**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent, assess, treat, and avoid worsening of a pressure ulcer which resulted in the development of cellulitis within a stage 2 pressure ulcer. These deficiencies resulted in worsening of a stage 2 pressure ulcer into a stage 4 pressure ulcer, additional multiple stage 2 pressure ulcers to develop, required hospitalization, and provided for the increased likelihood of serious complications including sepsis, further hospitalization, and death for one Resident (Resident #10) of two residents reviewed for pressure ulcers. Findings include: Resident #10 was admitted on [DATE] to the facility without pressure ulcer on his left buttocks. Resident #10 developed multiple stage 2 pressure ulcers on 4/28/23 including both buttocks. Resident #10 subsequently developed cellulitis in one of the pressure ulcers, was sent to the hospital on 5/17/23. While at the hospital Resident #10 required surgical debridement, additional antibiotics, and a wound vac. On 9/28/23, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were notified of the Immediate Jeopardy that began on 5/10/23, when R10 developed a facility acquired pressure ulcer, that worsened to a stage 4 pressure ulcer, leading to hospitalization, antibiotics, and surgical intervention. The Surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 9/29/23 at 2:15 PM, but noncompliance remained at the lower scope and severity of potential for harm that was not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Resident #10 (R10) Review of a Face Sheet revealed R10 was originally admitted on [DATE], with pertinent diagnoses of diabetes mellitus, muscle weakness, and open wounds to bilateral feet. Review of R10's admission Minimum Data Set (MDS) assessment, dated 4/18/22 revealed a risk for developing pressure ulcers and R10 had an existing stage 2 pressure ulcer. A subsequent five-day MDS for R10, dated 6/8/22 revealed an existing stage 2 pressure ulcer and the development of two additional stage 2 pressure ulcers. R10 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15/15. Review of R10's admission Assessment, completed 4/13/22, reflected a clinical note .Patient's skin is with issues. Bilateral feet have dressings that were completed prior to patient's hospital discharge 4/13/22. Feet have erupted bolus (sic) related to edema . Review of R10's Clinical Note, dated 4/14/22, read in part, Resident admitted to the facility with a stage 2 pressure ulcer to coccyx measures 2 x 2 x 0.1 . (Note: Did not specify unit of measurement.) Review of R10's Clinical Note, dated 4/15/22, read in part, .notified of an open area just below patient's right buttock 2.6 x 1 cm (centimeter) sheered open area . Review of the Care Plan for R10, date printed 9/27/23, read in part, Problems: .is at risk for alteration in skin integrity .range of motion deficit .bowel incontinence, Foley catheter .non-ambulatory .Interventions: 2 assist with bed mobility/repositioning during care rounds and as needed .Observe skin integrity during cares, bathing/showers and weekly skin checks for signs and symptoms of alterations and report accordingly .treatment to right buttock pressure ulcer as ordered .Foley catheter to aid in wound healing . Review of R10's Braden Scale (a tool used to predict the likelihood of a resident to develop a pressure ulcer), dated 4/18/23, reflected R10 was at risk for developing a pressure ulcer. Review of R10's Physician Orders, dated 4/14/22 through 9/27/23, revealed orders for Clear Zinc Barrier Cream, to buttocks, start date 4/14/22 through 1/18/23. A second order for Magic Butt Cream, to buttocks, had a start date 1/19/23 through 5/18/23. On 9/27/23 at 8:30 AM, an interview was conducted with R10 who was lying in bed on his back. R10 was asked about any skin conditions on his backside and confirmed he did have a stage 4 pressure ulcer to his right buttock. R10 had an observed wound vac (a type of therapy for wounds) powered on at the bedside on the nightstand with the tubing from the wound vac leading to R10's buttock area. The wound vac, per R10 was making a lot of racket. An observation was made of the wound vac, which indicated an improper seal and was fluctuating pressure from 65 to 125 millimeters of mercury (mmHg) on the screen. The wound vac canister was a third full of serosanguinous drainage from R10's stage IV pressure ulcer. R10 stated he had additional sores on his left buttocks. On 9/27/23 at 8:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) D, who was asked if R10's wound vac was working properly and replied, I need to take a look at the dressing, but it sounds like the dressing is not properly sealed. On 9/27/23 at 12:00 