**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake: MI00138676. Based on observation, interview and record review, the facility failed to ensure accurate/completed skin assessments, timely implement adequate interventions to prevent the development and/or worsening of wounds, and failed to monitor, timely identify and treat the worsening of wounds for two (R802 and R804) of two residents reviewed for pressure ulcers, resulting in R802 to have developed bilateral heel wounds, a stage 3 coccyx wound and the need to be transferred and admitted to the hospital for the infected bilateral heel wounds which required Intravenous (IV) antibiotics; and the potential for worsening pressure ulcers for R804. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility's failure to prevent and care for pressure ulcers. On 8/16/23 at 10:27 AM, the complainant was interviewed via telephone when asked, the complainant stated R802 developed multiple wounds at the facility. The complainant stated on 7/27/23 R802 wounds were observed with the facility nurse which revealed in part .bilateral full thickness pressure ulcers with foul smelling purulent drainage and necrotic edges . The complainant stated a coccyx wound was also identified as well as skin impairment to the scrotum. The complainant stated R802 was transferred to the hospital and admitted for Intravenous (IV) antibiotic treatment for bilateral infected heels. The complainant explained the course of treatment was intense and the family ultimately decided to place R802 in hospice care. R802 was discharged home on hospice care on 8/2/23 and died four days later on 8/6/23. Review of the medical record revealed R802 was admitted to the facility on [DATE] with diagnoses that included: alzehimer's disease, unspecified displaced fracture of surgical neck of left humerus and a fall. A Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 2 (which indicated severely impaired cognition) and required the assistance from staff for all Activities of Daily Living (ADLs). Further review of the MDS Skin Condition section documented the resident was admitted to the facility with no pressure ulcers. Review of an admission summary dated [DATE] at 9:36 PM, documented in part .Guest arrived to facility via stretcher at 8pm from (hospital name), A&O x1 (alert and oriented times one), hospitalized for fall encountering a subdural hematoma and (L) humerus fx (fracture), sling in place to LUE (left upper extremity) .Skin assessment completed with discoloration noted to LUE and (L) (left) shoulder, scabbed area on (R) (right) hand and RFA (right forearm) . Review of the facility weekly Skin & Wound assessments dated: 6/24/23, 7/2/23, 7/10/23, and 7/18/23 documented no wounds or skin impairment were identified for R802. Review of an admission Braden assessment dated [DATE] documented a score of 17, which indicated the resident was at risk for pressure ulcers. Review of a progress note dated 7/21/23 at 12:37 PM, documented in part .Resident's daughter notified of areas to heels and potential friction cause by shoes. Daughter states she will bring different shoes. Review of a Nurse Practitioner (NP) note dated 7/21/23 at 3:07 PM, documented in part .Patient seen and examined. Patient observed ambulating in room .Pt has severe cognitive deficit .Patient observed standing at sink, bil (bilateral) heel wounds noted. Appear to be from patient's shoes which he wears daily .Nursing notified, will + treatments .+ heel wounds to bil. Heels .treatment orders for heel wounds, monitor sites .Follow up with ortho (orthopedics) - appt (appointment) 7/27/23 . Review of an Occupational Therapy treatment encounter note dated 7/21/23 at 3:32 PM, documented in part .Patient dressed and seated in w/c (wheelchair) upon therapist arrival. NP notifying this writer of bilateral heel wounds. Observed patient's feet to which both heels have open wounds, right one with blood present. Nurse on hall aware and to assess. Tx (Treatment) session focused on seated activities to prevent further shearing of shoes on heels . Prior to the NP identification of R802's heels and notification to the nursing staff on 7/21/23, there was no documentation of the staff to have identified the changes to R802's heels. Review of a Skin & Wound Evaluation dated 7/21/23 at 11:29 AM, documented in part .Friction from shoes .Left Heel .In-House Acquired .New .Area 2.8 cm2 (centimeters squared) .Length 2.3 cm (centimeters) .Width 1.5 cm .Depth Not Applicable .Ruptured blister .Exudate - None .Indication that current shoes may be causing friction . Review of a picture of the Left heel attached to the assessment revealed a ruptured blister with depth observed, although depth was not documented in the assessment. Review of a Skin & Wound Evaluation dated 7/21/23 at 11:38 AM, documented in part .Friction from shoes .Right Heel .In-House Acquired .New .Area 3.5 cm2 .Length 2.4 cm .Width 2.0 cm .Depth Not Applicable .Slough 60% of wound filled . Review of a Skin & Wound Evaluation