**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #57: A review of the Electronic Medical Record (EMR) for Resident #57 (R57) revealed admission to the facility on 4/12/23 with a sacral stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone). A review of the Minimum Data Set (MDS) assessment dated [DATE] identified R57 as requiring maximal staff assistance with turning while in bed. R57 attended a wound clinic monthly for evaluation and treatment of the pressure injury. The MDS documented the use of a pressure-reducing device for R57's bed. A review of the care plan for R57 revealed a plan of care for impaired skin integrity. The care plan contained an intervention for a specialty air mattress to R57's bed. The care plans indicated R57 required extensive assistance with two staff assistance to reposition and turn in bed. On 2/27/24 at 8:15 a.m. and 3:23 p.m., R57 was observed in a back-lying position on a standard mattress. R57 was asked if the mattress on the bed was the same mattress used since admission. R57 responded, No - I don't have the good one anymore. A review of wound clinic notes revealed R57 was last assessed on 2/1/24. The wound clinic notes included an order for the use of a specialty bed/mattress for pressure-reduction. The order provided the name of a fluid immersion-simulation mattress or an air mattress to be used on R57's bed. On 2/28/24 at 10:42 a.m., the facility wound nurse, Licensed Practical Nurse F (LPN F), was observed completing a dressing change to R57's wound. The sacral wound was a stage 4 pressure injury measuring 7.1 cm x 5.4 cm x 6.8 cm with 4.0 cm of undermining (the destruction of tissue or ulceration extending under the skin edges). LPN F was asked why R57 did not have the mattress ordered by the wound clinic. LPN F said R57 used to be on a [name of a specialized mattress with air cell technology used for advanced wounds]. When asked the reason R57 was not currently on the air mattress, LPN F said R57 moved rooms from one unit to another unit and the mattress wasn't moved with R57. LPN F did not provide a response when asked why the air mattress wasn't moved when R57 was moved to a different unit. On 2/28/24 at 3:43 p.m., the wound clinic orders for a specialty mattress were reviewed by the DON. The DON agreed R57 should be on an air mattress and said the air mattress should have been moved when R57 was moved to another unit. The DON said the facility had air mattresses, but the mattresses were misplaced. The DON said they were attempting to locate the missing air mattresses. R57 was moved from the previous unit to the current unit on 12/23/23. Wound clinic orders on 12/4/23, prior to R57 moving to the current unit, included the order for R57 to be on a specialty bed/mattress for pressure reduction, either an air mattress or a fluid immersion-simulation mattress. The 'Skin Management' policy read in part . Guests/residents with wounds and/or pressure injury and those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Appropriate preventative measures will be implemented on guests/residents identified at risk and interventions are documented on the care plan. R57 was identified as being at high risk for pressure injury development. R57 scored 12 on a Braden scale (a tool used in health care to assess and document risk for developing pressure injuries). According to the 'Skin Management' policy section Appendix A Intervention Guidelines, residents with a Braden score of 12 require a pressure redistribution support surface placed on the bed. The 'Skin Management' policy section 'Attachments' included a mattress grid. The grid read [name of a specialized mattress with air cell technology] is good for residents with stage 3 & 4 [pressure injuries]. The NPIAP clinical practice guidelines (npiap.com) include in part: . Support surfaces are an important element in pressure injury prevention and treatment because they can prevent damaging tissue deformation and provide an environment that enhances perfusion of at-risk or injured tissue. support surfaces play a significant role in an individualized comprehensive management plan for pressure injury prevention and treatment. For individuals with existing full thickness pressure injuries (i.e., Category/Stage III or IV pressure injuries, unstageable pressure injuries and deep tissue pressure injuries), perfusion to injured tissue benefit from support surfaces with additional features (e.g., alternating pressure or air fluidized) . Specialty support surfaces to consider for individuals with a pressure injury include alternating pressure air mattresses, mattresses with a low-air-loss feature and air fluidized beds (Expert opinion) . Based on observation, interview, and record review, the facility failed to ensure necessary treatment and services to promote