicated to follow up with in house Nurse Practitioner for new wound treatment orders. Review of Resident #1's Wound Consultation, dated 1/18/23, indicated he/she had a Stage 4 pressure injury (full thickness wound`) located on his/her right elbow related to the medical device (splint). Review of Resident #1's Orthopedic Report of Consultation, dated 1/20/23, indicated he/she was seen for the Stage 4 pressure injury to his/her right elbow. The Consultation indicated the following findings and recommendations: -Right olecranon pressure injury with osteomyelitis -Incision, bursectomy, and bone debridement on Monday (1/23/23) -Discontinue antibiotics -Wound care; clean wound with hydrogen H2O2 (hydrogen peroxide) and apply dry sterile dressing and elbow pad every day -No sling or splint -No Physical Therapy Review of Resident #1's Physician Interim Orders, indicated there was no documentation to support that an order was obtained from the Physician regarding the recommendations for the Orthopedist related to his/her right elbow and transcribed by the Unit Manager onto his/her Treatment Administration Records (TAR). Review of Resident #1's Facility TAR, dated 1/10/2023 through 1/17/2023, indicated there was no documentation to support his/her right arm splint was removed for hygiene. Further review of Resident #1's Medical Record indicated there were no Nursing Progress Notes with documentation to support Nursing removed his/her right arm splint for hygiene and to assess his/her skin condition beneath the arm splint. During an interview on 2/14/23 at 3:16 P.M., Nurse #1 said that on 1/17/23, he and the Unit Manager removed Resident #1's right arm splint to check his/her skin integrity and upon removing the splint he saw an open area, with foul smelling moderate serosanguineous (fluid yellowish/pink in color) drainage on his/her right elbow and it was red and warm to touch. Nurse #1 said he notified the Nurse Practitioner and said orders were obtained for a treatment to Resident #1's right elbow and to send him/her to the ED for evaluation. Nurse #1 said there was no order on Resident #1's January TAR to remove his/her right arm splint for hygiene and said the only treatments were to monitor Circulation, Sensation, and Movement (CSM) and skin integrity (health of the skin) to his/her right upper extremity every shift. Nurse #1 said he was not aware of the recommendation orders from Resident #1's Orthopedic Consult follow up visit on 1/10/23. During an interview on 2/22/23 at 4:39 P.M., Nurse #2 said that (upon admission Resident #1 did not have an order to remove his/her right arm splint for hygiene) and said she was monitoring CSM and skin integrity to his/her right elbow as ordered. Nurse #2 said she could not recall being told by the Unit Manager or the day Nurse at the change of shift that Resident #1 had new orders to remove his/her arm splint for hygiene. Nurse #2 said she could not remember what interventions were on Resident #1's plan of care for his/her right arm splint and if there was no order to remove the splint then it most likely would not be on his/her plan of care. During an interview on 2/16/23 at 3:24 P.M., the Unit Manager said that on 1/17/23, Resident #1's Family Member asked her if anyone had looked at his/her skin under the arm splint and said she and Nurse #1 went to inspect Resident #1's skin. The Unit Manager said she observed Nurse #1 remove his/her right arm splint and they found an open area on his/her right elbow and said there was redness around the area. The Unit Manager said Nurse #1 notified the Nurse Practitioner and she immediately reported the findings to the Director of Nurses (DON). The Unit Manager said Resident #1's initial Physician orders were not to remove his/her right arm splint and on 1/10/23 he/she returned from an Orthopedic Consult visit with recommendation orders to remove his/her arm splint for hygiene. The Unit Manager said she signed Resident #1's Orthopedic Consult on 1/10/23 and verified recommendations with the Nurse Practitioner to obtain orders. The Unit Manager said that she was responsible for writing Physician orders and transcribing the orders onto Resident #1's January TAR. The Unit Manager said she wrote a Physician's order and transcribed the orders onto Resident #1's TAR and said that the sheet from his/her TAR's probably got lost. However, Review of Resident #1's medical record indicated that there was no documentation to support that on 1/10/23 the Unit Manager wrote a Physician order, transcribed the new recommendation orders to Resident #1's January TAR or that she updated his/her plan of care on 1/10/23. Review of Resident #1's Hospital Discharge summary, dated [DATE], indicated that Resident #1 had an intercondylar distal humerus fracture, which was splinted and due to prolonged splinting, an olecranon ulcer subsequently formed. The Summary indicated that on 1/23/23 Resident #1 was taken to the Operating Room (OR) for right elbow bursectomy, and debridement of olecranon osteomyelitis and he/she was transferred to the Post-Anesthesia Care unit (PACU) for recovery. The Summary indicated Resident #1's right elbow incision was closed with sutures, he/she received a course of Intravenous (IV) antibiotics during his/her hospitalization and