**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00150640. Based on interview and record review the facility failed to provide safe and adequate assistance with bed mobility for one Resident (#2) of three residents reviewed for accidents, hazards, and supervision. This deficient practice resulted in a fall with major injury, hospitalization, and death. Findings include: Resident #2 (R2) Review of a complaint submitted to the State Agency (SA) on [DATE], revealed, on [DATE], [Registered Nurse (RN) H] called the complainant and told them [R2] was having a routine brief exchange done by one staff member [Certified Nurse Assistant (CNA) D]. Complainant R stated that they were informed [CNA D] had rolled [R2] on her side. Complainant R stated that they were told that during this incident, [R2] fell out of bed, broke her shoulder and hip, and hit her head. Complainant R stated that [R2] passed away at the hospital on [DATE]. Complainant R stated that prior to this incident, there had always been two people present to change [R2]. Review of R2's hospital course, dated [DATE] through [DATE], revealed the following: a.) admitted to emergency department (ED) at 2:09 PM. b.) Results of x-rays suspected right proximal humeral fracture (broken bone in the upper arm that connects the shoulder and the elbow) and suspected impacted right subcapital femoral neck fracture (broken bone in the upper leg that connects the hip/pelvic area of the ball and socket joint that connects to the hip) at 3:50 PM. c.) Transferred to intensive care unit (ICU) and appeared toxic at 8:33 PM. d.) Went into rapid ventricular rate (RVR - irregular fast heartbeat), code blue (cardiac arrest), attempted arterial line (a thin, flexible tube inserted into an artery to monitor blood pressure and obtain blood samples), lifesaving emergency protocol was initiated including cardiopulmonary resuscitation (CPR) and advanced cardiovascular life support (ACLS), and emergently intubated (breathing tube inserted to assist with breathing) at 11:49 PM. e.) Death on [DATE] at 12:10 AM with death diagnosis of principle problem PEA (pulseless electrical activity) suspected embolic event. Some causes of a PEA are sepsis and trauma. Review of R2's death certificate, dated [DATE], read in part, .contributing cause of death: Complications of mechanical fall with fractures with approximate interval between onset and (death) .Hours . On [DATE] at 5:44 PM, Complainant R was called to review the allegations of the complaint intake. Complainant R stated, [R2] was undergoing a brief change with only one staff even though R2 was care planned to receive assistance from two. There were always two staff when we came to visit. The facility said [CNA D] was performing a brief change, [R2] was rolled onto her side. The facility claimed [R2] kicked her leg out, which contributed to the fall. Complainant R was asked if R2 was able to kick her leg out. Complainant R replied, No, [R2] could only stretch, and the facility staff had raised the bed. Emergency Medical Technician (EMT) said that they were not sure how [R2] got into the position she did. It made no sense to them. The facility said [R2] slid out of the bed and there is no way that she could do that. On [DATE] at 6:12 PM, an interview was conducted with Family Member (FM) Q regarding R2's fall at the facility. FM Q replied, The facility Nursing Home Administrator (NHA) and the Director of Nursing (DON) said that the report from the ED stated that a staff member was trying to stand [R2] up, but she hasn't stood her up in years. The NHA and the DON told them that there was a nurse in there and they were changing [R2], and she picked up her leg and slid off the bed and slid down to the floor as they were cleaning her. There was a bruise on [R2's] face. There was only one person in the room with her apparently. When I came to the facility to visit there was always two staff providing care to do a brief change. Review of R2's Emergency Medical Services (EMS) run report, dated [DATE] at 1:13 PM, read in part, .Dispatch priority: Critical (Priority 1) .Patient complaints: Right shoulder pain .Other symptoms: Pain: Hip .Cause: Fall from bed. Trauma criteria: Anticoagulants and bleeding disorders. Narrative: Dispatched via 911 to above address (local skilled nursing facility [SNF]) for a [AGE] year-old female who has fallen out of bed and has right arm pain. EMS arrive on scene to find patient lying supine [face up and on the back] on the floor next to her bed (at an approximate 45-degree angle from bed with head closer to bed and feet further from bed) .Staff x 3 at patient's side stating one staff was present and changing patients [brand name incontinence brief] when patient slid out of her bed. This staff states patient hit her head on the head of the bed rail as she was falling. Patient is on a blood thinner: Apixaban. No other details of fall were given .Patient