healing and prevent wound infection for two Residents (R57 & R71), out of four residents reviewed for pressure injuries. This deficient practice resulted in harm with delay and/or removal of recommended pressure relieving mattresses, delayed healing, and worsening of condition with the development of osteomyelitis for R71. Findings include: This deficiency pertains to Intake MI00140165. Resident R71 During a telephone interview on 2/22/24 at 4:19 p.m., Confidential Complainant C (a licensed, medical professional) expressed concern regarding the facilities failure to timely implement pressure injury interventions to promote healing. Complainant C stated, What the (specialty) wound clinic had ordered the facility has not implemented (timely) . [R71] went septic (extreme response to an infection) and was diagnosed with osteomyelitis (a serious bone infection) . I don't think [R71] would be in the condition [they] are in if [the facility] was putting dressings on [the] wounds, turning [R71] every two hours . The pressure ulcer went down to the bone and became infected. [R71] has an implanted PICC (peripherally inserted central catheter used for many types of intravenous (IV) antibiotics) and is starting a six-week course of antibiotics . [R71] went into the facility with this (sacral) wound but it has gotten progressively worse. Review of R71's Minimum Data Set (MDS) assessment, dated 12/19/2023, revealed R71 was admitted to the facility on [DATE], with active diagnoses that included the following, in part: Urinary tract infection (UTI) (Last 30 days), malnutrition, pressure ulcer of sacral region, Stage 4, need for assistance with personal care, muscle weakness, and morbid obesity. R71 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Section M0300. Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage revealed one (1) Number (Stage) 4 pressure ulcer, present upon admission, defined on the MDS assessment as Stage 4: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. During a telephone interview on 2/27/24 at 3:13 p.m., when asked about the specialty Wound clinics repeated recommendation for a pressure relieving mattress, Complainant C stated, [R71's] wounds were getting worse and worse not having the pressure relieving mattress that was ordered, lack of repositioning, lack of following wound care orders . I was concerned that R71 was going to get osteomyelitis. When asked if the facility appeared to begin to comply with wound clinic orders and recommendations near the time of R71's diagnosis of osteomyelitis, Complainant C stated, exactly! During an observation of wound care for R71 on 2/28/24 at 12:07 p.m., Registered Nurse (RN)/Wound Care Nurse F removed the dirty [Name Brand] sterile gauze from the interior of R71's sacral pressure injury. RN F sprayed wound cleanser unto two separate sterile 4 x 4's for cleansing of the interior of R71's pressure ulcer. RN F used a clean, gloved hand (not sterile) as she inserted her hand into the interior of R71's large Stage 4 pressure injury and attempted to wipe the entire inside surface of the wound with the two separate 4 x 4's. No wound cleanser was sprayed, irrigated, or rinsed inside of the wound. The surface of the wound was mechanically wiped in an attempt to cleanse the entirety of the Stage 4 wound. Undermining was noted to be present in the wound. RN F measured the wound on 2/28/24 at approximately 12:12 p.m., as: 8.4 cm (centimeters) length x 12.6 cm wide, depth of 5.1 cm, and 6.4 cm maximum undermining. During the continued observation of wound care, RN F packed sterile [Name Brand] rolled gauze into R71's Stage 4 pressure injury, by placing her hand, repeatedly inside of the wound as additional sterile gauze was placed inside the pressure ulcer. RN F applied an absorbent pad over the wound with only one piece of tape securing the pad on the top side of the wound. The absorbent pad edges were open on the side and the bottom, with a tail of the wound open to potential exposure by feces, as well as the packing of the sacral pressure injury. There was no barrier to prevent feces from contaminating the Stage 4 pressure injury or the open tail area of the wound. During an interview at this same time, RN F was asked when the APP (Alternating Pressure Mattress) was placed on R71's bed, RN F said she would have to check R71's medical record. During an interview on 2/28/24 at 12:36 p.m., RN F confirmed the Specialty Wound Clinic had recommended a low air low mattress to aid in healing R71's Stage 4 pressure ulcer. RN F reviewed R71's Care Plan and confirmed the care plan was revised to show the new mattress on 1/19/23. RN F acknowledged that was most likely the day that R71 received the pressure relieving mattress. RN F stated, Originally, we (facility) did not have a (pressure relieving mattress) at the time (of the Wound Clinic Order). As people (residents) come and go, and we had talked about ordering (a pressure relieving mattress), but I don't know where that happened. Review of the Specialty Wound Clinic Progress Note Details for R71, provided by the facility revealed the following visit details: 10/5/23: This information was obtained from the Patient (R71) .