**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement measures to prevent additional pressure wound and/or prevent the development and worsening of pressure injuries for two Residents (R108 & R7) of five reviewed, resulting in harm for R108 with the development of a stage III pressure wound which worsened, required hospitalization, antibiotics, and wound debridement. Findings Include: (All times are recorded in Eastern Daylight Time.) This citation is related to intake #MI00145848. Resident 108 (R108) Reivew of the complaint intake information from the State Agency, dated 7/23/24, read in part, .They stated he (R108) was doing fine .While driving up to see him on 4/19/24, [Licensed Practical Nurse] (LPN) D] called and said that dad wasn't doing well .She also told us that he has (sic) a pressure wound and she thought it was a Kennedy ulcer, which meant death was imminent within a few days to weeks. When we got there, (LPN D) met us at the door and said that 'we could move him to comfort care so he's comfortable'. I advised that we would be doing everything we can to get him better and rehabilitated .I scheduled a medical transport from [facility name] to (out of state facility) . Between the time I left on 4/27/24 and when he arrived in the out of state facility on 5/13/24, the wound grew in depth, and became extremely infected. It appears they [skilled nursing facility] did nothing to the wound after I left. A wound care Registered Nurse (RN) from (out of state facility) came to assess his pressure wound on 5/15/24 and she immediately called the ambulance because the wound was so badly infected, and she was afraid he was septic. In the emergency department (ED) out of state, they started intravenous (IV) antibiotics immediately. He was admitted and stayed in the out of state hospital until 6/10/24 . R108 was hospitalized for 28 days because of the severity of the infected pressure wound. A Kennedy ulcer, also known as Kennedy terminal ulcer, is a specific type of pressure ulcer that manifests in terminally ill patients. A Kennedy ulcer is a distinct type of pressure ulcer that primarily affects individuals in the terminal stages of illness or nearing the end of life. It is characterized by its sudden onset and rapid progression, often appearing as a sharply defined, irregularly shaped lesion with a dark maroon or purple hue. Kennedy ulcers typically develop on the sacral or coccygeal area but can also occur on other pressure points, such as the heels, hips, or elbows. Kennedy ulcers are painful, non-blanchable lesions with surrounding tissue exhibiting signs of impending necrosis. Unlike traditional pressure ulcers, Kennedy ulcers may not exhibit the typical signs of tissue breakdown, such as erythema (redness) or inflammation. Instead, they often appear deep, crater-like wounds with minimal surrounding tissue trauma. On 9/5/24 at 4:54 PM, an interview was conducted with the complainant. The complainant stated, On three different occasions the wound care nurse told me that he (R108) had a Kennedy ulcer. I did not know any different and so I just did not think it was that bad and I thought the wound care nurse and the practitioner were providing the correct treatment and knew what they were doing. When we got to the hospital out of state the pressure wound was open (worse in depth visible with flesh, size, and odorous). I know that even with the wound he was not on a turn schedule at the facility prior to transfer. When we went to visit him in state name, they kept him up in his wheelchair for extensive periods of time and no one came in and turned him. We would visit for hours and hours at a time only briefly leaving to get something to eat. The medical transport van had two emergency medical technicians and a RN in the back riding with him and ensured he was being turned and repositioned every one to two hours and they stopped to get dad something to eat. The complainant stated, After my dad arrived in out of state facility I went to see him, and he said, 'Is that me that smells?' 'Is that my a**?' I replied, 'Yes dad. That is your a** that stinks.' On 9/5/24 at 5:47 PM, Complainant I emailed photos of R108's pressure wound including one photo dated 5/8/24, which was taken while R108 was under the care of the facility. A request was made to an out of state hospital for R108's medical records on 9/6/24 via fax. On 9/6/24 at 1:11 PM, an interview was conducted with Family Member (FM) H, who stated, I can picture it just like it happened. On 5/8/24 I went to visit my dad and LPN D used their phone to take a picture of my dad's pressure wound. FM H stated, I had no idea it looked that bad. It got progressively worse. I could put my whole fist inside the wound he had. It was so bad. I swear on a stack of Bible's that the doctor was never there at the facility. They did not turn and reposition him and he was up in his chair 60% of the time. I went to see him three or four times while I was in the area. He was not on any antibiotics