dated 7/21/23 at 11:49 AM, documented in part .Open Lesion .Coccyx .Acquired (left blank) .Area 2.7 cm2 .Length 2.5 cm .Width 1.6 cm .Depth Not Applicable .Slough 100% of wound filled .New . Review of a picture of the coccyx wound attached to the assessment revealed a coccyx wound, not an open lesion as documented in the assessment. Review of the medical record revealed no prior identification of the coccyx wound or skin impairment identified by the facility staff. Review of a NP note dated 7/27/23 at 1:30 PM, documented in part .Patient seen and examined. Patient observed sitting in chair. Pt has severe cognitive deficit .Patient appears to be wincing and shaking in pain .Daughter at bedside, was going to take patient to ortho appointment today. NP was notified to see patient due to uncontrolled pain and b/l (bilateral) heel wounds. Heel wound undressed - dark wound beds to b/l heels with small amount of foul-smelling purulent blood-tinged drainage. Both heels with surrounding blanchable erythema. Patient wincing while heel wounds being assessed. Daughter agreeable to send patient to hospital via ambulance for evaluation of wounds, likely IV antibiotic therapy. Discussed with .(assigned nurse name, DON name and director) .Skin .rash (Excoriation to groin) and ulcer (DTI's - Deep Tissue Injury- to b/l heels with s/s (signs/symptoms) infection. Stage 3 (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible) to left buttock.) .Pressure injury of heel - B/l DTIs with small amount of foul-smelling purulent blood-tinged drainage .Patient sent to hospital for wound evaluation .Pressure ulcer of unspecified heel, unspecified stage . Review of the medical record revealed no documentation of the facility staff to have identified the worsening of the resident wounds prior to the identification on 7/27/23 when the resident was transferred to the hospital. This indicated R802 who was admitted to the facility for rehabilitation after a fall at home developed two bilateral heel wounds and a stage 3 coccyx wound within 5 weeks after being admitted to the facility with no wounds and to have developed an infection of the heel wounds shortly after. Further review of the medical record documented that daily treatment for the heels- cleanse, triple antibiotic ointment and abdominal wrap daily for two weeks and coccyx- cleanse, apply skin barrier cover with aquacel pad daily for two weeks was implemented. Review of the care plans revealed the interventions implemented were not adequate to prevent the development or the worsening of the resident wounds. Further review of the care plans revealed the heels and coccyx was not added to the .potential impairment for skin integrity . care plan until 7/27/23, the day R802 was transferred to the hospital for their infected wounds. Review of the June 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) documented the implementation of Float heels to be applied on 6/21/23, however the record did not document why the float heels were implemented. Review of the hospital medical records revealed the following: A ED (Emergency Department) Provider Notes dated 7/27/23 at 4:52 PM, documented in part .Patient presents to the Emergency Center today with a wound problem .patient has been in a subacute rehab facility .for a left proximal humerus fracture .Six days ago, ECF (Extended Care Facility) staff informed the patient's daughter of blisters he had developed on his bilateral heels. The patient has been having difficulty standing and ambulating due to the pain .wounds are foul-smelling with purulent drainage .ulcer on the patients coccyx .Ulcers to bilateral heels with surrounding erythema 2.5 cm with some necrosis and purulent drainage .WBC (White Blood Cell) 13.7 (H- high) .Patient with infected pressure ulcers of bilateral heels, concerned for possible osteomyelitis. Purulent drainage on exam .Antibiotics started .CRP (C-Reactive Protein levels- under 10 milligrams per liter is considered normal) 225 .Labs show leukocytosis, 13.5 .Escalation of care including admission/observation was considered. Patient will be admitted .Disposition: admission .Final Impression: Infected pressure ulcers of bilateral heels . Review of a History and Physical dated 7/28/23 at 9:54 AM, documented in part .admitted to our facility on 7/27/2023 with worsening of bilateral heel wounds .He has been in an extended care facility where they (family) felt like his wounds were not being properly cared for. Staff at the facility had told the family that patient developed blisters on his heels .he was complaining of severe leg pain at which time the family remove the bandages and found his wound had purulent drainage. For this he was brought into our facility .Given oral and IV analgesics, IV hydration and a dose of IV vancomycin and Zosyn (antibiotics) .Continue IV vancomycin and Zosyn . Review of a Discharge Summary dated 8/2/23 at 8:59 AM, documented in part .Date of admission: [DATE], Date of discharge: [DATE] . Diagnosis - Primary