states she has 9-10/10 pain in right shoulder. Patient says, Ow. Several times when there is a bump in the road .Approximately halfway through transport, patient states her hip hurts; this is a new onset per patient .Weight: 149.7 kg (kilograms) [329.34 pounds] . On [DATE] at 5:36 PM, an interview was conducted with Paramedic P who was asked if they had recalled R2 and her transfer out of the nursing facility. Paramedic P replied, Yes, it was very odd, and our team questioned what happened because [R2] was in an odd position from sliding out of bed and it did not add up. [R2] was at an angle to the bed, and she had hit her right arm on the left side of the bed. It was a weird situation. The CNA changed [R2] by herself. [R2] was three hundred pounds, and our team [EMS crew of three] could not move her by ourselves. The facility staff and our team had used the Hoyer lift to put [R2] on the gurney. I recall the CNA having a small body frame size. Review of R2's transfer form, dated [DATE] at 1:31 PM, revealed an unplanned transfer to a local hospital from a fall, hitting head, and complained of pain 10/10 in right shoulder and shoulder blade. Code status - full code. Usual functional status - Not ambulatory. Review of R2's initial fall report, dated [DATE] at 2:14 PM, read in part, .Description other intervention(s): Education to staff that 2 people assists (sic) need to be done with two people . Review of R2's progress note, dated [DATE] at 2:13 PM, read in part, This nurse [RN H] was heading down the hallway with medication cart to pass medications and [CNA D] come out of this resident's [R2] room and said [R2] fell out of bed! This nurse [RN H] instructed housekeeping to grab me the vitals cart and then grab the clinical management out of another residents room .This nurse [RN H] walked into [R2's] room at 1:10 PM to see her lying on the floor naked next to her bed with a pillow under her head .Once vitals obtained .called [on-call providers name] at 1:12 PM and he ordered to ship resident .EMS arrived .two CNAs and two people from EMS helped get this resident up with the Hoyer lift. [R2] was then taken out of the facility by EMS . Review of R2's progress note, dated [DATE] at 6:25 PM, read in part, .called [local ED] on a update .resident will be admitted up to ICU, residents blood pressures were very low and a central line had to be inserted, and [name brand medication - a vasoconstrictor] started. Resident also has a right femoral neck fracture. Review of facility investigation report, date [DATE], read in part, Resident: [R2] is a [AGE] year-old female resident, admitted on [DATE]. Primary diagnoses include .hemiplegia [muscle weakness or partial paralysis on one side of the body], morbid obesity and heart failure. Resident has a BIMS [brief interview for mental status] of 13 [indicative of intact cognition] and requires 2-person assistance for transfers and ambulates independently in her wheelchair .Reported Incident .had a witnessed fall on [DATE] .x-ray's showed right femur fracture and humeral fracture .Investigation .At 1:15 PM, Aide [CNA D], had checked on [R2]. [R2's] brief was soiled so the aide [CNA D] gathered up supplies she needed to change the resident [R2]. The aide [CNA D] was cleaning up the resident and had the resident roll to her [R2's] side and grab the side rails for assistance. The resident [R2] rolled to her side, then the resident crossed one leg over the other and as she did that she continued to roll and fell onto the floor. The aide [CNA D] attempted to prevent the resident from falling but was unable to stop the fall .Investigation Conclusion: [R2] is a 2-person assist for bed mobility. Review of R2's fall root cause analysis investigation tool, dated [DATE] at 1:10 PM, read in part, .Fall Huddle (What was different THIS time?): Resident being assisted with one-person assist instead of two-person like care planned. Root Cause of This Fall: Care plan not followed . On [DATE] at 10:00 AM, an interview was conducted with RN H who was asked if she recalled the fall in December for R2. RN H replied, Yes, I was heading down the East Hall with my medication cart to pass medication and [CNA D] came out of [R2's] room stating that she [R2] fell out of bed. I immediately went to assess [R2], who was lying on the floor next to her bed with her feet further away from the bed and her head closer to the bed and asked for clinical management to come. [R2] is not mobile, and she does not walk. [R2] was complaining of pain in her right shoulder. I asked [CNA D] what happened and [CNA D] told me she did not know. After EMS left [CNA D] said she rolled [R2] up on her side away from her to wipe her and [R2] rolled off the bed and [CNA D] told me she was by herself. On [DATE] at 10:35 AM, an interview was conducted with CNA D who was asked if she recalled the fall in December for R2. CNA D replied, Yes, I went in to [R2's] room because