**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00138042. Based on observation, interview and record review, the facility 1) Failed to provide care following professional standards of practice and facility policy to prevent the development of avoidable pressure injuries, 2) Failed to accurately measure and stage residents' pressure injuries, and 3) Failed to promptly identify and provide necessary treatment for a deteriorating pressure injury for four residents (Resident #192, Resident #6, Resident #13, and Resident #26) reviewed for pressure injuries, resulting in R192 requiring emergent surgical intervention for sepsis and acute osteomyelitis of a Stage 4 sacral wound. Additionally, this deficient practice placed all residents residing in the facility at risk for the development of avoidable pressure injuries, a delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. Findings include: Resident #192 (R192): Review of an admission Record revealed R192 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: stroke. R192 was a Full Code (all resuscitative procedures implemented). Review of a Minimum Data Set (MDS) assessment for R192, with a reference date of 11/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R192 was severely cognitively impaired. Review of the Functional Status revealed that R192 required extensive 2 person physical assistance with bed mobility, transferring, and toileting. During an interview on 10/11/23 at 12:15 PM, Family Member (FM) T reported that she was not notified of the extent of R192's sacral/coccyx wound until she was admitted to the hospital. FM T reported she was aware of some skin breakdown on R192's buttocks approximately 2 weeks prior to the hospitalization and stated, I thought it was just a diaper rash and reported she had not seen the wound herself. FM T reported that family would visit R192 and report back to FM T that they could smell her wound and had noticed that R192 wasn't turned and would be in the same position all day long. FM T reported that her niece visited R192 on 1/21/23 and was concerned that R192 was going to die and didn't feel R192 was receiving proper care and wound treatment. FM T was concerned and brought it to management's attention and was told that skin breakdown could be fast moving at times. FM T reported that between 9-10 AM on the morning R192 was sent to the hospital (1/23/23) she spoke with Wound Care Nurse (WCN) H regarding her concerns, and he reported he would assess her wound. FM T reported WCN H was shaken and reported R192 would be transferred out to the hospital. Review of R192's admission Skin Assessment dated 11/22/22 revealed no documentation of skin breakdown and/or injury on R192's buttocks. R192 had a suspected deep tissue injury to her left heel and unstageable vascular injury to her left great toe. Review of R192's Braden Scale for Predicting Pressure Sore Risk dated 11/28/22 and 12/18/22 revealed R192 was at risk. Review of R192's Braden Scale for Predicting Pressure Sore Risk dated 12/30/22 revealed a score of 13 indicating R192 was moderate risk. Review of R192's Care Conference Note dated 11/28/22 revealed, .Risks: At risk for skin breakdown d/t (due to) limited mobility. Skin .no issues identified . (No other Care Conference documentation received prior to survey exit). Review of R192's Behavior Symptoms from admission [DATE] to discharge 1/23/23 revealed R192 did not display behaviors and did not refuse care and wound treatments. Review of R192's Physician Order dated 11/22/22 revealed, Skin Assessment weekly (Day) every day shift every Mon for skin. Review of R192's weekly Skin Observation Tools from 11/23/22 to 1/16/23 revealed the following: There was no documentation of skin breakdown and/or injury on R192's buttocks until 1/9/23. There were no wound measurements documented in any Skin Observation Tool assessments. There was no weekly Skin Observation Tool completed on 12/12/22. There was no weekly Skin Observation Tool completed on 12/26/22. There were no additional Skin Observation Tools completed prior to R192's transfer to the hospital on 1/23/23. Review of R192's weekly Skin Observation Tool dated 12/19/22 revealed .Left Heel pressure sore, Left great toe Vascular, right heel pressure . A new area of facility acquired pressure injury identified on R192's right heel. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new pressure area. Review of R192's Physician Progress Note dated 12/25/22 revealed, .Patients skin observation tool reviewed from 12/19/2022, no new skin issues noted . Confirming the provider was unaware of the new pressure injury on R192's right heel. Review of R192's Skin and Wound Evaluation dated 12/27/22 revealed .Left Ischial Tuberosity (no descriptive documentation: type of wound, stage of wound, etc.) Wound Measurements-Length 1.0 cm x Width 0.9 cm. