**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review facility failed to: 1) accurately assess, monitor and prevent the development of pressure ulcers consistent with professional standards of practice to prevent avoidable pressure ulcers; and 2) implement care-planned and non-care-planned interventions for one Resident (R37) of three reviewed for pressure ulcers, resulting in facility acquired stage 3, a deep tissue pressure injury, and unstageable pressure wounds and the increased likelihood for delayed wound healing and/or worsening of wounds and overall deterioration in health status. Findings include: Review of the facility, Skin Care Policy, dated 2/22, reflected, It is the policy of the [named facility] to routinely protect residents/patients from skin breakdown and injury. All nursing staff when working with residents/patients in giving care will inspect, apply preventative treatments (when necessary), and document each resident/patient ' s skin for any changes and to communicate skin concerns to the wound nurse for assessment and intervention .Any treatment that requires assessment, ongoing monitoring, and re-evaluation to determine effectiveness needs to be performed/applied by a licensed nurse (ex. Biofreeze, pain relief, antifungal cream, s/sx of rash resolving, etc.). Using the Skin Care Protocol, the charge nurse will provide the necessary treatment or referral to the Wound Care nurse. All stageable wounds will be referred to the Wound Care Nurse .The specified cream used will have an order written in PCC that will be transcribed onto the TAR for assessment and documentation purposes .The skin care plan will be updated when creams are ordered. The focus/problem statements should be updated with the current condition/issue and the treatment intervention should state: Apply treatment per orders.The wound nurse and/or clinical mentor will assess all new skin issues that are documented in POC and document in the Skin Assessment UDA instead a Progress note .All residents/patients with skin issues will be assessed and documented on by the Clinical Mentor and/or Wound Care Nurse every 7 days. This includes any residents/patients that have interventions from the Skin Care Protocol .All residents/patients that have stageable wounds will be followed, assessed, and documented on by the Wound Care Nurse on a weekly basis . Review of the facility, Skin Protocol, dated 12/22, reflected, PRESSURE INJURIES: This staging system should be used ONLY to describe pressure injuries. Wounds that are not caused by pressure should not be staged with this system. i.e. arterial, venous, diabetic, skin tears, tape burns, dermatitis, maceration or excoriation. A pressure injury is a localized injury to the skin and/or underlying tissue. This injury is usually located over a bony prominence, as a result of pressure. They may also be related to pressure in combination with friction and/or shear. Stage I: Non-blanchable Erythema .Stage 2: Partial thickness- loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. Without slough or serum filled bulla or vesicle. Stage 3: Full thickness tissue loss-Slough may be present. Sub-cutaneous fat may be visible but bone, tendon or muscle is not exposed. The difference between Stage 2 and Stage 3 is the depth .Unstageable: Full thickness skin or tissue. Depth is unknown due to being obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown, or black) in the wound bed. Suspected Deep Tissue Injury: Depth is unknown. Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shearing . Review of the Face Sheet and Minimum Data Set (MDS) with ARD date 8/2/23, reflected R37 was a [AGE] year old male admitted to the facility on [DATE] related to dementia, Alzheimer's disease, chronic obstructive pulmonary disease, hypertension (high blood pressure), kidney disease, urinary tract infection with chronic indwelling catheter, heart failure, anxiety, and depression. The MDS reflected R37 had a BIM (assessment tool) score of 00 which indicated his ability to make daily decisions was severely impaired, and he required two-person physical assist with bed mobility, transfers, dressing, toileting, and one person assist with locomotion on unit, eating, hygiene, and bathing. The MDS assessment reflected R37 had no behaviors including rejection of care. Continued review of the MDS, dated with ARD date 10/18/23, reflected no rejection of care. Further review of the MDS reflected one new unstageable pressure ulcer that was not present on admission or readmission. During an observation on 10/30/23 at 3:10 PM, R37 had a contact isolation sign posted outside his door with the door open. R37 was lying flat on back yelling out for staff to removed pants. Staff observed enter R37 room and reinforce he did not have pants on. R37 appeared confused but easily redirected. During an observation on 10/31/23 around 7:30 a.m., R37 was in bed, lying flat on back with eyes closed. Review of the facility Matrix, dated 10/30/23, reflected R37 had a unstageable facility acquired pressure ulcer. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 7/26/23, reflected R37 had a score of 13, which indicated moderate risk. Further review of the Braden assessment completed on 5/19/23 reflected a score of 16, which indicated at risk for developing pressure ulcer. Review of R37 Nursing Progress Notes, dated 7/20/23 at 3:05 p.m, reflected, On assessment of resident's buttocks/coccyx area, it was noted that there is a small area of excoriation at inferior portion of coccyx. It was also noted that area surrounding coccyx and extending onto bilateral buttocks is erythematous. RN [registered nurse] placed an Allevyn over area of excoriation and applied Chamosyn to all erythematius areas. RN notified CM[clinical mentor] regarding this issue. Also notified wound team . Review of R37's Treatment Administration Record (TAR), reflected, Weekly Assessment Due: Please complete resident's weekly assessment and document in the Nursing Assessment Form - Long Term Care every day shift every Fri for Monitoring. The TAR reflected staff initials on 7/11, 7/14, 7/21, and 7/28. Review of the Electronic Medical Record (EMR), reflected no evidence of the Nursing Assessment Form, dated 7/21/23. Continued review of the EMR reflected a Nursing Assessment Form, dated 7/28/23 at 2:34 pm, reflected R37 had a new or worsening skin or wound with notes that included, Coccyx and upper buttocks skin breakdown. TX started to wash with soap and water apply chamosyn and hydrocellular foam dressing change daily.(eight days after first observed 7/20/23). Continued review of the EMR reflected no evidence R37 new coccyx skin breakdown had been assessed by CM or wound nurse between 7/20/23 and 7/28/23. Review of R37's Nursing Progress Note, dated 7/30/23, reflected, RN performed skin assessment on resident. With assessment, it was noted that there is a significant area of concern on resident's sacrococcygeal area. Tissue denuded noted with gentle cleansing with sterile saline and 3X3 gauze. Beneath denuded tissue, area is open and bright red. In center of denuded area, there is an area with black tissue at the base, and another separate small area with yellow slough tissue at its base. Peri-wound area is noted to be largely erythematous. Erythema does not blanch on palpation. RN suspects Kennedy ulcer, however, will leave diagnosis to wound team. Treatment of area included gentle cleansing with sterile saline on a 3X3 gauze, and pat dry with gauze. Prescribed dressing placed over area and secured with paper tape. Resident turned on side to offload area as much as possible and will continue to turn resident Q2 hours and PRN. RN also noted on skin assessment that resident has developed blanchable erythema of bilateral heels. Skin noted placed on both heels, and heels also covered with Allevyn . Note completed by Registered Nurse (RN) D. Review of the, Skin and Wound Evaluation V7.0, dated 7/31/23, reflected R37 had a new facility acquired unstageable (obscured full-thickness skin and tissue loss) pressure ulcer to the coccyx that measured: 4cm length x 3.3 cm width x 0.5 cm depth. The Evaluation reflected wound bed was 60% slough (non-viable skin) and 20% eschar(dead tissue) with no epithelial or granulation indicated. Review of the, Skin and Wound Evaluation V7.0, dated 10/5/23, reflected R37 had facility acquired unstageable pressure ulcer to the coccyx area that measured: 0.5cm x 0.4cm x 0 cm. The evaluation reflected 100% slough to wound bed. Review of the, Skin and Wound Evaluation V7.0, dated 10/31/23, reflected R37 had a facility acquired unstageable pressure ulcer to the coccyx area that measured: 4.4 cm x 3.9 cm x 0.4 cm. The evaluation reflected 100% slough to the wound bed. Review of the Wound Evaluation, dated 10/31/23, reflected a deteriorating facility acquired unstageable coccyx pressure wound. The evaluation included notes, Unstageable to coccyx, deteriorating. Increase in size of wound this week. Area is 100% slough. Periwound intact, fragile, with purple erythema. Scant serous drainage. No odor noted. Denies pain to area. Medihoney, and foam dressing. Review of the Physician orders, dated 7/1/23 through 7/31/23, reflected R37 had an order for, Cleanse coccyx and buttocks with soap and water dry apply chamosyn and hydrocellular foam dressing. Change daily one time a day for Skin breakdown coccyx Start Date-07/29/2023. The Physician orders reflected no evidence of treatment orders for R37 coccyx skin breakdown between 7/20/23 and 7/28/23(eight days). Review of the Palliative Care Determination Form, dated 8/2/23, reflected R37 was determined to have life expectancy of 6 months or less, as evidenced by, Decline of intake, weight loss (not significant). cognitive decline slower processing time, increased hours in bed, increased weakness/requires increased assist with cares, unstageable pressure to coccyx. The form indicated R37 was appropriate for palliative care related to end stage dementia. Review of the Weekly Skin Assessment V2, dated 8/8/23, reflected R37 had blanchable redness to bilateral heels with treatment started for skin prep to heels.