PM, an observation was made of R10 sitting up in his wheelchair in his room. On 9/27/23 at 2:15 PM, a second observation was made of R10 sitting up in his wheelchair in his room. (Note: Remained in the same position and was not offered repositioning or off loading during this time or reminded to make small positioning changes while up in his wheelchair.) On 9/27/23 at 2:30 PM, an observation was made of R10's pressure ulcers to his bilateral buttock with Registered Nurse (RN) A and LPN D. LPN D had already removed all R10's dressings and cleaned his wounds. R10 was lying in bed on his right-side with his back side exposed. RN A did measurements as follows: a.) Left upper buttock, stage 2, measured 4.9 x 3.8 cm, and appeared yellow base tissue, b.) Left lower buttock, stage 2, measured 2.5 x 1.3, and appeared yellow base tissue, c.) Sacral mid, stage 2, measured 1.5 x 0.8 cm, and appeared yellow base tissue, d.) Right mid buttock to the 7 to 11 o'clock side of the stage 4 pressure ulcer a C shaped stage 2 mostly pink and open in the middle portion with a yellow base tissue and measured 0.5 cm, e.) Right buttock gluteal cleft, stage 4 (with wound vac), measured 6.5 x 5 x 4.3 cm depth, on the boarder dark purple portions at 1 - 11 - and 9 through 7 o'clock, and in the wound bed slough was noted, f.) Right buttock distal to the stage 4 in the 12 to 2 o'clock area, measured 5.5 x 5.5 unstageable circular area covered in patched of dark purple, yellow, and red in various portions. Review of facility Wound Care Log, no date, page one revealed R10 had five facility acquired wounds as follows: a.) Stage 2 on to left lower buttock, started on 3/3/23, and measured 2 x 2, b.) Stage 2 on right lower buttock, started on 3/3/23, and measured 3 x 3, c.) Split in gluteal cleft right side, started on 3/3/23, and measured 4 x 0.5, d.) Stage 2 left center buttock, started on 3/10/23, and measured 2 x 2, e.) Stage 2 right center buttock, started on 3/10/23, and measured 2 x 2. Review of R10's Long Term Care Physician Progress Note, dated 3/8/23 lacked any documentation of facility acquired stage 2 pressure ulcers or any new orders related to treatment of the pressure ulcers. On 9/28/23 at 10:00 AM, an interview was conducted with RN A, who was asked about R10's pressure ulcers. RN A stated that she and the DON recently took over wound care monitoring and management in the last two weeks. RN A confirmed R10 had some facility acquired pressure ulcers on his buttocks. RN A confirmed R10 had two stage 2 pressure ulcers on his left buttock and one stage 2 and a stage 4 pressure ulcer that were all facility acquired that started the end of April 2023. Further interview with RN A confirmed she and the DON took over wound care and management related to inconsistencies related to wound care measurements (not having unit of measurement in documentation and not completed weekly), interventions, lack of physician oversight, and communication with the physician regarding pressure ulcer care. RN A also confirmed the prior wound care nurse was not certified. On 9/28/23 at 10:30 AM, a policy for pressure ulcer care was requested. This surveyor was notified that the facility did not have a policy specific to pressure ulcer care and the only policy the facility had was titled, Wound Treatment Management. Review of the Census tab for R10, revealed an admission to the hospital on 5/17/23 through 5/23/23. Review of R10's Weekly Skin Assessments, dated from 2/6/23 through 5/15/23, revealed a single question, Did you notice any new skin issues? All R10's weekly skin assessments were answered with a No. Review of facility Wound Care Log, no date, page two revealed R10 had three facility acquired wounds as follows: a.) Stage 2 left buttock, started on 4/15/23, and measured 1 x 1, b.) Stage 2 left buttock, started on 4/28/23, and measured 1.5 x 1.5, c.) Stage 2 right buttock, started on 4/28/23, and measured 2 x 2. Review of R10's Clinical Note, dated 4/16/23, read Resident has a new stage 2 pressure ulcer to left buttock which measures approximately 1 x 1 with wound bed having pink granulation present, no odor or drainage noted, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, will continue with .magic butt cream . Review of R10's Clinical Note, dated 4/19/23, from Certified Dietary Manager (CDM) B read in part .Left buttocks pink, sheared, small open area per nursing notes. Resident with level 7 diet with variable food average 50-100% with most meals 100% .multi-vitamin everyday ordered for resident to facilitate healing. Will monitor status ongoing. Review of R10's Clinical Note, dated 4/28/23, read in part Resident has a new stage 2 pressure ulcer to left buttock