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new skin breakdown. (Wound measurements are to be completed weekly and should have been documented on 1/3/23, 1/10/23, and 1/17/23). Review of R192's Physician Order dated 12/27/22 revealed, Calmoseptine Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to buttock/sacrum topically two times a day for wound management. Review of R192's Consultation Physician Progress Note dated 1/3/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .She denies any pain, however, she does have a new sore to the medial malleolus of her left ankle that is starting to open and seems painful when pressing on it. The RN (Registered Nurse) on staff states he will have her attending look at it and address today. She also has a wound on her left big toe that looks as if it may be opening up .Patient has a newly developed superficial skin wound to the medial malleolus of her left leg, erythematous and painful with palpation. Beginning to open up . Review of R192's Skin and Wound Evaluation dated 1/3/23 revealed a facility acquired right medial malleolus pressure injury documented as identified on 12/28/22 and measuring-Length 0.5 cm x Width 0.3 cm. and a facility acquired right heel pressure injury measuring-Length 1.6 cm x Width 0.3 cm. Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the new pressure injuries. Review of R192's Skin and Wound Evaluations revealed no subsequent wound measurements (Wound measurements are to be completed weekly and should have been documented on 1/10/23 and 1/17/23). Review of R192's Consultation Physician Progress Note dated 1/6/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .me and the RN assisted her in sitting up and boosted her up so she can eat. We also positioned her with a pillow under her bottom because she was stating she was having discomfort on her bottom. She is still complaining of pain to her left ankle and foot due to newly developed sores. RN states (facility medical doctor) will be rounding today and will assess the wounds and need for oral antibiotics .Patient has a newly developed superficial skin wound to the medial malleolus of her left leg .starting to develop more than one wound on the same foot/lower leg. The pain in R192's buttocks indicated the beginning of a pressure injury and the need for facility nursing staff to assess the area and implement interventions to prevent the formation of and/or the worsening of the pressure injury. Review of R192's Physician Progress Note dated 1/6/23 revealed, .3. Coccyx wound (stage 2 pressure) . There were no measurements documented. Review of R192's Physician Order dated 1/6/23 revealed, Medihoney Wound/Burn Dressing .apply to bilateral feet/ankles topically one time a day every other day for wounds. bilateral feet/ankles apply betadine moistened gauze to necrotic tissue, cover with Medihoney, dry dressing, wrap with kerlix, tape to secure. Review of R192's January Treatment Administration Record revealed the treatment was not completed until 1/7/23. Review of R192's Electronic Health Record revealed no documentation of R192's Stage II coccyx wound with measurements or wound description (Skin Observation Tool or Skin and Wound Evaluation). Review of R192's Physician Order dated 1/6/23 revealed, Aquacel Ag Burn External Pad 4-apply to coccyx topically one time a day every Mon, Wed, Fri for wound cleanser, pat dry . Confirming the provider was not notified of the new wound identified by the consulting provider and reported to facility nurses on 1/3/23. Review of R192's January Treatment Administration Record revealed the treatment was not completed until 1/9/23. Review of R192's weekly Skin Observation Tool dated 1/9/23 revealed the following new areas of facility acquired pressure injuries and skin injury with no measurements or wound description: Left (posterior) ankle-Pressure, Right (posterior) ankle-Pressure, and Coccyx-split. R192's facility provider identified the pressure injury on R192's coccyx as a Stage II (not a split) which would require facility nursing staff to obtain wound measurements (length, width, and depth) and the description of the wound and wound bed. Review of R192's Consultation Physician Progress Note dated 1/10/23 revealed, Reason for Consultation: Evaluate for rehabilitation needs .she states she has pain in her left foot due to her current wound. She was recently put on wound care 2-3 times weekly now .The wounds on her (bilateral) lower ankles have not improved much at this time .Wound getting deeper and opening further . Review of R192's Electronic Health Record revealed no documentation that the physician and R192's Power of Attorney (POA) were notified of the deterioration of R192's wound. Review of R192's Nurses Progress Note dated 1/12/23 revealed, patient has 2 wounds on her left heel and Achilles tendon, they are eschar (dead tissue), and the eschar that was on the heel has sloughed off, however it is draining purulent drainage, her ankles are cherry red and hot to the touch, NP (nurse practitioner) was made aware . Confirming a delay in provider notification of the worsening of R192's wounds (approximately 2 days). Review of R192's Physician Progress Note dated 1/13/23 revealed, Patients coccyx sore and left lateral malleolus are slow to improve due to poor immobility .Patients skin observation tool