Problem: Wound drainage .presented to the hospital with bilateral heel wounds .At an outside facility he apparently developed these heels ulcers which were noted by family and found to be having purulent drainage which was brought to our facility. Initially had significantly elevated CRP/ESR (Erythrocyte Sedimentation Rate) and was started on oral/IV analgesics as well as IV antibiotics. Patient was evaluated by orthopedic surgery, infectious disease, podiatry, vascular surgery .He completed 1 week of IV antibiotics while admitted . Family elect home with hospice care .Plan for discharge home with hospice this afternoon. Discussed with family, new prescriptions for Augmentin to complete 1 week as well . Further review of the hospital medical record revealed photographs taken of both heels by the hospital staff that reflected the documented assessment findings by the hospital providers. On 8/16/23 at 2:22 PM, the Director of Nursing (DON) was interviewed. The DON was asked if they were familiar with R802's care at the facility and replied they remembered they received a call on the last day of the resident being in the facility because R802's daughter stated that R802's heels were necrotic, needed debridement and the resident needed to go out for IV antibiotics. The DON stated they went down to R802's room to assess their heels and they denied the heel wounds to be necrotic as stated by R802's daughter. The DON then stated they told R802's daughter that it is their choice to transfer R802 to the hospital and the facility staff then facilitated R802 to be transferred to the hospital. The DON was then read the NP note dated 7/27/23 that reflected R802's heel wounds were infected, a stage 3 coccyx wound and the need to be transferred to the hospital for IV antibiotics. The DON stated they did not talk to the NP and was unaware of the NP note dated 7/27/23. The DON was then read the portion of the NP's note from 7/27/23 that documented that the NP communicated their findings with the DON and the DON stated they could not recall. The DON was asked why who and when the first identification of the coccyx wound was made by the facility staff and the DON stated they were unsure. The DON stated staff should have written a progress note of the identification of all of R802's wounds. The DON was then asked about the skin assessment completed on 7/18/22 which failed to identify any skin impairments, despite three days later two heel and a coccyx wound to have been identified, the DON replied they were unable to answer the question but if staff observed any skin impairments the protocol is to take a picture, notify themselves (DON) and the physician and implement treatment. The DON was asked if the facility staff applied socks to R802's feet to prevent the rubbing of the skin against their shoes and the DON stated they were unable to answer that. The DON was asked the facility's protocol on the identification of a wound worsening and stated staff should take a picture and notify the physician. The DON was then asked if additional interventions should had been implemented on the care plan for the heels and coccyx wounds to prevent worsening besides the treatment implemented and the DON stated additional interventions should have been implemented on the care plan and was unable to state why additional interventions were not implemented. The DON was asked why the float boats was ordered on 6/21/23 and the DON stated they were unsure. The DON was then asked if the facility followed up with the staff to see how this happened and how they could prevent this incident from happening again in the future considering that the facility staff applied treatments daily to the wounds, showered/bathed resident, changed the briefs of the resident daily and failed to identify the worsening of the wounds, the DON replied they did look into it but .we probably should have looked into the situation a little better to see what happened . At this time the DON was informed of the concerns of accurate skin assessments, the implementation of adequate interventions, the monitoring of the wounds and the timely identification and treatment of the worsening of R802's wounds. The DON stated they would look into the concerns and follow back up. No further explanation or documentation was provided by the end of the survey. R804 Review of the facility documentation provided for residents with pressure ulcers (PU) identified there were a total of 10 residents currently with PU's, and three of these residents had acquired PU's while in the facility. Further review of the documentation identified R804 had developed two unstageable PU's (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) since admission into the facility, one on the left heel and one on the right heel. These were identified by nursing staff on 8/9/23. On 8/16/23 at 11:47 AM, R804 was observed seated in a wheelchair that was pushed up to a table in the dining/activity room. Both of R804's feet were observed resting directly