she had her call light on. [R2] was soiled so I went to get stuff to clean her up and, in the process, [R2] lifted her leg over her other leg, and she rolled off the bed onto the floor. CNA D was asked if there was another CNA working at the time she was providing care for R2 and replied, Yes, but she was with another resident. CNA D was asked if R2 was a one or two-person assistance for incontinence care and replied, I could have sworn she was a one-person assist, but I guess she was a two-person assist. [R2] had paralysis on her left side both upper and lower. On [DATE] at 10:55 AM, an interview was conducted with RN O / East Unit Manager who was asked if she recalled R2's fall in December. RN O replied, Yes, I was in the area. Staff came and got me and told me [R2] had fallen out of bed onto the floor. [R2] said her arm hurt. RN O was asked who was in the room at the time of the fall. RN O replied, [CNA D] was cleaning her up. RN O was asked how many staff should have been assisting with a brief change. RN O replied, [R2] required two staff assistance for a brief change. On [DATE] at 1:45 PM, an interview was conducted with the DON regarding R2's fall in December. The DON stated I was in the next room with the NHA doing a 72-hour care conference with another resident when staff came and got me. [CNA D] was not sure how [R2] fell exactly, but she put her leg over her other leg and lost her balance. [CNA D] tried to catch [R2] but could not. I interviewed [CNA D] and asked her why there was only one aide in the room and [CNA D] stated, I could do it by myself. The DON went on to further explain that [CNA D] was able to state what [R2's] [NAME] and care plan was and repeated it to me. [CNA D] rolled [R2] away from her while she was providing care and did not follow policy. Review of R2's care plan, dated [DATE], read in part, .Goal: Resident has an ADL (Activities of Daily Living) self-care performance deficit related to fluctuating ADLs, generalized weakness, hemiplegia .Interventions .Bed mobility: 2 person assist .Toileting: 2 person assist .Goal: Resident is at risk for falls/injury related to decreased strength and endurance, history of falls .hemiplegia and hemiparesis . Review of R2's ADL report, dated [DATE] through [DATE], revealed R2 was dependent for toileting and was assisted by one staff. Review of policy titled, Activities of Daily Living (ADLs), dated [DATE], read in part, Policy: The facility takes measures to minimize the loss of residents' functional abilities, including activities of daily living (ADLs) Policy Explanation and Compliance Guidelines .2. The facility provides maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome based on their comprehensive assessment. 3. A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene .5. The facility maintains individualized objectives of the care plan through periodic review and evaluation. Review of policy titled, Accidents and Supervision, dated [DATE], read in part, Policy: Each resident will be assessed for accident risk and will receive care and services in accordance with their individualized care plan. Each resident will receive adequate supervision and assistive devices to prevent accidents .3. Implementing interventions to reduce hazard(s) and risk(s). 3. Implementation of Interventions - using specific interventions to try to reduce a resident's risk from hazards in the environment. The process includes .e. ensuring that the interventions are put into action .5. Supervision - Supervision is an intervention and means of mitigating accident risk. The facility provides adequate supervision to prevent accidents. Adequate supervision is .b. Based on the individual resident's assessed needs and identified hazards in their environment . Review of policy titled, Fall Prevention Program, dated [DATE], read in part, Policy: Each resident will be assessed for the risks of falling and will receive care and services in accordance with the level of risk to minimize the likelihood of falls .Policy Explanation and Compliance Guidelines .5. Each resident's risk factors, and environmental hazards will be evaluated when developing the resident's comprehensive plan of care . Review of policy titled, Falls - Clinical Protocol, dated [DATE], read in part, Policy Explanation and Compliance Guidelines .2. Based on the assessment an initial plan of care will be developed and implemented to address identified risks .5. Interventions should be developed and implemented per the assessed needs .6. In addition, interventions for direct care givers should be placed on the CNA care card or similar format .