reviewed from 01/09/2023, no issues noted . Note: measurements of wounds were not documented in the Skin Observation Tools and therefore the provider could not accurately determine if there was deterioration or improvement in the wounds. Review of R192's Consultation Physician Progress Note dated 1/14/23 revealed, She has not had much improvement in the wounds in her (bilateral) ankles and feet .The wounds are holding her back slightly with therapy .Therapy progress as of 1/13/23: off of therapy at this time due to her (bilateral) foot and ankle wounds. Confirming a decline in R192's condition due to the worsening of the wounds. Review of R192's weekly Skin Observation Tool dated 1/16/23 revealed, .Left Heel pressure sore, Left great toe Vascular, right heel pressure, Bil (bilateral) posterior ankles pressure, Coccyx split . No measurements documented. Review of R192's Health Status Note dated 1/17/23 revealed, IDT (Interdisciplinary Team) at risk meeting today reviewed resident for supplementation secondary to wounds. Resident has a vascular appointment scheduled and team will revisit after appointment to reevaluate wounds and ability to heal. R192's sacral/coccyx wound was not addressed during the review. Review of R192's Nurses Progress Note dated 1/19/23 revealed R192 had a vascular appointment. Review of R192's Electronic Health Record revealed no documentation that the IDT completed a risk meeting regarding R192's wounds following the vascular appointment as documented in the Health Status Note on 1/17/23 prior to her discharge to the hospital on 1/23/23. Review of R192's Care Plan revealed Resident to have air mattress. Date Initiated: 01/19/2023. Confirming a delay in treatment for the Left Ischial Tuberosity pressure injury identified on 12/27/22 and the Coccyx Stage II pressure injury identified on 1/6/23. Review of R192's Physician Progress Note dated 1/20/23 revealed, .Patient wound was assessed with Department of Nursing. Skin care to coccyx area, regressing a little bit. We will continue to treat and monitor . Review of R192's Electronic Health Record revealed no documentation that R192's Power of Attorney (POA) was notified of the regression of R192's coccyx wound and no change in the coccyx wound treatment. Review of R192's Pulse Summary revealed R192 had a heart rate of 117 (normal range 60-100). Elevated heart rates are indicative of systemic infection. R192's pulse was not reassessed until the time of her acute transfer to the hospital on 1/23/23 3 days later. Review of R192's Temperature Summary revealed R192 had a temperature of 100.3 on 1/20/23. Elevated temperatures are indicative of systemic infection. R192 was administered Tylenol 650 mg to reduce the fever. Review of R192's Nurses Progress Note dated 1/22/23 revealed, upon cna (Certified Nursing Assistant) changing patient, she called the author to come in and see the patient wound, the patient has a wound on her coccyx, it was oozing pus that is brown and running out of a whole (sic) in the upper part of the wound, it has been documented prior, author proceeded with the treatment that is ordered, and monitored. Review of R192's Electronic Health Record revealed no documentation that R192's wound had purulent drainage/pus drainage prior to this assessment. There was no documentation that the physician and R192's Power of Attorney (POA) were notified of the deterioration and/or change of the condition of R192's wound. The presence of purulent drainage, the deterioration of the coccyx wound, and elevated temperature and heart rate indicated an acute change in R192's condition requiring physician notification and medical intervention. Review of R192's Nurses Progress Note dated 1/24/23 revealed, Resident sent to (hospital name omitted) for possible wound infection with increased drainage and very strong odor, Dr (doctor) and family notified. Pt sent on 1/23/23 (at) 1200 (12:00 PM). Review of R192's Hospital Documentation beginning on 1/23/23 at 2:05 PM revealed, The patient is a 89 y (year old) female with complicated past medical history presenting to the ED (emergency department) via (ambulance) from Chesaning Nursing facility for evaluation of a wound check. Per report the patient has wounds to her feet and coccyx that need to be debrided. Per EMS (Emergency Medical Services) the patient was hypotensive (low blood pressure) in the 80's/40's. Per report the patient also is a little bit more altered than her baseline of being alert and oriented to herself and where she is. Per nursing staff the patient is noted to be in atrial fibrillation with RVR (rapid ventricular response). Skin .Findings: Wound present. Comments: Multiple foul smelling wounds draining a thin brown discharge. 