on the leg rests (hard surface) and the resident wore light blue socks with grippy material on both feet. There were no visible pressure relieving materials in use such as a pillow, cushion or padded protective boots. Although R804 had significant cognitive impairment, they responded to simple questions asked. Review of the clinical record revealed R804 was admitted into the facility on 7/27/23 with diagnoses that included: anterior dislocation of left humerus, type 2 diabetes mellitus without complications, unspecified psychosis, adjustment disorder with mixed disturbance of emotions and conduct, meningitis, other encephalitis and encephalomyelitis, urinary tract infection (UTI), hypertension (HTN), and bacteremia. According to the MDS assessment dated [DATE], R804 had moderately impaired cognition, required extensive assistance of two or more people for bed mobility, was totally dependent upon two or more people for transfers, had no functional limitation in range of motion for upper and lower extremities, used a wheelchair for mobility, was not on a therapeutic diet, had no weight fluctuations, was at risk for developing pressure ulcer/injury upon admission but did not have any, and had a pressure reducing device for the bed. Review of the skin/wound care plan initiated on 7/27/23, revised on 7/28/23 documented, The resident has the potential impairment to skin integrity r/t (related to) UTI, Anemia, Anterior Dislocation of left Humerus, Arthritis, Hypothyroidism, Back pain, PUD (Peptic Ulcer Disease) and HTN. The following interventions were initiated on 7/27/23, with the exception of one added 8/10/23: Educate resident/family/caregivers of causative factors and measures to prevent skin injury. Identify/document potential causative factors and eliminate/resolve where possible. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. pressure reducing cushion to protect the skin while up in chair. Float Heels (initiated 8/10/23). Review of two Braden Scale assessments (tool used to determine risk for PU development; a lower score indicates a higher level of risk for PU development) documented on 7/28/23 (score of 11 = high risk) and on 8/10/23 (score of 13 = moderate risk). Review of R804's Skin & Wound Evaluation V7.0 assessment dated [DATE] documented, .Pressure .Unstageable: Obscured full-thickness skin and tissue loss .Location Right Heel .In-House Acquired .How long has the wound been present? .New .Staged by .In-house nursing .Wound Measurements .Area 12.5 cm2 (centimeters squared) .Length 5.6 cm .Width 3.2 cm .Depth Not Applicable .Exudate .Light .Serous . The remaining sections of this assessment for wound pain, orders, treatment, and notifications including practitioner/resident/responsible party/dietician/therapy were left blank (incomplete). There was no documentation available for review that any of the above disciplines or emergency contact had been notified of the significant change in R804's skin condition with two unstageable PU's. Further review of the progress notes revealed there were no skin/wound documentation included in the progress notes for the change identified on 8/9/23. Additionally, review of R804's physician orders for the treatments implemented once the PU's were identified on 8/9/23 revealed there was no treatment/interventions implemented until 8/10/23. Review of the two treatment orders for R804's PU's included: The first started on 8/10/23, Cleanse Bil. Heels with NS, pat dry, apply foam dressing, wrap with kerlix and secure with tape. Change every 3 days and PRN (as needed) if soiled/dislodged. As needed for if soiled/dislodged. There were no PRN treatments documented. The second started on 8/11/23, Cleanse Bil. Heels with NS (Normal Saline), pat dry, apply foam dressing, wrap with kerlix and secure with tape. Change every 3 days and PRN (as needed) if soiled/dislodged. In the morning every 3 day(s). Treatments were documented as completed on 8/11/23 and 8/14/23. Review of the physician/extender documentation included: An entry on 8/10/23 at 12:20 PM by Nurse Practitioner (NP 'D's) documented, .Patient seen and examined today for new bil (bilateral) Heel wounds. Patient observed in wheelchair .A&Ox2 on exam today .Pt (patient) has new bil heel wounds. + Drainage to R heel wound .Will + treatment and monitor .Discussed and agreed upon with [Name of Medical Director], Cont (Continue) wound care, monitor bil. Heel wounds . An entry on 8/16/23 at 3:00 PM by NP 'D' read, .Patient seen and examined today for f/u (follow-up) on bil. Heel wounds .Patient observed in wheelchair, in no acute distress. Awake and alert, Able to answer simple questions. A&Ox2 on exam today .Bil heels assessed. L (Left) heel with intact eschar cap, no s/sx (signs/symptoms) of infection at this time R (Right) heel with deep tissue injury; unable to visualize wound bed, not stageable at this time .Discussed and agreed upon with [Name of Medical Director] Cont wound care, monitor bil. Heel wounds . A phone interview was conducted