(documented on 7/30/23 nursing progress note as blanchable erythema of bilateral heels). Review of the Treatment Administration Record (TAR), dated 8/1/23 through 8/31/23, reflected R37 had order for skin prep to bilateral heels daily starting 8/8/23. Continued review of the TAR reflected additional order that reflected, L heel: cleanse with NS, apply thin layer of chamosyn, cover with 4x4 allevyn Q3D every day shift every 3 day(s) for Preventative Skin Care, dated 8/18/23 through 8/30/23. The TAR reflected no evidence of treatments orders between 8/1/23 and 8/8/23 for R37 heels. Review of the Skin Wound Progress Note, dated 8/15/23, reflected, WCN assessed bilateral heels. R heel intact, dry and calloused. L heel intact, soft, and slow to blanch. Recommending chamosyn and allevyn to L heel Q3D preventatively. Review of R37 Weekly Skin Assessment V2, dated 9/26/23, reflected, left Heel red, blanching and boggy right heel has area of callous. Review with the Skin and Wound Evaluation V7.0, dated 10/17/23, reflected R37 had a new(no date completed) facility acquired stage 2 pressure ulcer to the left heel that measured: 1.9cm x 1.2cm x 0cm with 100% epithelial(wound covered, surface intact). (Suspected Deep Tissue Injury according to facility Skin Protocol). Continued review of the assessment included a note, NEW [NAME] Stage 2 to L Heel. Area is 100% epithelial. Periwound intact and fragile. No drainage or odor noted. Denies pain. Recommending skin [NAME], white foam (non-adherent) and kerlix. Review of the Skin and Wound Evaluation V7.0, dated 10/24/23, reflected R37 had a new(no date completed) facility acquired deep tissue injury to the left heel. Review with the Skin and Wound Evaluation V7.0, dated 10/31/23, reflected R37 had a new(no date completed) facility acquired deep tissue injury to the left heel that measured: 1.8cm x 1.3cm x 0cm with 100% epithelial. Review of the MDS, dated [DATE], reflected R37 had one unstageable pressure ulcer not present on admission and no unstageable pressure injuries presenting as deep tissue injury, locked on 10/25/23.(Skin and Wound Evaluation evidence of deep tissue injury, dated 10/17/23 and 10/24/23). Review of R37 Care Plan, dated 7/3/23 through 11/1/23, reflected interventions that included, Rolling: Extensive assist with Bed mobility device with revision date of 7/3/23. Continued review of the Care Plan reflected update, dated 8/1/23, Rolling: Extensive assist x 2 with Bed mobility device. The Care Plan reflected most recent update, dated 10/16/23, that included, Bed mobility: dependent Supine > sit: dependent Sit > supine: dependent Rolling: dependent with Bed mobility device Boosting up in bed; dependent .touch pad call light on chest while in bed for safety due to resident's visual deficit, dated 10/6/23 . Heel manager while in bed, revised 5/21/23 to current . Specialty Mattress, initiated 10/31/23(coccyx wound identified 7/20/23 according to Progress Notes) .Treatments per orders, initiated 10/9/23 . Turn every 2 hours side to side and as needed, Date Initiated: 08/01/2023, revised 8/14/23 to include, Turn every 1 hours side to side and as needed to current (11/1/23) .Weekly and as needed skin checks Date Initiated: 08/09/2023. During an observation on 10/31/23 at 4:15 p.m., R37 in bed on back with eyes closed. During an observation on 10/31/23 at 2:46 PM, R37 was laying in the bed, flat on back with heels elevated with eyes closed. During an interview on 10/31/23 at 3:00 PM, Wound Nurse (WN) G reported had been the facility wound care nurse since March 2022. WN G reported she was not wound care certified. WN G reported staff email WN G and wound team for all new abnormal skin issues and completes evaluation within 24 hours. WC G reported documents in skin and wound evaluation with picture and follows all true Pressure Ulcers, vascular wounds, surgical wounds every seven days. WN G reported nurses are expected to complete skin assessments on rehab unit every shift and long-term units weekly and palliative residents every shift located under assessment tab of EMR. WN G reported she is responsible for staging 95% of all resident wounds and follows about 35 to 40 wounds every 7 days currently at facility. WN G reported determines wound treatments and consults with Medical Director and Nurse Practioner as needed. During an observation on 10/31/23 at 5:15 pm, R37 was lying flat on back in bed, eyes closed in same position. During an observation on 11/1/23 at 8:10 AM, R37 was lying flat on back in air mattress, eyes closed, lights off with catheter bag located on window side of bed. During an interview on 11/01/23 at 8:20 AM, RN D reported was R37 nurse