1400 (2:00 PM): This patient has SEPSIS and evidence of END ORGAN FAILURE (altered mental status). Therefore, a CODE SEPSIS was activated. The source of infection is most likely skin .multiple necrotic wounds. We will proceed with surgical debridement of this infected unstageable sacral decubitus ulcer in the OR today. She is a high risk surgical candidate due to her medical comorbidities, but without intervention, I am concerned that she will have worsening sepsis and potential septic shock. Review of R192's Surgical Debridement Procedure dated 1/24/23 revealed, Evidence of necrotic tissue was visualized with foul-smelling purulent drainage (pus) deep to the overlying eschar. The excisional debridement was then performed, which included skin, dermis, subcutaneous tissue, muscle, fascia, periosteum, and ultimately bone, as well as necrotic tissue and abscess tissue. This was performed largely with cautery as well as with sharp dissection .Once the sacral ulcer was completely dissected off the underlying tissue, this was also passed off for pathologic evaluation, and this included the coccyx. The exposed portions of sacral bone also appeared quite unhealthy .The resulting wound measured 15 x 21 x 7 cm. Review of R192's Surgical Pathology Report dated 1/26/23 revealed, NECROSIS AND MARKED ACUTE INFLAMMATION INVOLVING SOFT TISSUE AND BONE MARROW, CONSISTENT WITH ACUTE OSTEOMYELITIS. Osteomyelitis is an infection in the bone requiring urgent medical intervention. The infection can travel into the bloodstream and cause sepsis. Common symptoms include fever and elevated heart rate. Review of R192's Palliative Care Consultation Note dated 1/26/23 revealed, Palliative care consult secondary to infected stage 4 decubitus ulcer of sacrum .presented to the ED 1/23 from Chesaning Nursing and Rehab for wound check .Workup in ED suggests sepsis from wounds .Attending services has updated pt's daughter/DPOA-HC (Durable Power of Attorney-Healthcare) (FM T) and on 1/26 she was made DNAR (Do Not Resuscitate). Hospice or palliative care were also discussed with (FM T) and she expressed interest in palliative care, prompting current consultation. R192 was discharged from the hospital with end-of-life care on 2/7/23. R192 date of death was 2/18/23. R192's Care Plan: Review of R192's Care Plan revealed, Resident is at risk for skin breakdown related to impaired mobility, incontinence Date Initiated: 11/23/2022 . Assess skin during care, report any red, bruised, or open areas promptly to the charge nurse . Resident is to be turned every 2 hours to prevent skin breakdown . Review of R192's Care Plans revealed no documentation for R192's actual skin breakdown identified on admission (left heel and left great toe.) There were no interventions to offload pressure to R192's heels and to prevent continued breakdown to R192's toes. R192's Care Plan did not reflect the facility acquired right heel pressure injury identified on 12/19/23 and 1/3/23 with updated interventions to prevent the worsening of the injury. R192's Care Plan did not reflect the facility acquired Left Ischial Tuberosity identified on 12/27/23 with updated interventions to prevent the worsening of the injury. R192's Care Plan did not reflect the facility acquired Stage II pressure injury to her sacrum/coccyx identified on 1/6/23 with updated interventions to prevent the worsening of the injuries. R192's Care Plan did not reflect the facility acquired left and right posterior pressure injuries identified on 1/9/23 with updated interventions to prevent the worsening of the injuries. Review of R192's Nurses Progress Note dated 12/21/22 revealed, Resident requested for her heel protector boots to be taken off and stated that they make her uncomfortable and she is unable to sleep. Resident encouraged to keep them on to reduce risk of skin breakdown. Will continue to observe. Review of R192's Nurses Progress Note dated 1/4/23 revealed, Resident noted to decline heel boots several times this evening. Resident in agreement to try a heel wedge cushion and stated that it is much more comfortable for her. will notify wound nurse in AM. R192's Care Plan did not reflect that R192's discomfort with heel protector boots was addressed on 12/21/22 with a new intervention implemented. The use of the heel wedge cushion was not implemented on R192's Care Plan. Resident #6 (R6): Review of an admission Record revealed R6 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, diabetes, heart disease, and gastro-esophageal reflux. Review of a Minimum Data Set (MDS) assessment for R6, with a reference date of 7/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicated R6 was severely cognitively impaired. Review of the Functional Status revealed that R6 required extensive 2 person physical assist for bed mobility, transferring, toileting, and personal hygiene. Review of R6's Care Plan revealed, (R6) has an actual alteration in Skin Integrity r/t decreased mobility, weakness, incontinence and function .Bridge heels while in bed. Date Initiated: 07/11/2023 .Monitor of s/s of redness/open areas on skin, paying particular attention to bony prominences, notify nurse when identified. Date Initiated: 02/23/2022 .Turn and reposition frequently. Date Initiated: 07/11/2023 . Review of R6's Skin Observation Task completed by facility CNA's revealed a Red Area was identified on 10/2/23 and 10/7/23. No specific locations of the skin integrity concerns documented. Review of R6's Bathing on