which measures approximately 1.5 x 1.5 with wound bed having pink granulation present, no odor or drainage noted, there is a new stage 2 pressure ulcer to right buttock that measures 2 x 2, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, also a lot of scar tissue present in gluteal cleft will continue .magic butt cream . Review of R10's Clinical Note, dated 5/4/23 at 6:38 AM, read in part Notified by Certified Nurse Aide (CNA) of change in wound status from pink to red .per communications from management, notified on-call provider of change in patient status. Wound was reddened, hot, firm to touch, and painful when pressed per resident .probable cellulitis (a bacterial infection of the skin), started on amoxicillin and doxycycline .Nurse Practitioner (NP) stated need for follow-up and further monitoring by wound care nurse and day providers . Review of R10's Long Term Care Progress Note, from NP F dated 5/4/23, read in part Encounter info: Cellulitis; called by nursing in regards to concerns for possible cellulitis on the right hip, patient has what appears to be a pressure sore on the right gluteal fold, redness noted above that wound appears to be cellulitis. Reddened area is warm to touch, no fluctuance felt .Plan: .started on amoxicillin twice daily and doxycycline twice daily for 5 days. Wound care to evaluate patient for open wound and provide interventions .Patient will need follow-up to ensure resolution. Review of R10's Clinical Note, dated 5/4/23 at 3:14 PM, read in part, .he continues oral antibiotics for cellulitis .redness noted to right hip .there is an area that is firm, warm to the touch more erythematous than the other areas .the DON observed the area .Magic butt cream applied to buttocks per order .will continue to monitor for changes. Probiotic order was processed . Review of R10's Clinical Note, dated 5/6/23, read in part .magic butt paste applied to buttocks, open area with shearing present .will continue to monitor. Review of R10's Clinical Note, dated 5/9/23, read in part .Magic butt cream applied to buttocks per order .there is an area that is firm, warm to the touch more erythematous (and blanchable) on his right hip/butt .doctor was in to assess cellulitis today and extended his antibiotics .and also ordered a foley catheter to help promote wound healing to his buttocks, as he is incontinent .will continue to monitor for changes. (Note: No physician documentation dictated regarding the visit.) Review of R10's Clinical Note, dated 5/12/23, read in part Resident continues with stage 2 pressure ulcer to left buttock which measures approximately 1.5 x 1.5 with wound bed having pink granulation present, no odor or drainage noted, continues with stage 2 pressure ulcer to right buttock that now measures 8 x 3, some serosanguinous drainage noted peri wound is reddened but blanchable, continues with area of reddened and hard tissue on right buttocks which is being treated for cellulitis, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, also a lot of scar tissue present in gluteal cleft will continue with .magic butt cream . (Note: measurements on wound care log were dated 5/10/23 and lacked physician communication of increase in wound size). Review of R10's Hospital Summary, dated 5/17/23, read in part .Diagnoses this visit: Pressure injury of buttock, stage 4 .Hospital Course: .Patient was continued on vancomycin, taken to OR (operating room) on 5/18/23 for incision and drainage, he was found to have a stage 4 pressure ulcer, it was unroofed and debrided. Final measurements of the wound 12 cm x 7 cm in area, 2 cm in depth and I cm of undermining at the superior edge with 1 cm of underlying at the inferior lateral aspect .Wound care was consulted, patient continues with enzymatic debridement .plan is to transition to a wound VAC (negative-pressure wound therapy, also known as a vacuum assisted closure, is a therapeutic technique using a suction pump, tubing and dressing to remove excess exudate and promote healing) . Review of facility Wound Care Log, no date, page three revealed R10 had three facility acquired wounds as follows: a.) Stage 2 left buttock, started on 4/28/23, and measured 1.5 x 1.5, b.) Stage 2 right buttock, started 4/28/23, and measured 2 x 2 - Measured 8 x 3 on 5/10/23 - Measured 14 x 6 x 2 on 5/24/23 with tunneling at bottom and at right of wound approximately 2 - 2.5 and now a stage 4 pressure ulcer. Review of R10's Clinical Note, dated 5/24/23, read in part Resident admitted back to the facility yesterday after hospitalization .stage 4 pressure ulcer measures 14 x 6 x 2 and there is tunneling at the bottom of the wound and the left side of the wound that measures approximately 