[admitted ] 9/13/23 to [Facility Name] on PO (oral) Vanco (vancomycin), which has been completed. The wound VAC (vacuum) had been used up until October 3, when the nursing home decided to discontinue it and switch to wet-to-dry dressings with Dakin's (wound solution). Per [Family Member (FM)] who is a nurse and is present at the bedside and patient, there were not enough staff trained in how to use the wound VAC and once she got to the nursing home, they had repeated problems keeping it on and to suction. Since being admitted to the nursing home, she has unfortunately developed multiple satellite areas of breakdown has non-blanchable redness to purpuric changes to the skin on bilateral buttocks/perineal area. Patient reports she has to call the staff requesting to be turned. She has a regular mattress . Wound VAC to be reapplied by nursing home. Contact [Name] if education is needed. App (alternating pressure mattress)/Dolphin mattress needed. Reposition every 2 hours . Recheck in 3-4 weeks. Wound Assessment (10/5/23) of the Coccyx, Stage 4 Pressure Injury Pressure Ulcer measurements are 7.8 cm length x 7 cm width x 8 cm depth, with an area of 54.6 sq (square) cm and a volume of 436.8 cubic cm. No tunneling, sinus tract, or undermining was noted. Wound Orders from the wound clinic on 10/5/23 included the following for the Stage 4 pressure injury: .Off-Loading (of pressure): Specialty Bed/Mattress for Pressure Reduction: Alternating pressure relief mattress. Turn every 2 hours. Avoid direct pressure over wound site while limiting side lying position to 30-degree tilt and/or HOB (head of bed) elevations to 30 degrees in bed . Negative Pressure wound Therapy: Wound VAC negative 125 mmHg Continuous - Black foam to wound bed, assuring that no foam is touching good skin. Cover with drape. Track to patients left flank area if tolerated. Change 3x/week. 10/27/23 Wound Clinic Progress Note: .Wound VAC supplies were not sent (by the facility) with the patient (R71) and our supplies are not compatible with the NPWT (Negative Pressure Wound Therapy) device the patient has .Patient still has not received an APP pressure relieving mattress, stating this was not ordered, but review of orders sent 10/5/23 show this was included with the orders. Today, orders faxed and printed, highlighted, and sent with patient. Staff should call with questions . Recheck in 1 month. 12/7/23 Wound Clinic Progress Note: The sacral wound is measuring larger with new breakdown along the right lateral margin. The wound VAC is not in place. A week after the prior visit a staff member called to let us know the VAC was leaking and having other issues, so they decided to discontinue it. The patient still does not have an APP or comparable pressure-relieving mattress. FM reports .told by staff at [Facility Name] that it was 'too expensive' . A wound VAC remains the best option for the wound and order will be sent to reapply this. Patient still needs APP mattress . 1/15/24 Wound Clinic Progress Note: Pt (patient) returns for recheck of sacral pressure ulcer . [R71] has developed new breakdown around the sacral wound and has a slough and eschar-covered wound to the left buttock. The sacral wound is with significant slough, new undermining from 6:00 - 11:00, sacrum can be felt at the base of the wound, and there is new tunneling within the wound bed around 8 o'clock and 11o'clock. There is tissue necrosis along the wound edges where the undermining is greatest .The nursing home is not able to continue with the wound VAC and their local provider gave orders to hold it due to worsening wound. A culture of the wound was taken, and patient was placed on Vanco and Rocephin (strong antibiotics). Will request culture results. [FM] is present and reports MRSA and e. coli were both present . She is still on a regular mattress and family is still being told a new one will not be purchased as she is on a wait list for transfer to a different facility once a bed becomes available. [R71] reports not being repositioned side to side to keep her off the sacral area more than a few times in a 24-hour period, and repositioning is limited to placing a pillow under her back. Encouraged to set an alarm on her phone for every 2 hours and to call out for assistance with repositioning if this is not occurring .I am concerned about new bone exposure, tissue necrosis, and tunneling toward new wound. Imaging for further evaluation