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation is linked to intake MI00141867. Based on observation, interview, and record review, the facility failed to provide pressure ulcer care per professional standards of practice for one Resident (R10) of three reviewed for pressure ulcer care. This deficient practice resulted in the worsening of a facility aquired pressure injury to an unsgateable pressure injury requiring antibiotics. Findings include: R10 R10 developed an in house Moisture Associated Skin Damage area on 11/24/23 which subsequently worsened to stage II, and ultimately progressed to an unstageable pressure injury on 2/5/24 with worsening measurements through 2/26/24. R10 also developed a wound infection, requring treatment with antibiotics. The facility failed to ensure the approriate pressure reducing surface for the bed was in place, failed to provide aspetic (clean technique) wound care, failed to consitently measure and document wound care, and failed to appropriately turn/reposition R10 for pressure relief. On 2/29/24 at 8:30 AM, an observation was made of R10 in her room lying on her left side in bed. R10's bed mattress was a regular mattress. R10 lacked a pressure reduction mattress or an air mattress. On 2/29/24 at 8:45 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked if the facility had an air mattress or a pressure reduction mattress for R10 and replied, We ordered one. The NHA was then asked when it was ordered and replied, I would have to check. On 2/29/24 at 9:20 AM, an observation was made of R10's incontinence care with Certified Nurse Aide (CNA) D. R10 had a very pungent odor when CNA D started to provide incontinence care. R10's wound dressing on her sacral area was observed to be a 4 x 4 cm (centimeter) foam boarder gauze which was completely saturated, and drainage was observed on her incontinence brief. CNA D replied to this Surveyor, Do you think I should let the nurse know so she can change the dressing? On 2/29/24 at 9:35 AM, an observation was made of Registered Nurse (RN) C providing a wound dressing change on R10. RN C failed to wash her hands prior to starting the wound dressing change and did not use wound cleaner to clean R10's wound prior to soaking up the wound drainage with gauze and applying medi honey, calcium alginate, and a new foam boarder gauze. RN C left the bottom of the foam boarder dressing unsealed just above the coccyx area which left the potential for stool incontinence to enter the open wound. RN C brought one 4 x 4 gauze to clean R10's wound that was saturated with drainage. On 2/29/24 at 9:45 AM, an interview was conducted with RN C who was asked how often she had to perform the dressing change for R10. RN C replied, Sometimes. The dressing change is ordered for evening shift to compete. RN C was asked how and if she documents that she completed the dressing change and replied, Um, I don't. On 2/29/24 at 10:15 AM, an observation was made of CNA D and CNA F repositioning R10 after her incontinence care and placed R10 on her left side. This surveyor asked CNA D which side R10 was lying on and replied, Oh yeah! I need to turn her on her other side she was just on her left side. On 2/29/24 at 10:45 AM, an interview was conducted with the Regional Clinical Nurse (RNC) N and asked what types of interventions were in place for R10 to help reduce and heal pressure ulcers and replied, We added an air mattress as an intervention. The RNC N was asked when the pressure reduction mattress was ordered for R10 and replied, I am not sure. I would have to ask the administrator. RNC N was asked if the frequency of dressing changes for R10 was sufficient for the amount of drainage R10 was having and replied, I will change the orders. On 2/29/24 at 12:30 PM, an interview was conducted with the Director of Nursing (DON) regarding R10's pressure ulcer. The DON was asked why dietary was not consulted sooner about the wound not healing and replied, Dietician comes on Thursday or Friday each week. I talked with her on the first or second of February about another resident and I am not sure why we did not talk about [R10] that same day. We did discuss her on 2/8/24 The DON was asked about a pressure reduction or distribution mattress and replied, I am not sure when we ordered it. I would have to ask the administrator. The DON was asked why wound evaluations were not documented between 12/19/23 through 1/16/24 and replied, That was when the old wound nurse manager was here, and we let her go. I think she purposely removed the wound measurements from the task list. The DON was asked if wounds are discussed regularly and replied, We talk about them daily. The DON was asked if wounds were discussed so frequently then why did the measurements get missed for almost a month and replied, I am not sure why. During the above interview, the DON was made aware of CNA D not knowing which way that R10 had been positioned during care rounds and repositioning and that CNA D had placed her back on the same side. The DON responded, Maybe a visual chart would benefit them with knowing which position in the correct way to place the resident on a turning schedule. The DON was asked if wound measurements should