for the wound. I was not happy at all with what went on at the facility. They were shooting from the hip providing care for dad. We had a meeting with the nurse, physical therapist, and others to develop a treatment plan and the very next day they had it screwed up because they were not turning and repositioning him or changing the gauze on the dressing for the wound. They were making a plan because we had complained they were not doing their job turning and repositioning, so he was not on his right side. They called the wound a Kennedy ulcer. The dressing was a couple piece of gauze with some tape. On 5/8/24 they were putting A & D ointment on it. The wound care Nurse Practitioner (NP) spent ten minutes with him and never asked my dad a thing. He was not eating, was losing weight, and was losing his strength. My dad told me that the wound hurt, and he has a high pain tolerance. They just could not get their act together. I am so glad we had him transported elsewhere and now he is doing much better after receiving the treatment he should have gotten at the facility. Review of R108's admission Record, revealed an original admission to the facility on 4/10/24, with medical diagnoses including polymyalgia rheumatica (inflammatory disorder causing muscle pain and stiffness around the shoulders and hips), benign prostatic hyperplasia (age-associated prostate gland enlargement), hyperlipidemia (elevated blood cholesterol), and hypertension (elevated blood pressure). R108's admission Minimum Data Set (MDS) assessment, dated 4/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 indicating R108 had moderately impaired cognition. Review of an admission Skin Assessment, dated 4/10/24, revealed areas of skin impairment described as follows: right lateral inside toe scab, right side coccyx red area, left lower side back (lacked description), left hand (lacked description), left lateral outer arm near elbow bruise, right top of arm scab, and right shin old scar. No open areas of skin were documented in the initial skin assessment on admission. Review of the Braden scale for prediction of pressure wound risk, dated 4/10/24, revealed a score of 16 which indicated R108 was a high risk for developing pressure wounds. Review of a progress note, dated 4/11/24, read in part, Resd (resident) is being monitored for falls and weakness .Skin id (sic) dry and intact .Resd is Ax2 (assistance of two staff) with walker and Ax1 (assistance of one staff) for ADLs (activities of daily living) . An MDS assessment, dated 4/15/24, section E0800, read in part, .Did the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being? .Behavior not exhibited .section M Skin Conditions, revealed R108 was at risk for developing pressure ulcers and had no unhealed pressure ulcers . Review of a progress note, dated 4/18/24, read in part, Resd (resident) DTI (deep tissue injury)/blister to coccyx has opened. Red beefy tissue showing at wound bed, skin still partially attached. Will pas (sic) along to wound nurse for assessment . No mention of blister prior to this progress note. Review of R108's skin integrity event incident report, dated 4/19/24, revealed R108 developed an in house acquired pressure injury on their buttocks that measured 10 (length) cm (centimeters) x 8 (width) cm x 0.4 (depth) cm. Review of R108's Wound Management Detail report, dated 4/19/24 through 5/10/24 revealed the following: a.) 4/19/24 - Wound type: Unspecified Ulcer, wound location: Right buttocks/coccyx, date identified: 4/19/24 at 12:30 PM, date created: 4/19/24 at 8:42 PM, present on admission: No, measured 6.0 cm, L (length) x 4.0 cm, W (width) x 0.3 cm, D (depth) cm. Wound comments: Res was found to have a blister-like area that opened on 4/18/24 with beefy red tissue showing to (sic) the wound bed. When doing skin assessments today, res presents with an unstageable wound that is likely a Kennedy ulcer to the right glut/coccyx area that is surrounded by a DTI (deep tissue injury) .DTI surrounding is dark maroon/red/purple and extends 5 cm. b.) 4/26/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area that is surrounded by DTI. Necrotic tissue to entire wound measuring 5 cm x 3.7 cm with irregular edges and an area of slough to lateral side measuring 5 cm x 0.1 cm. DTI surrounding is dark maroon/red/purple and extends 4.7 cm from necrotic tissue in an irregular shaped circle pattern. Treatment changed. Light serosanguinous drainage noted. c.) 5/3/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area that is surrounded by DTI. Necrotic tissue to entire wound measuring 5 cm x 3.5 cm x 0.1 cm with irregular edges and an area of slough to lateral side measuring 4 cm x 0.1 cm. DTI surrounding is dark maroon/red/purple and extends 4.0 cm from necrotic tissue in an irregular shaped circle pattern. Light serosanguinous drainage noted. d.) 5/10/24 - Wound comments: Res with an unstageable ulcer to the right glut/coccyx area. Wound measures 5 cm x 3.5 cm x 0.2 cm with slough and granulation tissue