and evaluation of osteomyelitis is recommended. I do still think the wound VAC is the best option for wound care and encouraging some granulation . Review of a 2/7/24 MRI (Magnetic Resonance Imaging) of R71's sacrum without contrast Patient Communication revealed the following, in part: FINDINGS: There is a large soft tissue ulceration overlying the distal sacrum measuring 7.4 cm (centimeters) craniocaudal by 7.6 cm transverse by 2.5 cm in depth. There is surrounding inflammatory thickening of the adjacent fat and soft tissues. Inflammatory changes extend into the sacral spinal canal . In addition to spinal canal involvement, there is abnormal marrow signal involving the first and second coccygeal segments, consistent with osteomyelitis .IMPRESSION: 1. Large soft tissue ulceration overlying the sacrum . osteomyelitis of the upper coccygeal segments, and presacral soft tissue edema . The report was noted on 2/9/24, with IV Vancomycin for six weeks and IV Rocephin prescribed in the physician handwriting on the document. Section M1200. Skin and Ulcer/Injury Treatments (check all that apply), included the following: pressure reducing device for chair, pressure reducing device for bed, nutrition or hydration intervention to manage skin problems, pressure ulcer/injury care, application of nonsurgical dressings and applications of ointments/medications . Of note, C. Turning/repositioning program was not checked to show R71 was participating in a structured turning and repositioning program for pressure ulcer treatment for the Stage IV sacral pressure injury. Review of R71's POC (Plan of Care) Response History for ADL (activities of daily living) from 2/14/24 through 2/27/24, documented the provision of routine standard care which includes evaluating skin daily and reporting changes . turning and repositioning . Certified Nurse Aide (CNA) staff were to document once per shift confirming they had provided that routine standard care for R71. Review of the 14-day period revealed 6 days out of the 14-day period had undocumented shifts for turning and repositioning as specified in the routine standard care. During an interview on 2/27/24 at 8:27 a.m., R71 was observed sitting in bed at an approximate 30-degree angle. When asked about wound care interventions provided by the facility, R71 said the facility did not always turn and reposition her every two hours and commented that she did not routinely refuse turning and repositioning. An IV pole for administration of antibiotics was observed on the right, exit side of R71's bed, and a PICC line was visible on R71's right arm. When asked about a mattress to distribute pressure on the Stage IV (four) sacral wound, R71 stated, It is an air mattress, but it is not plugged in (to an electric outlet) or anything. When asked how long she had the new pressure distribution mattress, R71 stated, I have had it for about a month, maybe a little more. When asked about the facility follow through with the specialty wound clinic recommendations, R71 stated, The Wound clinic would comment about my bad care (at the facility), and they would write a recommendation about the care they wanted me to receive . Review of R71's Care Plan History Report (showing all care plan intervention changes), revealed the following pressure ulcer interventions, in part: 9/13/23 (admission Date): Pressure reduction mattress to bed. Date Initiated: 9/13/23. Revision on 1/19/24 to [Name Brand] mattress in place for pressure redistribution. Resolved on 2/26/24 (at time of recertification survey): Frequently turn/reposition [R71] in shorter periods at a 30-degree angle to relieve pressure and PRN (as needed.) [R71] often allows a pillow to be placed at her side, however, [R71] does not allow the pillow to be placed to offload pressure adequately and likes it to be placed more for comfort. Date Initiated: 10/19/2023, Resolved Date: 2/26/24. Initiated 2/26/24 (during survey): Turn q (every) 2 hr., avoid direct pressure over the wound site while limiting the side-lying position to 30-degree tilt &/or HOB elevation to 30 degrees in bed. Use pillows for positioning. During an interview on 2/28/24 at 5:30 p.m., the Director of Nursing did acknowledge the Wound clinic did recommend a new pressure relieving mattress for the resident (R71) as early as 10/5/23, and a mattress was not placed on R71's bed until 1/19/24. The mattress was taken off of a bed in a hall being renovated and placed on R71's bed. No action was taken by the facility for three months, although a pressure relieving mattress was ordered (recommended) every visit at the wound clinic. When asked how the DON would have packed sterile gauze into R71's Stage 4 sacral pressure injury, the DON stated, I would have used a sterile, cotton-tipped applicator. When asked about using two