be documented weekly and replied, Yes. Including all previously measured areas such as depth and or tunneling. The following measurements are for the same sacral/coccyx wound for R10 as follows: Review of R10's wound evaluation, dated 11/24/23, revealed moisture associated skin damage (MASD) measuring 0.6 x 0.5 cm (centimeters) and in house acquired. Review of R10's wound evaluation, dated 12/18/23, revealed a stage II pressure ulcer measuring 0.8 x 0.6 cm. *Note: No wound evaluations documented 12/19/23 through 1/16/24. Review of R10's wound evaluation, dated 2/5/24, revealed an unstageable pressure ulcer measuring 3.5 x 1.7 cm. Review of R10's wound evaluation, dated 2/12/24, revealed an unstageable pressure ulcer, with interventions as follows: Incontinence management, mattress with pump, moisture barrier/control, and turning/repositioning program. Review of R10's wound evaluation, dated 2/19/24, revealed an unstageable pressure ulcer measuring 3.2 x 1.9 cm with a depth of 1.0 cm and undermining 0.8 cm. Review of R10's wound evaluation, dated 2/26/24, revealed an unstageable pressure ulcer measuring 3.9 x 2.1 cm and lacked any measurements for depth and undermining. Review of R10's care plan, date 8/23/23, read in part, .Focus: Resident has episodes of (bladder / bowel) incontinence .Interventions: Uses disposable briefs .Assist resident with toileting needs every 2 hrs [hours] .Check at regular intervals and change as needed .Observe peri (skin surrounding genitals and rectal area)/rectal-area for redness, irritation, skin excoriation/breakdown .Provide peri-care after each incontinence episode .Focus: Resident is at risk for impaired skin integrity . Review of R10's care plan, date 1/19/24, read in part, . Focus: Resident has impaired skin integrity as evidence by: unstageable pressure ulcer to coccyx .Goal: Healing and/or improvement . Interventions: Resident is to be repositioned q2h [every two hours] .Administer treatment(s) per orders . Complete wound evaluation to observe the progress of the resident's skin condition . Review of R10's physician order, dated 2/29/24, revealed the following, Amoxicillin-Pot Clavulanate Tablet 875-125 mg [milligram], give 1 tablet by mouth every 12 hours for bacterial infection for 10 days will pull first dose out of backup. Review of R10's progress note, dated 2/28/24 at 7:35 PM, read in part, . Site of infections: coccyx wound. Reason on antibiotics/new signs & symptoms: She went to the wound clinic apt. [appointment] today for her first visit for the assessment of the coccyx wound. Per wound clinic she will be started on [brand name antibiotic] b.i.d. [twice daily] give one tablet p.o. [by mouth] for 10 days. x-ray the right pelvis 3 views for osteomyelitis. Labs to be obtained on 2/29/24 . Review of R10's progress note, dated 2/29/24 at 7:31, read in part, .Wound appears to be infected, thick purulent drainage noted. Resident started on antibiotics today for possible sepsis. Area is deep, very dark base, tunneling noted at all edges. Wound with very pungent odor, odor is noted at doorway . Review of R10's physician order, dated 2/28/24 at 4:09 PM, revealed the following, Ceftriaxone sodium solution reconstituted 1 gm [gram], inject 1 gm intramuscularly one time only for infection . Review of R10's progress note, dated 2/22/24 at 2:53 PM, read in part, .Wound clinic consult .consult out to wound clinic, awaiting to be seen . Review of R10's physician order, dated 2/7/24 through 2/9/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply Medi honey/honey gel to wound bed. Apply calcium alginate AG (Silver) to wound bed. Cut to size of open area. Apply skin prep to peri wound. Cover with border foam. Every evening shift for wound care. Review of R10's physician order, dated 2/5/24, revealed the following, Ensure Roho is in place to w/c [wheelchair] at all times for weight distribution. Every shift, and Resident is to be repositioned q2 [every two] and PRN [as needed]. Assist resident to reposition in chair frequently. Limit time upright in w/c. Every shift for wound care. Review of R10's physician order, dated 11/25/23 through 12/11/23, revealed the following, Cleanse coccyx and (R) [right] buttock wounds r/t (related to) MASD with wound cleanser, pat dry with gauze, apply skin prep to peri wound, cover wounds with hydrocolloid (moisture absorbing dressing type) dressing. Change dressing Every evening shift every 3 day(s) for MASD. Review of R10's physician order, dated 12/12/23 through 12/18/23, revealed the following, Cleanse coccyx wounds r/t [related to] MASD with wound cleanser, pat dry with gauze, apply skin prep to peri wound, cover wounds with hydrocolloid dressing. Change dressing every 3 days and PRN if soiled or dislodged. Check placement of dressing Q [every] shift. Discontinue when healed. Every evening shift every 3 day(s) for MASD. Review of R10's physician order, dated 12/19/23 through 