and regularly cared for R37. RN D reported R37 received daily dressing changes to coccyx and left heel Kennedy ulcers. RN D reported WN G stages wounds. During an observation on 11/01/23 at 8:25 AM, R37 was laying on back in bed with head of bed elevated with student assisting with meal. During an interview and observation on 11/01/23 at 12:09 PM, Certified Nurse Aid(CNA) H reported was responsible for caring for R37 at that time. CNA H reported had repositioned R37 about 10:30 a.m. and performed catheter care. CNA H was questioned if R37 had a cath secure in place and location? CNA H reported thought cath secure was in place on left leg but could not recall. CNA H entered R37 room and verified R37's cath secure was located on the right leg. R37's call light was located on the floor when CNA H entered the room CNA H placed on top of R37's blankets without clipping on. CNA H reported was working today as CNA staff but usually responsible for restorative therapy. Review of the CNA documentation task, Turn & reposition side to side every hour while in bed on 11/1/23 at 3:30 p.m., reflected no evidence or documentation that R37 had been turned and repositioned since 11/1/23 at 4:00 a.m. (over 10 hours). Review of the CNA documentation task, Standards of Care, including Was Resident cared for following standards of care, [NAME], and CNA treatment sheet? on 11/1/23 at 3:00 p.m. The Task was last documented as completed on 10/31/23 at 10:12 p.m. Review of the TAR, dated 9/1/23 through 10/31/23, reflected 19 holes with missing documentation to indicated treatments were completed. During an observation on 11/1/23 at about 3:45pm, RN D asked CNA H assist with R37 wound care. CNA H responded he was unable to assist because he was finally able to do his actual job duties, while pushing a scale down the hall. During an observation on 11/01/23 at 4:00 PM, RN D entered R37 room after gathering wound care supplies with CNA I to assist. R37 was lying in bed on back and RN D spoke to R37 directly in ear and explained plan because R37 was very hard of hearing. R37 appeared calm and able to follow direction with no resistance of care. R37 top covers were pulled down and R37 t-shirt was gathered tight around upper chest and saturated in what appeared to be urine. The fitted sheet was urine stained with a large, dried circle ring stain that appeared to be urine. The pad under R37 appeared to be urine saturated. CNA I and RN D removed R37 brief which appeared dry with recent loose stool observed. CNA I and RN D gathered additional supplies after reported need to clean urine from R37 skin from the shoulders down with soap and water. Staff removed urine-soaked clothing and linens and performed pericare. R37 had very red raised skin that appeared to be missing top layer of dermis in straight line of right upper back rib area about 6 inches long and 2 inches wide with open area thin straight line about 1 inch long. RN D reported was a new wound and appeared to be caused by saturated t-shirt that was gather up around R37 chest. An additional area of red raised erythema was observed at right flank area near ribs about 5 inches by 1 inch. R37 repeated several times that back rib area was painful and was overheard say, ouch while CNA gently cleaned back with soap and water. RN D reported both those area were new for R37. RN D removed the undated dressing from R37 coccyx area. R37's coccyx area was very red with open wound, about silver dollar size, to right coccyx area with slough present, appeared to be full thickness skin loss(stage 3) and dark red non blanchable area extending from right to left coccyx about pear size with three darker area within that appeared deep tissue injury about dime to quarter size. R37 had bright red area on right inner knee that appeared to be from other knee pressure about golf ball size. R37 had bright red indentations of foley catheter tubing on right upper thigh. RN D reported verified large area of non-blanchable skin to coccyx was new along with area on right inner knee and right upper thigh. RN D reported they needed to position pillows better to prevent pressure points. RN D completed wound care to coccyx area and R37 complained of pain during treatment. R37 followed directions from staff with no resistance after staff verbalized plan directly in R37 ear related to very hard of hearing. During an interview on 11/01/23 at 5:00 PM, CNA I stated, I am so embarrassed. CNA I reported was not R37 CNA that day and had no idea what she was walking into. CNA I reported R37's CNA had left today at 1:00 p.m. CNA I verified R37's brief was dry and pad, fitted sheet and t-shirt were saturated in urine. CNA I reported if staff would have been turning R37 every hour they should have seen that. CNA I reported R37 required every one hour turning and repositioning related to skin breakdown and staff know because on R37 [NAME]. CNA I reported R37 allows staff to reposition him.