he/she was discharged back to the facility on 2/02/23. During an interview on 2/14/23 at 3:18 P.M., the Director of Nurses (DON) said that the Facility's Investigation started when the Unit Manager reported to her that after removing Resident #1's right arm splint, an open wound was noted on his/her right elbow, and he/she was sent to the Emergency Department (ED) for evaluation. The DON said Resident #1 returned from an Orthopedic Consult on 1/10/23 with new recommendation orders and to remove his/her right arm splint for hygiene. The DON said review of Resident #1's medical record indicated that a Physician order to remove the splint for hygiene, per the Orthopedist recommendations, although the order was obtained, the order was not transcribed onto his/her TAR and the plan of care was not updated. The DON said it was the responsibility of the Unit Manager to write the Physician's order, transcribe the new orders onto Resident #1's TAR and update his/her plan of care and said that the Unit Manager had not followed through with the Facility's process for Consult recommendations which includes, reviewing the consult, verifying new recommendations/orders with the Physician and or Nurse Practitioner, writing a Physician's order, transcribing the orders to resident's TAR, and update the plan of care. The DON said she expects all Nurses who receives a resident's Consultation Report to follow the Facility's process. On 02/14/23, the Facility was found to be in Past Non-Compliance and presented the Surveyor with a plan of correction which addressed the area(s) of concern as evidenced by: A. On 1/17/23, Resident #1 was transferred to the Hospital for an evaluation, and returned to the facility with new orders for an antibiotics for diagnosis of cellulitis, daily dressing changes to right elbow area and anterior splint with orders to remove splint every shift to inspect his/her skin and pain managed with prescribed pain medication. B. On 1/18/23, Resident #1, and all residents residing in the facility, had a full body skin checks conducted by Nurse Management Staff to verify that no other skin areas were present. C. On 1/18/23, Resident #1 was seen by the Wound Care Specialist in the facility and new dressings orders were confirmed with the Nurse Practitioner. D. On 1/18/23 - 1/20/23, Resident #1's Plans of Care were reviewed and update with interventions related to his/her right humerus fracture. E. On 1/18/23 to 1/24/23, the Staff Development Coordinator, educated Licensed Nursing Staff on the care requirements for Resident #1's splinted right arm. F. On 1/20/23, all residents that utilize splints were reviewed by Nursing Management to verify splints are applied as ordered and no skin issues were identified related to splint usage. G. On 1/22/23, an audit of residents requiring splints/braces was completed by Nursing Management to verify all orders were reflected in the current Care Plan, skin intact, and Certified Nurse Aide (CNA) care card is updated. H. On 1/23/23, an audit was conducted by Nursing Management to review Consult Reports for the past 30 days to verify that all recommendations were followed through. I. From 1/18/23-1/24/23, the Staff Development Coordinator, provided education was provided to Licensed Nursing staff on the requirement to review consultation paperwork thoroughly and ensure all recommendations are followed through and communicated appropriately to staff. J. From 1/18/23-1/24/23, the Staff Development Coordinator provided education was provided to Licensed Nursing staff and Certified Nurse Aides (CNAs') regarding the following: -the implementation and use of a communication binder that will be kept at Nursing Stations for staff to review changes to resident plans of care. - the need for staff to inquire about care needs, such as splints if unaware of a residents plan of care. - the facility process for skin checks, including skin under splints and other medical devices that are to be removed and if not to be removed inspect the surrounding skin area of the medical device. K. The Unit Manager is currently out of the Facility and will be re-educated by Nursing Management upon her return. L. On 1/19/23 Education was provided to the Rehabilitation Department by the Rehabilitation Manager regarding the expectation that education will be provided to staff when a resident has a new splint or brace ordered. M. On 1/18/23, The Facility implemented a new process, that all consult sheets from the previous day will be brought to morning meeting for team review to verify all recommendations were followed through and telephone order slips will be reviewed at morning meeting to verify correct order transcription into the Point Click Care (PCC) computer system. N. The Quality Assurance Nurse and/or Designee will conduct daily audits x2 weeks, then weekly x30 days, and monthly thereafter on all residents that utilize splints and braces to verify Physician orders are followed for the wearing schedule, including skin checks, CNA care cards are up to date, skin is intact, and Nursing Care Plans are correct. The results of the audits will be brought to QAPI meeting quarterly until the committee determines compliance. O. The Director of Nursing and/or Designee are responsible for overall compliance.