sterile 4 x 4's sprayed with wound cleanser, to insert your hand into the wound and mechanically rub the areas of the wound you could access as a method of wound cleaning, the DON said she would spray the wound cleanser into the wound and did not think that the mechanical rubbing of the wound would cleanse all aspects of the deeply undermined pressure ulcer. The DON acknowledged the concerns regarding the potential for continued fecal contamination of both the main Stage 4 sacral wound and the tail on the sacral wound. Review of the Skin Management policy, dated 12/15/2022, listed the National Pressure Ulcer Advisory Panel (NPUAP) Guidelines in the 'Cross-References' section of the policy. The NPUAP changed its name to the National Pressure Injury Advisory Panel (NPIAP) in 2019. The NPIAP Clinical Practice Guidelines (npiap.com) provide standards for cleansing wounds. The guidelines included in part . Apply cleansing solution with enough pressure to cleanse the wound bed without damaging tissue or driving bacteria into the wound, generally between 4 and 15 pounds per square inch (Expert opinion) . irrigation pressure between 4 and 15 psi should be adequate to clean the surface of the pressure injury without causing trauma to the wound bed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is linked to intake #MI00139805 Based on observation, interview, and record review the facility failed to care for multiple pressure wounds according to physician orders for three Residents (R4, R5, & R6) out of three residents reviewed for pressure ulcer care. This deficient practice resulted in R6 developing infection, deterioration of pressure wound, hospitalization, wound debridement, and sepsis. Findings include: Resident #6 (R6) Review of R6's progress note, dated 7/12/23 at 10:46 AM, read in part, Nursing noticed during morning medication pass that patient was difficult to arouse. Resident will fall asleep suddenly during conversation . (Providers name) notified of patient's current condition. Advised to continue to monitor. Review of R6's progress note, dated 7/12/23 at 12:01 PM, read in part, .Writer in to assess, will only arouse with deep sternal rub, very weak and lethargic .New orders obtained for x-ray of coccyx to rule out osteomyelitis . Review of R6's progress note, dated 7/12/23 at 6:28 PM, read in part, .Patient has noted spitting up some clear thick mucus from her mouth. Review of R6's progress note, dated 7/12/23 at 9:05 PM, read in part, .O2 (oxygen saturation) was taken and found to be at 75-80%. Oxygen was increased to 4 liters and O2 was 100%. Pupils were dilated and unresponsive. On call was notified, and the resident was sent to the ER (emergency room). Review of R6's skin and wound evaluation, dated 4/12/23, revealed, Wound type, open lesion, coccyx fistula, measured 1.5 cm (centimeter) x 0.5 cm x 1.5 cm, present on admission. According to the MDS (Minimum Data Set) assessment dated , 4/19/23, R6 was cognitively intact, non-ambulatory and required extensive assistance with mobility, with diagnoses including weakness, chronic pain, pressure ulcer stage 4, urinary incontinence, and obesity. Review of R6's skin and wound evaluation, dated 4/20/23, revealed, Wound type, open lesion, coccyx fistula, measured 0.4 cm x 0.2 cm x 1.9 cm, and was noted to be deteriorating. Review of R6's skin and wound evaluation, dated 5/4/23, revealed, Wound type, MASD (moisture associated skin damage), sacrum, measured 7.7 cm x 5.2 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 5/11/23 measured 9.3 cm x 7.0 cm, b. On 5/18/23 measured 8.6 cm x 8.2 cm, c. On 5/25/23 measured 7.3 cm x 5.5 cm with eschar. The Physician order, dated 5/4/23, revealed, Sacral unstageable: cleanse with wound cleaner, pat dry, apply Medi honey to gauze and then apply to wound bed, cover with (brand name foam dressing), every shift for MASD. Review of R6's TAR (treatment administration record), dated 5/4/23 through 5/25/23, revealed, wound care was not performed on the 10th during day shift and on the 13th, 14th, 15th, 16th, 21st, 22nd, and on the 25th during evening shift. Review of R6's provider progress note, dated 5/19/23 at 12:00 AM, read in part, .Wound has improved slightly overall but unfortunately the (sic) are is consistently soaked with urine which is impeding healing .Addendum Details: Wound .Dressing intact, however saturated with urine. Staff provided education on urinary incontinence, frequent changes, and turning and repositioning every two hours side to side while in bed .Wound nurse to initiate unavoidable pressure injury tool .Addendum created date: 5/29/2023 at 1:16 PM. *Note: This addendum was placed after the resident was admitted to the hospital on [DATE] and ten days after the originally dated 5/19/23 progress note. Review of R6's progress