with R804's first emergency contact. When asked about whether they had been notified of the resident's development of two unstageable PU's, they reported they were not, they found it out themselves when the went to ask the nurse why the resident had leaking on the bottom of their heels. They further reported they thought it was weird because weren't they supposed to change her stockings, and it wouldn't happen just like that. When asked if they could recall the specific date or name or nurse, they reported they were not sure but maybe a week or so ago. When asked if the resident had a history of skin breakdown, especially for those areas, the emergency contact reported there was no history of breakdown and they were worried about an infection now that the skin was broken. On 8/16/23 at 2:21 PM, an interview was conducted with the DON. When asked who was responsible for notifying the family/responsible party for changes in condition such as new skin breakdown, the DON reported it should be the nurse that identified the changes to the family and physician. When asked when would treatments be implemented upon identification of new PU's, the DON reported that should be done immediately as well as adding interventions to float heels and turn/reposition immediately. When asked why there were no treatment orders implemented until 8/10 and 8/11 when the wounds were identified on 8/9, the DON reported there should've been a treatment initiated on the day they were identified. The DON was asked to review the skin and wound evaluation from 8/9/23 with the missing documentation and confirmed the incomplete documentation. When asked what other disciplines should have been notified, the DON reported the Registered Dietician (RD) and would expect an evaluation within a day or so. The DON was informed there was no additional nutritional assessments or progress notes since an initial dietary assessment on 7/28/23. When asked if there is a change in skin condition, such as a new or worsening wound, where would that documentation be maintained, the DON reported usually they would get a picture, put in a treatment, the nurse notifies myself and I notify my people, but the nurse should write a note. The DON was unable to explain why this had not occurred for R804. When asked about the intervention added to float heels and what that meant specifically, given the observation of R804 seated in the wheelchair with their heels directly on the hard leg rests, the DON reported R804 frequently stayed in the wheelchair but they were not sure as you can't float heels in a wheelchair. When asked if there was a wound physician that consulted with the facility, the DON reported there was not, but that NP 'D' evaluated weekly. The DON further reported they monitored the wounds weekly via the dashboard (not available to surveyors) and they would go through the wound pictures to make sure treatments were appropriate. When asked if they had identified any concerns with R804, or previously such as during their quality improvement reviews, the DON reported they did not. On 8/16/23 at 3:05 PM, an interview was conducted with RD 'A'. When asked if they had been notified of R804's two unstageable PU's since 8/9/23, they reported they did not. When asked how they would be notified, RD 'A' reported usually in meetings held in the morning. When asked had they been notified, what alternate interventions might they have implemented for R804, RD 'A' reported they would have reviewed the food acceptance record, they would've interviewed the resident, watched her eat, maybe implement a multi-vitamin with minerals and maybe more protein or a supplement like prostat, mighty shake, or ensure. On 8/16/23 at 3:46 PM, the Administrator reported NP 'D' was no longer at the facility and provided their phone number to call. On 8/16/23 at 3:46 PM, NP 'D' was attempted to be contacted by phone, there was no answer, and a message was left to return the call. On 8/16/23 at 4:01 PM, a phone interview was conducted with NP 'D'. When asked when they were first notified of R804's two unstageable PU's, they reported they were notified the same day they first saw R804's wounds (8/10/23). When asked what interventions would they recommend implementing when new PU's were identified, NP 'D' reported they would always recommend pressure reduction. When asked how the facility was to provide pressure reduction when R804 is in wheelchair, NP 'D' reported the heels should have added protection such as a pillow and the order for the foam dressing might also help add cushion to that area and to encourage R804 to raise their legs up (to take pressure off of heels). NP 'D' was asked if they would consider additional supplements, they reported that would typically be something the RD would order and there should've definitely been a notification to do that. NP 'D' was informed that did not occur and reported it was unfortunate those breakdowns happened, but their goal was to maintain the wound and prevent infection.