scattered throughout the wound. Necrotic tissue that is 3 cm x 3 cm x 0.1 cm with irregular edges that is in the middle of the wound. DTI surrounding is dark maroon/red/purple and extends 3.5 cm from necrotic tissue in an irregular shaped circle pattern .Res with no s/s (signs or symptoms) of infection to area with light serosanguinous drainage noted . Observation of the photo of R108's pressure wound, dated 5/8/24, revealed a Stage III pressure wound to the right sacral region, round in shape, dressing pulled down away from the wound revealing a completely saturated dressing with serosanguineous drainage; red/yellow in color. No ¼ inch packing was observed as physician ordered. There was one piece of folded 2 inches (in.) x 2 in. gauze lying on top of the center of the padded dressing entirely saturated with serous drainage; clear and bloody in color and some yellow purulent exudate. The surrounding peri area of the wound was reddened and swollen all the way around the wound extending out approximately two inches. The wound had some purulent appearing drainage, undermining, mucus, stringy tissue, a brown and yellow piece of tissue in the center that appeared to be hanging off underlying tissue below that had some granulation. The dressing appeared to be an adhesive island wound dressing (porous) approximately 4 in. x 5 in. and in the center a pad measuring 2 in. x 2.5 in In the photo the wound appears to be larger than the dressing. R108's wound showed signs of infection in the photo dated 5/8/24 as described above. Review of R108's physician order, dated 4/23/24 through 4/26/24, revealed an order to apply A & D ointment to right buttocks wound four times a day and as needed to keep wound protected. Review of a progress note for R108, dated 4/23/24, read in part, .Side to side positioning every two hours and air mattress overlay. Wound healing supplement per facility . R108's physician orders lacked any order for an air mattress or for to check for settings and functioning. Review of R108's care plan, dated 4/24/24, read in part, Problem: Urinary incontinence .provide incontinence care after each incontinent episode. Use moisture barrier product to peri area .Problem: Resident is at risk for skin breakdown .report any signs of skin breakdown (sore, tender, red, or broken areas.) .Problem Start Date: 04/19/24. Category: Pressure ulcer/injury. Resident has a pressure ulcer, DTI, R (right) buttocks, suspected Kennedy ulcer .Assess the pressure ulcer for stage, size, presence of granulation tissue and epithelization, and condition of surrounding skin 7 days .apply dressings per MD (medical doctor) order . Progress note for R108, dated 5/7/24, read in part, Weight/wound review: current weight 194.8 pounds, down 7% in last 30 days triggers for significant loss, oral intake has dropped off recently to 0-25%, had been fair 50-75% .Recommend increasing oral supplement to 120 cc (cubic centimeters/4 ounces) three times a day . Review of Recap of Stay, dated 5/13/24, revealed, R108 was transferred to another facility out of state to out of state. R108's pressure injury wound was not measured prior to his discharge. Skin condition note was described as: areas of skin impairment and described as declining unstageable pressure injury right glut (gluteal/buttocks). The discharge MDS assessment, dated 5/13/24, section M skin conditions, revealed R108 had no unhealed pressure ulcers . From review of R108's complete medical record it appeared the discharged MDS, dated [DATE], was inaccurate related to the related to the Wound Management detail reports. Review of progress note, dated 5/13/24, read in part, .He (R108) does continue with declining unstage (sic) pressure injury to right glut. Does have occasional c/o (complaint of) pain to same .,Prior to leaving an order was given for prn (as needed) tramadol (pain medication) .Resident happy about transfer .Res. discharged at 4:05 PM (central time zone). An interview was conducted on 9/11/24 at 10:02 AM, with LPN D. When asked if she recalled R108 and replied, Yes, I remember him well unfortunately. He was a nice guy. LPN D was asked if R108 had any open areas on admission and replied, No, but he did have a few scabs, a couple of bruises, and a small, reddened area to his right side near his coccyx. LPN D stated, R108 was at risk for developing pressure wounds. LPN D was asked what the initial treatment was and replied, Side to side repositioning and barrier cream. LPN D was asked when R108's pressure wound first opened and replied, It first opened up on 4/18/24 and was described as red, beefy tissue underneath. LPN D stated, I opened up wound management for R108 and I had the DON look at the wound on 4/18/24 and we called it a Kennedy ulcer. LPN D was asked if R108's wound was opened why she classified it as an unspecified ulcer. LPN D stated, Because I am not always sure what they are, but then I detail them in the notes section. So, in the notes is where I reflect what they are classified as. LPN D