1/29/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply collagen as directed to (coccyx). Skin barrier wipe to peri wound. Cover with (border foam). Every evening shift. Review of R10's physician order, dated 1/29/24 through 2/7/24, revealed the following, Cleanse with wound cleanser. Pat dry. Apply calcium alginate AG (silver) to wound bed. Cut to size of open area. Apply dermaseptin (skin protection ointment) to peri wound. Cover with border foam. Every evening shift for wound care. Review of R10's treatment administration record (TAR), dated February 2024, revealed wound care was not documented as provided on the 7th and the 27th of the month. Review of R10's treatment administration record (TAR), dated January 2024, revealed wound care was not documented as provided for 10 opportunities of 31 days. Review of R10's progress notes, dated January 2024, lacked any nursing notes to support the above wound dressing changes not documented as completed. Review of R10's treatment administration record (TAR), dated December 2023, revealed wound care was not documented as provided for 9 opportunities of 20 days. Review of R10's progress notes, dated December 2023, lacked 8 of 9 nursing notes to support the above wound dressing changes not completed. Review of R10's tasks, dated 10/27/23, revealed a turning per care plan. Review of R10's tasks, dated 2/5/24, revealed a turning and repositioning every 2 hours. Review of R10's interdisciplinary team notes (IDT), dated 11/24/23 through 2/29/24, revealed one note entered in the electronic medical record on 1/29/24 when R10's pressure ulcer was noted to be worsening. Review of R10's minimal data set (MDS), dated [DATE], revealed in section E no refusals of care and in section M marked no pressure ulcers and at risk for developing. Review of R10's wound clinic visit report, dated 2/28/24, revealed a care plan for nutrition, osteomyelitis, pressure ulcer, soft tissue infection, and wound/skin impairment. At the time of survey exit, R10 remained on a bed without an air mattress. Review of policy titled, Clean Dressing Change, dated 12/28/23, read in part, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Policy Explanation and Compliance Guidelines: . 3. Set up clean field with needed supplies for wound cleansing and dressing application .5. Wash hands and put on gloves . 10. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound . 14. Secure dressing . Review of policy titled, Wound Treatment Management, dated 10/26/23, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidenced-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change . Review of policy titled, Pressure Injury Prevention and Management, dated 1/1/22, read in part, Policy: This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries . Policy Explanation and Compliance Guidelines: . 3. Assessment of Pressure Injury Risk . c. Assessment of pressure injuries will be performed by a licensed nurse, and documented in the medical record . 4. Interventions for Prevention and to Promote Healing . c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions . include . i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc.); . iii. Provide appropriate, pressure-redistributing, support surfaces . f. Interventions will be documented in the care plan and communicated to all relevant staff . Review of policy titled, Pressure Ulcer/Skin Breakdown-Clinical Protocol, dated 1/1/22, read in part, Policy: Based on the comprehensive assessment of a resident, a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers . and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection . Policy Explanation and Compliance Guidelines: . 4. The interdisciplinary team will assess and document and individual's significant risk factors for developing PU/PI [pressure ulcer/pressure injury] . 7. Continued assessment and management . PUSH [pressure ulcer scale for healing] tool completed on PU/PI weekly during the weekly wound measurements . 15. The IDT team will review each pressure ulcer weekly for progress and changes . Review of NPIAP (National Pressure Injury Advisory Panel) standards of practice recommendations access on 3/14/24 located at: https://static1.squarespace.com/static/6479484083027f25a6246fcb/t/647dc6c178b260694b5c9365/1685964483662/Quick_Reference_Guide-10Mar2019.pdf Revealed the following: 7.9 For individuals with a pressure injury, consider changing to a specialty support surface when the individual: · Cannot be positioned off the existing pressure injury · Has pressure injuries on two or more turning surfaces (e.g., the sacrum and trochanter) that limit repositioning options · Has a pressure injury that fails to heal or the pressure injury deteriorates despite appropriate comprehensive care · Is at high risk for additional pressure injuries · Has undergone flap or graft surgery · Is uncomfortable · ' Bottoms out ' on the current support surface.