Monday/Wednesday task completed by facility CNA's revealed an area of Discoloration on 10/2/23, an Open Area on 10/4/23 and 10/9/23, and a Red Area on 10/11/23. No specific locations of the skin integrity concerns documented. Review of R6's Electronic Health Record revealed no documentation of new interventions implemented to prevent the worsening of the pressure injury, and no documentation that R6's family/guardian or the provider were notified. Review of R6's Skin Observation Tool dated 10/4/23 revealed, redness buttocks . No measurements documented. Review of R6's Skin Observation Tool dated 10/12/23 revealed no new areas of skin breakdown (known area to left foot 2nd toe and right foot 3rd toe). During an observation and interview on 10/11/23 at 1:45 PM, CNA Y and CNA U were providing incontinence care (removal of soiled brief and pericare) to R6. Near the top of R6's right buttocks, close to the intergluteal cleft, there was an open area approximately the size of a pencil eraser with a bright pink wound bed. CNA Y and CNA U reported they did not know if it was a new pressure injury. CNA U confirmed the presence of the open area. CNA Y reported she would notify Wound Care Nurse (WCN H) immediately. When incontinence care was completed, R6 was positioned on her back with no offloading devices in place (to prevent the worsening of R6's pressure injury) and R6's heels were not positioned off of the bed. Review of R6's Electronic Health Record revealed no documentation that R6's skin was assessed by a facility nurse or that R6's family/guardian or the provider of the new skin injury. Review of R6's Physician Order dated 10/11/23 revealed, Calmoseptine External Ointment 0.44-20.6 % (Menthol-Zinc Oxide) Apply to bilateral buttocks topically every shift for skin integrity. During an observation on 10/12/23 at 08:33 AM, R6 was in bed on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation and interview on 10/12/23 at 11:54 AM, CNA V and CNA U were providing incontinence care to R6. R6's brief was saturated and smelled strongly of urine. CNA U reported that R6 was to be changed every 2 hours. Near the top of R6's right buttocks, close to the intergluteal cleft, there was an open area approximately the size of a pencil eraser with a bright pink wound bed and there was a deep ruddy red indention from R6's brief. There was a new area of non-blanchable redness under the previously identified open area. CNA U confirmed the presence of the open area. Once incontinence care was complete there was no cream applied to R6's buttocks (as ordered on 10/11/23.) CNA U asked CNA V if there was a pillow that could be used to place behind R6's back to offload pressure, to which CNA V replied no. R6 was positioned on her back with no offloading devices in place and with no devices to bridge heels off of bed. During an observation on 10/12/23 at 01:53 PM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/12/23 at 03:33 PM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 04:00 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an interview on 10/13/23 at 04:03 AM, Licensed Practical Nurse (LPN) I reported that she was not aware that R6 had new skin breakdown on her bottom. During an observation on 10/13/23 at 04:49 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 05:31 AM, WCN H reported that the CNA's should have notified immediately upon finding a new area of skin breakdown. During an observation on 10/13/23 at 07:33 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation on 10/13/23 at 08:30 AM, R6 was on her back with no offloading devices in place. R6's heels were resting on the bed. During an observation and interview on 10/13/23 at 09:20 AM, WCN H observed R6's buttocks and confirmed a new area of skin breakdown. Resident #13 (R13): Review of an admission Record revealed R13 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: osteomyelitis (bone infection) in the sacral wound, dementia, and adult failure to thrive. R13 was a full code (all resuscitation procedures to be provided to keep the person alive in the case of a medical emergency). Review of a Minimum Data Set (MDS) assessment for R13, with a reference date of 7/29/23 revealed a Brief Interview for Mental Status (BIMS) score of 5, out of a total possible score of 15, which indicated R13 was severely cognitively impaired. Review of the Functional Status revealed that R13 required extensive 2 person physical assist for b ed mobility, was dependent on 2 people for transferring, and required extensive 1 person physical assistance for personal hygiene and toileting. Review of R13's Care Plan revealed, (R13) has pressure ulcer of sacrum and left shin Date Initiated: 08/01/2023 .