was asked if she could explain what a Kennedy ulcer was and replied, A terminal ulcer that is dark in color, opens fast, and has irregular boarders. LPN D was asked when the physician first seen R108's pressure wound and replied, The nurse practitioner came in to see his wound on 4/30/24 for the first time. LPN D was asked if pictures are ever taken of wounds and replied, No. LPN D was shown the photo of R108's wound dated 5/8/24 and replied, I did not take that the daughter did with her phone. That is R108's wound and yes it has redness surrounding the peri area. LPN D was asked if R108's pressure wound had any drainage and if it was ever cultured and replied, Yes, it had drainage, but just a light drainage and no it was never cultured. LPN D was asked if she was wound care certified and replied, No. I consult with the wound care representative and the nurse practitioner. An interview was conducted on 9/11/24 at 10:58 AM, with the DON and was asked if R108 had an air mattress and replied, Maintenance would know when it was implemented because they keep a log of when air mattresses are added to resident rooms. The DON was asked if she could run a report for R108's turning and repositioning and replied, We do not keep track of that because it is a standard of care. The DON was asked how she would classify a pressure wound that appeared to be red, beefy to the wound bed and replied, A stage three. Well, it depends on depth so possibly a stage two depending on depth. The DON was asked what a Kennedy ulcer was and replied, It is an ulcer people generally get near the end of life and it is generally unstageable. An interview was conducted on 9/11/24 at 1:01 PM, with the DON who was asked if air mattresses needed a physician order and replied, Not necessarily. The DON was asked if there should be a system to check off that the air mattresses are working properly and replied, We may or may not put an order in to check off that an air mattress is working properly, but it should be on the care plan too. On 9/11/24 at 1:15 PM, an interview was conducted with RN E who was asked if an air mattress needed a physician order and replied, Yes. RN E was asked if there is a system to check off if the air mattress is working properly and replied, Yes, usually an order and also on the care plan. On 9/11/24 at 1:20 PM, an interview was conducted with RN F who was asked if an air mattress needed a physician order and replied, Yes. RN F was asked if there is a system to check off if the air mattress is working properly and replied, Yes, I know another resident has it where I check it off that it is working and has the setting in an order. Review of R108's out of state hospital admission documentation, dated 5/15/24 through 6/10/24, revealed the following: a.) .admitted to ED 5/15/24 reason for visit buttocks wound. Diagnoses: Sacral wound and cellulitis. Presenting problem: Infected decubitus ulcer. EMS states that the wound is odorous . b.) Decubitus wound culture obtained in ED, labs drawn, IV inserted, and two different antibiotics started via IV. [NAME] blood cell count was elevated at 13.8 indicating infection was present in (R108) . c.) ED basic information: Patient reports noticing the wound becoming more sore and has a mal odor to it. Assessment and plan: Sacral wound - open wound of lower back and cellulitis . d.) ED Physical Exam: Right sacral wound about 4 cm x 6 cm, undermining a little 1 cm circumferentially, some purulent appearing drainage and a necrotic area of the skin on a pedunculated stalk . e.) Medical decision making: . here for concern of an infected sacral wound. Patient reports he has discomfort and pain at the area of the wound . f.) Transferred to inpatient at (out of state hospital) for further treatment . g.) Wound care consultation note: Sacral wound on admission, unstageable sacral pressure injury. Upon debridement, the wound is likely to be a stage IV given the current depth that is visible. Concern about the amount of odor, necrosis, and cellulitis. Have requested evaluation by general surgery . h.) Surgical consult note dated 5/16/24 read in part, Stage III right buttock/sacral pressure injury. Wound has become increasingly painful and malodorous over the last month. Wound debrided at bedside .Large amount of necrotic slough tissue within the wound bed was debrided .Wound cultures so far reveal heavy gram-negative bacilli . i.) Progress noted dated 5/18/24, read in part, .The following day surgery came back and performed a more extensive bedside debridement as well . j.) Progress note dated 5/21/24, read in part, .Assessment/Plan .Stage 4 skin ulcer of sacral region .Team saw the patient and suggested a wound VAC (a treatment that uses suction to help wounds heal) and that was placed on the 20th (May 2024) . k.) Progress note dated 6/9/24, read in part, .Assessment/Plan: 1.) Stage 4 skin ulcer of sacral region. The patient has a wound VAC in place. Medically stable for discharge. Awaiting insurance authorization .2.) Cellulitis