note/resident at risk (Managerial Review Meeting), dated 5/23/23 at 1:52 PM, read in part, .A number of educational attempts have been made with resident for education on turning and repositioning side to side, getting up in wheelchair, and allowing more frequent changes . *Note: No nursing notes or other documents were provided as requested to show documentation regarding R6 refusal of cares. Review of R6's progress note, dated 5/25/23 at 7:17 PM, read in part, Writer entered resident's room at 6:00 PM with dinner medications, resident was lethargic, difficult to arouse. Writer was able to arouse her, resident was only oriented to person .not able to answer questions .PCP (primary care physician) was notified .order to her resident sent to (local) ER for evaluation . Review of R6's local hospital ER provider note, dated 5/25/23, read in part, Patient has noted redness bilateral buttocks .bilateral redness to buttocks and coccyx are high suspicion for acute infection . Review of R6's progress note, dated 5/25/23 at 11:59 PM, read in part, Call received from (local) ER regarding resident status .resident will be transferred to (out of state hospital) for sepsis. Review of R6's hospital records, dated 5/26/23 through 6/2/23, revealed, an elevated white blood cell count, initiation of two different antibiotics, wound debridement, and a wound vac (a wound vacuum device that uses negative pressure to assist with wound healing). Review of R6's census, revealed she was readmitted to the facility on [DATE]. Review of R6's skin and wound evaluation, dated 6/16/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 11.8 cm x 9.6 cm x 5.5 cm, and undermining 4.2 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 6/29/23 measured 10.7 cm x 8.2 cm (lacked documentation of depth and undermining). Review of R6's care plan, dated 6/13/23, read in part, .is at risk for impaired skin integrity/pressure injury related to .pressure injuries, pain, decreased mobility .follow facility policies/protocols for the prevention/treatment of impaired skin integrity, observe dressing frequently to ensure it is intact and adhering, report loose dressing to nurse .provide incontinence care with each incontinent episode and as needed . The Physician order, dated 6/14/23, revealed, Change wound vac Monday, Wednesday, and Friday. Clean with wound cleanser, one time a day every Mon, Wed, Fri for wound. Review of R6's TAR, dated 6/14/23 through 6/28/23, revealed, wound care was not performed on the 19th and the 28th and marked 5 which indicated hold and see nurses note. *Note: No notes could be found to describe why the dressing was held on these dates. Review of R6's skin and wound evaluation, dated 7/6/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 9.5 cm x 8.4 cm x 6.8 cm, and undermining 3.3 cm. Review of R6's hospital records, dated 7/13/23 through 7/27/23, read in part, .admitted on [DATE] with fevers, bradycardia and hypotension, and lethargy, requiring intubation .If wound vac is off for more than 2 hours, the dressing should be removed and packed with dakins (wound bleach solution used to clean out the wound bed) 0.25% moistened gauze, and covered with ABD (abdominal pad dressing). This should be changed daily until vac can be reapplied .Acute medical issues: septic shock - secondary to either UTI (urinary tract infection) versus stage 4 sacral decubitus ulcer POA (present on arrival) . finished 5 day course of levofloxacin (antibiotic) . Review of R6's census, revealed she was readmitted to the facility on [DATE]. The Physician order, dated 8/9/23, revealed, Change wound vac Monday, Wednesday, and Friday. Clean with normal saline, pat dry, and apply new wound vac dressing .one time a day every Mon, Wed, Fri for coccyx wound. Review of R6's skin and wound evaluation, dated 8/17/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 9.8 cm x 7.9 cm x 4.1 cm, and undermining 4.3 cm, and noted to be deteriorating. Further skin and wound evaluations were as follows: a. On 8/24/23 measured 7.7 cm x 6.3 cm x 4.0 cm, and with undermining of 3.2 cm. Review of R6's TAR, dated 8/8/23 through 8/19/23, revealed, wound care was not performed on the 11th during day shift. The Physician order, dated 8/22/23, revealed, Change wound vac Tuesday, Thursday, and Saturday. Clean with normal saline, pat dry, and apply new wound vac dressing .one time a day every Tue, Thu, Sat for coccyx wound. Review of R6's TAR, dated 8/22/23 through 8/31/23, revealed, wound care was not performed on the 22nd and the 31st during the day shift and marked 5 which indicated hold and see nurses note. The Physician order, dated 9/1/23, revealed, Sacral ulcer: cleanse with Dakin's solution, packed with dampened Dakin's gauze. Cover with ABD pad with tape to affix. Place dry gauze between anus and wound