2-2.5. The left and bottom of the wound still has yellow slough present in the wound bed, the rest of the wound bed has red beefy tissue present, there was no odor from the wound itself but the old dressing did have odor, there was some serous drainage noted from the wound, treatment at this time consists of flushing the wound with normal saline, applying a chemical wound debriding agent to the wound base, then applying a wet to dry dressing . Review of R10's Surgical Progress Note, dated 5/30/23, read in part Patient was briefly evaluated on Friday, 5/26/23 prior to placement of wound VAC on right buttock. He had debridement of a necrotic pressure ulcer .Wound bed is approximately 80% healthy pink granulation tissue. Recommend starting wound VAC today. Reevaluate next week to see if any further debridement is needed. Review of R10's EMR progress notes and wound care log, from 6/7/23 through 6/18/23, revealed the lack of measurements of his stage 4 pressure ulcer (thirteen days). Review of R10's EMR progress notes and wound care log, from 8/17/23 through 8/25/23, revealed the lack of measurements of his stage 4 pressure ulcer (nine days). Review of R10's Clinical Notes, from 9/6/23 through 9/20/23, lacked any wound care measurement notes (fourteen days). On 9/28/23 at 11:30 AM, an interview was conducted with the DON. The DON was asked where the pressure ulcer measurements are documented and replied, The pressure ulcer wound care measurements are documented in the progress notes weekly in the EMR and no other place. The DON agreed that it is difficult to see any changes in pressure ulcer conditions if they are not documented in the EMR consistently. The DON had no explanation of why the pressure ulcer lacked consistent documentation weekly or why communication of the pressure ulcer worsening and increasing in size was not consistent. On 9/28/23 at 12:30 PM, an interview was conducted with the DON and RN A regarding R10's stage 4 pressure ulcer to his left buttocks, gluteal fold area. The DON stated that she was the primary care provider for R10 up until mid-April 2023 and another group of physicians took over and there was an unknown gap in supervision of wound care by a provider. The DON was asked if she observed R10's skin on his backside/buttocks area when she completed a visit on 3/8/23 and replied, I do not recall if I looked at his skin. The DON was asked if she was aware that R10, at the time of her visit on 3/8/23, had three open areas on his buttocks which were documented to start on 3/3/23. The DON was also asked about the two additional open areas which developed on 3/10/23 and replied, I do not recall. If I did not chart on them, then I most likely did not see them. What I do remember is [RN A] coming to me and we looked at it together at the same time and that was about two weeks ago. The DON and RN A were asked when they both took over wound care in the facility and both replied, Two weeks ago when we decided we needed to make changes because of what we were seeing. RN A was asked if she felt the wound care logs were correct and replied, I think they do not match and there are some incorrect entries. I was always taught to go by the nurses' notes when completing the MDS forms. The DON replied, I think you might be able to refer back to the sizes in some instances, but I would say rely on the nurses' notes. In review of the physician notes R10 was seen on 3/8/23 and then the next physician note is dated 5/4/23 is that correct? RN A replied, That is probably correct. I believe we printed all of them. The DON was asked if the wound was seen by a physician when it increased in size and replied, If there was a note. No. I do not think so. I do not see a note. I just see orders for cream and no dressing changes. RN A was asked about the wound care log and the dates of the resolved wounds on 5/18/23 when R10 was not even in the facility and replied, He was discharged , and it was poor wording. The wounds were not resolved. The DON was asked if there were any additional wound care measurements after 9/6/23 and replied, Not until we measured it on 9/20/23. RN A replied, I have not put measurements in yet from 9/27/23. On 9/29/23 at 11:40 AM, an interview was conducted with R10, who stated, I have been lying on my left side for three hours. On 9/29/23 at 2:45 PM, a second observation was made of R10's bilateral buttock. RN A, the DON, and LPN D were present. RN A measured the wounds, and the DON recorded the findings as follows: a.) Left buttocks, stage 2, and measured 2 x 1.5 cm. b.) Left gluteal fold, stage 2, and measured 0.3 X 1.6 cm, c.) Sacral mid, stage 2, and measured 4 x 3.7 cm, d.) Right buttocks C shaped, stage 