(R13) needs assistance to turn/reposition frequently/PRN Date Initiated: 08/01/2023 .Treat pain as per orders prior to treatment/turning etc. to ensure The (R13's) comfort. Date Initiated: 08/01/2023 . During an observation on 10/12/23 at 12:04 PM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/12/23 at 01:54 PM, R13 was in bed on her back with no offloading devices in place. During an observation and interview on 10/12/23 at 03:36 PM, R13 was in bed on her back with no offloading devices in place. R13 reported that staff do not reposition her and she was unable to reposition on her own. R13 was asked if she would want staff to reposition her and she stated she would like that. During an observation on 10/13/23 at 03:58 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 07:35 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 08:29 AM, R13 was in bed on her back with no offloading devices in place. During an observation on 10/13/23 at 09:29 AM, R13 was in bed on her back with no offloading devices in place. During an interview on 10/17/23 at 11:55 AM, CNA U reported residents that need assistance with bed mobility are to be turned every 2 hours minimum. During an interview on 10/13/23 at 06:38 AM, CNA S reported that it was difficult to provide care as ordered (repositioning and incontinence care) due to insufficient staff on 3rd shift. Resident #26 (R26): Review of an admission Record revealed R26 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: diabetes and depression. Review of a Minimum Data Set (MDS) assessment for R26, with a reference date of 9/4/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated R26 was cognitively intact. During an interview on 10/10/23 at 12:16 PM, R26 reported that he had concerns with staffing and the ability of the nurses and the aides to meet the needs of the residents based on the high acuity of the residents residing in the facility. R26 reported that there are many residents that require 2 assist for care and many residents that have behaviors. R26 stated, need to be staffed by acuity not numbers. On 10/13/23 at 10:10 AM a request for list of residents that required 2 person assist for bed mobility, transferring, toileting, and hygiene was sent via email. A list of residents that required 2 person assist for bed mobility was not received prior to survey exit. Review of the Resident Census and Conditions of Residents signed 10/10/23 revealed the following: 16 residents that were dependent on staff and 18 residents that required the assistance of 1 to 2 staff for bathing. 8 residents that were dependent on staff and 24 residents that required the assistance of 1 to 2 staff for transferring. 12 residents that were dependent on staff and 22 residents that required the assistance of 1 to 2 staff for toileting. Review of the facility policy Pressure Injury Prevention Guidelines last reviewed/revised 1/28/23 revealed, .1. Individualized interventions will address specific factors identified in the re[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00138565. Based on interview and record review, the facility failed to, 1) ensure a complete and accurate nursing assessment was done after a significant change involving 1 resident (Resident #701), and 2) ensure the facility had a policy to follow for assessment regarding signs/symptoms of infection (not feeling well, increased temp, tiredness, nausea), resulting in hospitalization with a diagnosis of urinary tract infection (UTI) and sepsis (extensive infection), antibiotic given, and the likelihood for serious injury. Findings Include: Review of the Face Sheet, Minimum Data Set (dated 2022 and 2023), hospital records dated 5/13/23, physician's and nurse's notes dated 5/1/23 through 5/14/23, revealed Resident #701 was 62 years-old, admitted to the facility in 2022 and readmitted on 2023, alert but not able to make healthcare decisions, had a pressure ulcer that required a urinary catheter to be put in place to decrease urinary tract infections (UTI's). The residents diagnosis included developmental delay, history of UTI and pressure ulcer. The resident had increased temperature (Temp.), tired and nausea and stated she did not feel well. She was transferred to the hospital on 5/14/23 and was admitted with a diagnosis of sepsis due to UTI. Review of the facility physician orders dated 4/17/23, revealed staff were to change the resident's Foley catheter every 30 days (due to history of UTI's). Review of the facility nurse's notes dated 5/5/23 revealed no documentation that the resident had an increased temperature or felt ill. Review of the next facility nurse's note's dated 5/12/23, stated Resident does not appear to be feeling well this shift. She was up in her wheelchair for a bit but requested to go back to bed. She also ran a low-grade temp. this afternoon of 100.1. She became nauseous after taking her evening oral medications. Resident is currently in bed. No documentation regarding a nursing complete assessment was found with this change of condition from previous 5/5/23 entry. Review of the facility Physician G notes dated 5/12/23, stated Collaboration with Nursing/patient regarding patient's overall status, changes and concerns. No documentation was found regarding the low grade temperature, or that the resident did not appear to be feeling well. Review of the next facility nurses' note's dated 5/13/23, revealed Patient family member concerned that her patient was sick for 2 days (on 5/12/23 and 5/13/23), today the