dressing to serve as a barrier for fecal matter, every shift for pressure ulcer (once every 12 hours). Review of R6's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 10th, 13th, 20th, 24th, and the 27th during the day shift and marked at 7 which indicated sleeping on the evening shift the 2nd, 3rd, and the 17th. Review of R6's skin and wound evaluation, dated 9/8/23, revealed, Wound type, stage 4 pressure ulcer, sacrum, measured 10.6 cm x 9.1 cm x 6.5 cm, and undermining 5.2 cm. Review of R6's TAR dated 10/1/23 through 10/10/23, revealed wound care was not performed on the 5th during day shift and marked 5 which indicated hold and see nurses note. Review of R6's progress notes, in the EMR (electronic medical record), dated 4/12/23 through 10/10/23, revealed no nursing notes as to why the wound dressing was incomplete. Review of R6's MDS's, dated 4/19/23, 5/25/23, 6/19/23, 7/12/23, 8/14/23, and 8/23/23, all revealed, section E behaviors, E800 Rejection of care: None exhibited. On 10/10/23 at 9:50 AM, an interview was conducted with R6. R6 was asked if staff reposition her every two hours and replied, Sometimes staff reposition her, but not always they are busy. On 10/10/23 at 3:50 PM, an observation was made of R6's wound care completed by LPN (Licensed Practical Nurse) C and the DON (Director of Nursing) assisted. R6's sacral area had some granulated tissue and some slough. R6's incontinence pad had a ring around the top half that was yellowish brown in color and appear to be either old, dried urine or serosanguinous drainage from her sacral wound. The DON was asked if she could see the ring on the incontinence pad and replied, Yes. The DON was asked if she felt that the ring should be on the pad and replied, No. We will change it after we are done doing her dressing change. On 10/11/23 at 8:30 AM, an interview was conducted with R6. R6 was asked how her night went and replied, I went to bed around one this morning. R6 was asked when she was awakened or last seen staff after she had fallen asleep and replied, It was around four this morning. My catheter was leaking last night, and they were in to change me around four. R6 was lying in her bed on her right side. On 10/11/23 at 11:30 AM, an observation was made of R6 in her room lying in her bed and remained on her right side in the same position for three hours. On 10/11/23 at 11:45 AM, an interview was conducted with the DON. The DON was asked about the wound dressing changes on the TARs and if there should be any blank spots on them and replied, No. The TARs should not have any blank spots on them and if they do then the nurse should write a progress note explaining why the wound dressing change was incomplete. The DON was asked if any wound dressing changes should be missed with an additional order scheduled as needed and replied, No. The 'as needed' gives nurses extra dressing changes for times when the first dressing change was missed, the dressing becomes loose, or is soiled. Resident #4 (R4) According to the MDS assessment dated , 4/28/23, R4 was non ambulatory and required extensive assistance with mobility, with diagnoses including end stage renal disease, diabetes mellitus, chronic pain, and arthritis. Review of R4's skin and wound evaluation, dated 10/5/23, revealed, A stage 3 pressure ulcer, right heel, measured 4.0 cm x 2.4 cm x 0.3 cm, with an initial start date of 7/6/23. *Note initially wound started on 7/6/23 and was a reddened area measuring 2 cm x 2 cm and later declined. Review of R4's care plan, dated 7/6/23, read in part, .has an actual impaired skin integrity related pressure ulcer right heel .treatment as ordered. The Physician order, dated 7/24/23, revealed, Right heel: clean with wound cleanser, dry, apply skin prep, each shift (twice daily), and leave open to air. Float heel. Review of R4's TAR, dated 7/24/23 through 7/31/23, revealed, wound care was not performed on the 25th or the 27th during day shift. The physician order, dated 8/3/23, revealed, Right heel: clean with wound cleanser, dry, apply gauze and wrap with kerlix and tape, every shift (twice daily). Review of R4's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on 8th, 10th, or on the 13th during day shift, and on the 16th during evening shift. The physician order, dated 8/19/23, revealed, Right heel: clean with wound cleanser, dry, apply Medi honey to gauze, apply gauze to wound bed, and wrap gently with kerlix and tape, every shift (twice daily). Review of R4's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on 21st, 23rd, 26th, 27th, or on the 28th during day shift. The physician order, dated 8/29/23, revealed, Right heel: clean with wound cleanser, dry, apply Medi honey to gauze, apply gauze to wound bed, and wrap gently with kerlix and tape, every day-on-day shift. Review of