2, measured 5.5 x 0.4 cm, e.) Right buttock lateral redness, measured 2.7 x 1.9 cm, f.) Right buttocks lower, stage 2, measured 1.6 x 1 cm, g.) Right buttock gluteal fold, stage 4, measured 5.2 x 5.5 x at 4 o'clock depth 2.6, at 12 o'clock depth 3.9 cm, and at the distal base measured 4.5 x 5.8 cm, circular area and at 7 and 8 o'clock dark purple around crest, with approximately 35% dark within the circular area along with other tissue colors of red, yellow and slough. Review of facility policy titled, Wound Treatment Management, dated 2/1/23, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound . Review of facility policy titled, Skin Risk Assessment and Prevention Protocol, dated 6/14/22, read in part, Purpose: Prevention of pressure injuries begins with the identification of persons at risk for developing pressure injury .G. Communication of pressure injury development, risk assessment, skin inspection results, and treatments will be consistent. Any change in skin condition is communicated to Wound Care Nurse and providers as soon as observed .Minimize Pressure: a. Assess for immobility .J. Encourage patients to make frequent, small position changes. K. Use pillows or wedge to reduce pressure on bony prominences. L. At a minimum nurses should turn patient every two hours .N. If the patient's condition limits repositioning, still attempt to off-load pressure .P. Patient's in a sitting position: 1. Encourage patients to shift weight every 15 minutes. Reposition every hour if patient is unable to reposition self . Review of facility policy titled, Physician Visits, dated 7/12/23, read in part, Purpose: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents .3. The resident must be evaluated at a minimum once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law .B. The Director of Nursing or Designee should: 1. Conduct monthly audits for timeliness of physician visits. 2. Contact the physician regarding an overdue physician visit. Record the physician's response regarding the overdue visit in the nurse's notes. 3. Notify the Medical Director of the need to make a visit, for the attending physician, if he/she is unable to visit. The Immediate Jeopardy that began on 5/10/23 and was removed on 9/29/23 when the facility took the following actions to remove the immediacy. 9/28/2023 1. Developed new paper-based skin assessment for weekly nursing skin assessment. 2. Developed new paper-based skin assessment for Wound Team use. Used weekly and PRN as identified by Wound Team. 3. Wound Team formally identified as MDS coordinator and Director of Nursing. 4. All residents: skin assessment performed by nursing with any suspected deep tissue injury identified over the next 24 hours. 5. Staff notified at each change of shift of date and time of onset of citation and abatement plan. 6. Medical director notified of abatement plan, 1900. 7. Policy drafted for Pressure Injury Focus Meeting. Pressure Injury Focus Meeting will be added to the current weekly interdisciplinary team meeting each Thursday. 9/29/2023 1. Wound Team to re-assess variances identified in the skin assessments performed 9/28/2023 & 9/29/2023. Skin assessments were completed on all residents by 1000 9/29/2023. 2. Interdisciplinary team special meeting to review skin assessments, discuss changes to meetings, and review new policy regarding Pressure Injury Focus Meeting and draft policies, and to develop meeting schedule for ongoing changes regarding overall wound care process. Residents requiring physician/provider assessment to be identified and communicated to medical director. Scheduled for 1545. 3. Drafting pressure injury policy with specifics for pressure injury a. Twice weekly skin assessment by Wound Care Team b. Turning schedule reviewed with staff and placed in resident room c. Review of pressure injury every 10-14 days with medical director or designee 4. Hospital wound care nurse in-service at 1415 for CENAs, RNs, LPNs, recorded for staff not present today to review at next worked shift. 5. Drafting admission policy stating the initial skin assessment will be conducted with two nurses. Specifically for Resident #10: 9/29/2023 Assessment by Wound Team and Surgical Services provider 1300. Instituted new wound care orders and follow up scheduled for 10/4/2023 with surgical services for debridement. Current interventions: Magic Cup, air mattress, Roho cushion for wheelchair, Ensure once daily, Foley catheter, registered dietician review monthly. Interventions above instituted: Twice weekly skin assessment by Wound Care Team, turning schedule reviewed with staff and placed in resident room, review of pressure injury every 10-14 days with medical director or designee.