author assessed patient (no documentation of a complete assessment was found dated 5/13/23), when asking patient does her throat hurt or is it sore, and the patient nod yes, later on in the shift the patient family member wanted patient temp check and said that the patient appeared hot, patient temp is 103, family member said she wanted the patient to be sent out to the hospital. DON (Director of Nursing) is aware. The facility transferred the resident to the hospital where she was admitted with sepsis (infection throughout body) due to UTI. During interviews done on 8/31/23 at 2:00 p.m. and 2:15 p.m., Nurses, LPN C and RN D revealed they should have done a complete and detailed assessment on the resident on 5/12/23 and on 5/13/23, regarding the resident's condition change and increased temperature. Review of the facility physician G notes dated 5/13/23, stated Collaboration with Nursing/patient regarding patient's overall status, changes, and concerns. I have addressed all concerns reported by patient/Nursing. We will continue to monitor overall health via medical staff. No documentation of an increased temperature (101.1 to 103 within 24 hour's) was found. The resident was transferred to the hospital on 5/13/23, and was admitted with sepsis due to UTI. During a phone interview done on 8/31/23 at approximately 3:00 p.m., Physician G revealed he was not informed of the change of condition on 5/12/23 nor on 5/13/23, regarding the residents increased temperature, not feeling well, tiredness and nausea. Review of the hospital notes dated 5/14/23 and hospital labs dated 5/13/23, stated [AGE] year-old female with past history significant for developmental delay who presents to the ED (Emergency Department) with a chief complaint of a fever that's been ongoing for a couple of days. Patient's (family member) reports that the patient has been febrile (have an increased temp.) for the past few days (a temp of 103.3 on 5/14/23 taken in the emergency room). She had an indwelling Foley catheter placed in September and has a history of frequent UTI's. ED course: Patient was hypotensive with a blood pressure of 103/47, history on arrival to the ED, CBC (complete blood count) revealed leukocytosis with WBC's elevated at 12.1 (signs of infection). Urinalysis (urine test) in the ED is suggestive of infection with (greater then) 100 WBC's (white blood cells, from infection), large leukocyte esterase, rare bacteria, and positive nitrites (infection due to UTI, sepsis indicators). Patient was started on Rocephin (IV antibiotic given for sepsis) and will be admitted to hospitalist service for further evaluation and treatment. Review of the hospital ED report dated 5/13/23, revealed the resident was diagnosed with sepsis and UTI. Review of the facility Sepsis Screener (undated) revealed staff were to fill out with all residents who presented with signs/symptoms of infection (including sepsis/increased temp.). No facility documentation was found dated 5/12/23 or on 5/13/23, regarding a sepsis screener having been filled out for the resident. Review of the facility SBAR-Physician/NP/PA Communication Tool (undated) revealed staff were to fill out with any change of condition. No facility documentation was found dated 5/12/23 or 5/13/23, regarding assessment and informing the Physician of a change of condition and an increased temperature. During an interview done on 8/31/23 at 1:20 p.m., the DON stated We should of done them (the Sepsis Screener and the SBAR), we didn't. We don't have a policy for them. Upon request for nursing education regarding filling out the Sepsis Screener and SBAR, the nursing orientation was the only time the facility had documented educating nursing staff on the need to fill them out. Review of the resident's facility Indwelling Catheter care plan dated 10/2/22, revealed no documentation of monitoring/assessing for signs or symptoms of infection (UTI); the resident had a strong history of UTI's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement preventive measures to prevent 2 Stage II (blisters) heel pressure ulcers for 1 resident (Resident #26) of 3 resident's review for pressure ulcers, resulting in 2 bi-lateral Stage II heel pressure ulcers, pain, discomfort, agitation and wound treatments. Findings Include: Stage two pressure ulcer is partial-thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents as an abrasion, shallow center or blister. High risk residents (immobile, bed bound) should be assessed weekly, when a condition, change or as needed and preventive measures should be in place including pressure relieving devices, position changes, and dietary supplements. National Pressure Ulcer Advisory Panel (NPIAP) Resident #26: Review of the Face Sheet, Minimum Data Set (MDS, Resident assessment tool dated 6/22, Physician orders and wound notes dated 7/19/22, revealed Resident #26 was 87 years-old, alert with confusion and behaviors, admitted to the facility on [DATE], and dependent on staff for all Activities of Daily Living (ADL's). The resident's diagnosis includes, Dementia, back pain, breast cancer and