R4's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on 1st, 5th, or the 6th, and on the 7th signed out as 5 (which indicated hold see nurses note), or on the 25th marked as 3 (which indicated absent). *Note R4 also had another physician order for the same wound care as needed which was not documented as completed for the same days the routine wound care was not signed out as completed daily. Review of R4's TAR, dated 10/1/23 through 10/10/23, revealed, wound care was not performed on the 5th. Review of R4's progress notes, in the EMR, dated 7/24/23 through 10/10/23, revealed no nursing notes to explain why the wound dressing changes were not electronically signed as completed. On 10/10/23 at 3:30 PM, an observation was made of R4's wound care completed by LPN C and assisted by the DON. R4's right heel was open with some slough and eschar. LPN C cleaned R4's right heel and applied the treatment per physician orders. Resident #5 (R5) According to the MDS assessment dated , 3/31/23, R5 was non-ambulatory and required extensive assistance with mobility, with diagnoses including chronic pain, contractures of the hand and ankle, and quadriplegia (paralysis of all four extremities). Review of R5's skin and wound evaluation, dated 9/28/23, revealed, Pressure stage 4, right trochanter, in house acquired, 1.0 cm x 1.8 cm x 0.9 cm, with undermining 1.3 cm, with an initial start date on 10/20/21. Review of R5's care plan, dated 3/17/23, read in part, .has an actual impaired skin integrity related to pressure injury to right trochanter and left medial plantar foot .conduct skin assessment weekly and measure area(s) and document .treatment as ordered. The Physician order, dated 2/17/23, revealed, Right trochanter: cleanse with wound cleaner, pat dry. Place collagen crystals to undermining and to wound bed, cover crystals with one layer of calcium alginate. Cover with optifoam (dressing), every, day shift for pressure injury. Review of R5's TAR, dated 7/1/23 through 7/31/23, revealed, wound care was not performed on the 1st, 3rd, 5th, 7th, 11th, 15th, 16th, 21st, 25th, 27th, and on the 29th during day shift. Review of R5's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on the 8th, 9th, 10th, 12th, 17th, and on the 26th during day shift. Review of R5's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 6th, 15th, and on the 22nd during day shift. Review of R5's TAR, dated 10/1/23 through 10/10/23, revealed, wound care was not performed on the 5th during day shift. The Physician order, dated 7/6/23, revealed, Left plantar aspect of left great toe and right lateral aspect of foot: cleanse with wound cleanser, pat dry, apply ski prep and attempt to keep pressure off. Review of R5's TAR, dated 8/1/23 through 8/31/23, revealed, wound care was not performed on the 8th, 9th, 10th, 12th, 17th, and on the 26th during day shift. Review of R5's TAR, dated 9/1/23 through 9/30/23, revealed, wound care was not performed on the 6th during day shift. Review of R5's progress notes, in the EMR, dated 7/1/23 through 10/10/23, revealed no nursing notes to explain why the wound dressing changes were not electronically signed as completed. On 10/10/23 at 4:15 PM, an observation was made of R5's wound care completed by LPN C and assisted by the DON. R5's right trochanter was open and undermined with granulated tissue. R5's left great medial wound was dry with eschar and dressing removed was dated 10/8/23. R5 wore an adult brief and his brief was noted to be soiled in the back and in the front the wetness indicator was indicating wetness. *Note foot dressing was overdue to be changed and noted to be signed out as completed on 10/9/23 and the nurses who performed the dressing change did not change his brief, they just reapplied the brief as it was. Review of facility policy titled, Clean Dressing Change, dated 9/18/23, read in part, 1. Check physician order for current, correct treatment .16. Document treatment given and wound/site appearance and changes in nurses' notes and elsewhere as needed. Review of facility policy titled, Skin Management, dated 7/14/21, read in part, Policy: It is the policy that the facility should identify and implement interventions to prevent development of clinically unavoidable pressure injuries .4. Guest/residents admitted with any skin impairment will have: Appropriate interventions implemented to promote healing. A physician's order for treatment .5. The licensed nurse will initiate documentation in the electronic health record (EHR), which includes a description of the skin impairment as follows: In the EHR facilities, the licensed nurse will document on the skin and wound evaluation for pressure injury and vascular ulcers. Document weekly until the area is resolved .9. The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record .