metabolic encephalopathy. The resident was be bound and often refused to get out of bed, increasing the risk. The resident did not have any redden areas or pressure ulcers on her heels upon admission. Review of the electronic medical record (Nursing and Therapy notes and evaluations dated 6/22) revealed the resident was at risk for development of heel pressures and had bi-lateral foot drop. Review of the resident's admission nursing assessment dated [DATE], revealed Resident #26 had a diagnosis of Dementia with confusion and it was documented that she had an unstageable scabbed hematoma (blood under the skin) on the right lower leg only, no other skin, wound or pressure ulcer were present upon admission from the hospital. Review of the facility Skin Observation Tools dated 6/30/22, 7/7/22 and 7/14/22, revealed no documentation of any concerns (redness, blisters, open skin, or pressure ulcers) regarding the resident's heels. Review of the facility Skin Integrity care plan dated 6/11/22, up-dated on 7/14/22, stated Bridge heels while in bed, monitor of s/s (signs and symptoms) of redness/open areas on skin, paying particular attention to bony prominence's (including heels), notify nurse when identified. Review of facility physician order dated 6/10/22 through 7/19/22, revealed no order for treatment of bi-lateral heels for Stage 2 pressure ulcers. Two observations made on 7/18/22 at 11:00 a.m. and on 7/19/22 at 7:00 a.m. and at 3:00 p.m., revealed the resident in bed with a pillow under her calves, both heels were directly on the mattress and a pair of black PRAFO boots (for preventive measures, keeps heels off mattress and for foot drop/contractures) were sitting on the bedside stand. The resident had bi-lateral foot drop and verbalized pain with any movement of her feet. Review of the physician orders dated 6/10/22, stated Resident to wear PRAFO contracture boots in bed to tolerance. Observe for s/s (signs and symptoms) redness/discomfort/skin breakdown. Review of the facility Skin Integrity care plan dated 6/11/22, had no documentation of PRAFO boots as a preventive measure for contractures/foot drop. Review of all the resident's care plan upon admission and dated 6/10/22 to 7/19/22, revealed no documentation of PRAFO boots. A third observation was made on 7/20/22 at 10:23 a.m., again the resident was in bed with a pillow under her calves and her heels were both on the mattress. The pair of black PRAFO were again, sitting on the bedside table. The resident verbalized pain when OT/Director of Rehab N pulled her sheet up to observe her feet. During an interview done on 7/20/22 at 10:08 a.m., Occupational Therapist/Director of Rehab N stated I assess their (residents) positioning for skin breakdown; I ordered her the boots (PRAFO boots), she (resident #26) should have them on when in bed. They should be on her; I will educate staff. Review of the facility Inservice sheet dated 7/20/22, revealed 5 Nursing Assistants had been educated by OT N regarding Resident #26 needing her PRAFO boots on when in bed and to check for signs/symptoms of discomfort, redness, skin breakdown. Take off during bathing and when out of bed. During a second observation done on 7/20/22 at 10:26 a.m., accompanied by the DON/Wound Nurse, The resident had Stage 2 pressure ulcers on both heel (blisters with skin intact). The DON measured the resident's stage 2 pressures to be, the right heel to be 2.4 cm by 2.7 cm, and the left heel to be 2.7 cm by 2.7 cm. Any movement done with the residents feet (by the DON) caused her to yell she was in pain. During an interview done on 7/20/22 at 10:26 a.m., the DON stated, When I was in the room earlier (right after this surveyor observed the resident in bed with the PRAFO boots sitting on her stand for the fourth time) to see her, staff told me to look at her heels. This is when the Stage 2 pressure ulcers were first identified by the facility, on 7/20/22. The DON said Resident #26's bi-lateral heel Stage 2 pressure ulcers were facility acquired. Review of the facility Skin & Wound Evaluation dated 7/20/22, revealed the resident had developed bi-lateral heel Stage 2 pressure ulcers and treatment had been initiated on 7/20/22 (the day this surveyor requested to observe the resident's heels and reported to the DON 3 observations of the resident's PRAFO boots not on the resident, sitting on bedside stand. Review of physician order dated 7/20/22, stated Lt (left) Heel: cleanse Lt heel with wound cleanser, pat dry, apply skin prep. Two times a day for wound healing. Rt (right) Heel: cleanse Rt heel with wound cleanser, pat dry, apply skin prep. Two times a day for wound healing. **Keep heels elevated while I bed.** Review of the resident's facility Skin Integrity care plan dated 7/20/22, stated Resident to wear B/L (bi-lateral) PRAFO, contracture/blisters on bilat heels, boots in bed to be worn at all times. Review of the facility Potential Breakdown Policy dated 1/26/16, stated All residents will be assessed to identify risk factors for skin breakdown. Interventions will be implemented to attempt to prevent skin break down.