of sacral region. On oral amoxicillin and clavulanate (antibiotic) . l.) R108 was discharge out of the hospital on 6/10/24 .Discharge Diagnosis: Stage 4 skin ulcer of sacral region .Recent wound care assessment last week: Infected stage IV sacral ulcer, status post bedside debridement on May 15 (2024), status post surgical debridement on May 17 (2024) .wound VAC started on May 24 (2024) .Per last wound care assessment last week: Significant (sic) improved (evidence of a pressure wound and not a Kennedy ulcer) .Wound care team will follow-up in clinic in 1 to 2 weeks . Review of R108's photo of the right sacral pressure wound, dated 6/14/24, revealed no infection surrounding the wound, significant reduction in size, and granulation tissue in the wound bed that appeared healthy. Resident 7 (R7) A quarterly MDS assessment, dated 8/13/24, section E0800, read in part, .Did the resident reject evaluation or care that is necessary to achieve the resident's goals for health and well-being .Behavior not exhibited .section M skin conditions, revealed R7 was at risk for developing pressure ulcers and had one unhealed pressure ulcer stage II . On 9/9/24 at 3:10 PM, an observation was made of R7 in his room, lying in bed. R7 had an air mattress that was set at 250 and static (not alternating pressure). R7's heel protector for his left foot was not on and his heel was touching the bed. On 9/10/24 at 8:30 AM, an observation was made of R7 lying in his bed, on his back, in his room. R7's air mattress was set at 250 and static. R7's heel protectors were both off and were in his wheelchair. R7's left heel was overlapping a pillow and resting on the bed and R7's right heel was also touching the bed off a pillow. On 9/10/24 at 8:35 AM, an interview was conducted with the DON, who was asked if R7's air mattress was at the correct setting and if their heel boot protectors should be on and heels off the bed and replied, I would have to check the orders for the air mattress settings to verify and the boots should be on and that the heels are to be floated. After reviewing the orders for R7 the DON returned and replied, The air mattress settings are incorrect. On 9/10/24 at 11:05 AM, an observation was made of R7 lying in his bed, on his back, in his room in the same position from the previous observation. On 9/10/24 at 2:00 PM, an observation was made with LPN D of R7's skin on their buttocks and peri area. R7's coccyx wound was healed, and their peri area was reddened with excoriation surrounding their peri area. LPN D stated, R7 was readmitted from a short hospital stay with a stage II (pressure wound) on their coccyx area. This area is known to open from time to time. Review of R7's physician order, dated 7/13/23, revealed an order for a pressure relief air mattress with setting 320. Review of R7's physician order, dated 10/3/23, revealed an order to check air mattress placement and functioning every shift. Review of R7's care plan, dated 1/2/21, read in part, Category: Pressure ulcer/injury. Resident is at risk for skin breakdown . is also dependent on staff for repositioning and incontinence care .Approach .Heel float boot while in bed and wheelchair .Float heels while in bed .low air loss alternating pressure relieving mattress setting at 320 .turn and reposition every 1-2 hours while in bed . Review of policy titled, New or Worsening Pressure Wounds, dated 1/2024, read in part, .Standard of Care: A resident who enters the facility without pressure wounds does not develop pressure wounds unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure wounds receives the necessary treatment and services to promote healing, prevent infection, and prevent occurrence of additional wounds and worsening of existing wounds .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This deficiency pertains to Complaint Intake #MI00138936 & #MI00137644. Based on observation, interview, and record review, the facility failed to provide necessary treatment and services to promote healing and prevent the development of pressure ulcers for four Residents (R1, R6, R30 and R51) of four residents reviewed for pressure ulcer care, out of a total sample of 15 residents. This deficient practice resulted in harm with the development of a facility acquired stage 3 pressure ulcer, the potential for delayed wound healing, infection, and deterioration of condition. Findings include: All times documented are Eastern Daylight Savings Time (EDST) unless otherwise noted. Resident #6 (R6) Review of R6's hospital admission documentation, dated 2/1/23, read in part, .visiting diagnoses list pressure injury of left buttocks stage 3 and pressure injury of right buttocks stage 3 - primary diagnosis bilateral pneumonia, sepsis abdominal pain . * Pictures from hospital show a stage three pressure injury to right buttocks circular in shape and bleeding. Surrounding tissue is purplish in color and scar tissue noted around the open area. Review of R6's hospital discharge instructions, dated [DATE], read in part, .for pressure ulcer on right and left buttocks: Calazime to area of concern with avoidance of open wounds. A sacral foam to cover the area due to the patient's immobility. The patient was encouraged to offload pressure to the right and left gluteal regions with rotating his position every hour. The patient will need assistance from nursing facility and or staff. When seated, a Roho cushion is recommended to assist an offloading pressure. Please assure that the patient's buttocks is clean and dry from urine and feces as he is wearing a brief. On 9/14/23 at 8:52 AM, an interview was conducted with Certified Nurse Aide (CNA) X. CNA X was asked if she could provide further information regarding the complaint which involved R6 and replied, Yes. R6 had a dressing on his right second toe. It was like a boarder gauze with adhesive around the edges to make it stick. CNA X was asked if she recalled seeing a date or telling anyone about the dressing and replied, Yes. The date on the dressing was 5/22/23 and I told the nurse on shift about it and told the oncoming CNA to keep a watch on R6 because I was worried about his toe. CNA X was asked why she was worried and replied, Well the dressing had been on for about two months. No one had changed it and the toe was red and oozing green pus. The nurse cleaned it and changed it that afternoon. The new dressing for R6's toe stayed on for about two weeks and then I did not see it anymore. I think it fell off and no one put a new one on. R6 also had a wound on his back side that was open and near his tailbone on the right and was red and had purplish coloring on the outer edges which almost looked like a bruise or deep tissue type wound. CNA X was asked if R6 had ever been difficult to provide care for and replied, I never had any problems with him. He was incontinent and needed incontinence care. I do not feel he was being changed as much as he needed to be, or he would not have open areas. On 9/14/23 at 3:20 PM, an interview was conducted with Registered Nurse (RN) G who was responsible for MDS documentation. RN G was asked about R6's wounds and replied, The stage 3 pressure ulcer was facility acquired and the stage 2 pressure ulcer was there prior to his last admission on [DATE]. Review of R6's Face Sheet, revealed the Resident was admitted to the facility on [DATE] with admitting diagnoses including hemiplegia and hemiparesis (paralysis of one side of the body) affecting right dominate side, kidney disease, diabetes mellitus, and dementia. R6's census sheet, revealed R6 was discharged on 10/24/20 and returned on 12/2/20 from a hospital stay. R6 had another discharge on [DATE] and returned on 2/6/23 from a hospital stay. The most recent discharge for R6 was on 7/30/23 and returned on 8/10/23 after a hospital stay. Review of R6's Minimum Data Set (MDS) annual assessment, dated 12/1/2022, revealed in section - M under skin conditions that R6 was at risk for developing pressure ulcers and had no unhealed or existing pressure ulcers. On 9/12/23 at 1:50 PM, an observation was made of R6 in his room. R6 was lying in bed with a foot boot protector on the right foot, a small bandage on the right second toe area, heels were resting directly on the bed, and no other dressings to the right foot. R6 had an air mattress that was set between 320 and 350 pounds per square inch (psi). R6 had a PICC (peripherally inserted central catheter) to his left upper arm with a dressing applied over the PICC and lacked a dressing date last changed. On 9/12/23 at 1:55 PM, an interview was conducted with the ADON F who was asked if R6's PICC dressing had a date on it and if the dressing should have a date on it. ADON F replied, No, it does not have a date. Yes, it should have a date on it to indicate when it was last changed. Review of R6's physician order, dated 1/25/23, read in part, Right lateral foot: Adhesive foam change once a week, as needed if loose, soiled, or saturated. Remove when showering and alleviate pressure at all times. Review of R6's electronic medical record (EMR) progress note, dated 9/2/22, read in part, Intra Disciplinary Team (IDT) met with discussion of resident who continues to have wound to his right gluteal. No change noted this week .Care plans reviewed and are appropriate. Review of R6's weekly skin assessment, dated 9/7/22, read in part, Continues with wound on buttocks near coccyx. *Documentation lacked wound measurements. Review of R6's EMR progress note, dated 9/30/22, read in part, IDT review of resident who continues with a stage II to his sacrum. He has not had improvement in wound status in the last two weeks .Care plans are reviewed and are appropriate. Review of R6's weekly skin assessment, dated 10/12/22, read in part, Right glute open sore / right foot blister. *Documentation lacked wound measurements. Review of the EMR, revealed an order scanned and dated 10/19/22 with ICD-10 code L89.313, which is code for; pressure ulcer of right buttock, stage 3, size 1 x 0.5 x <0.2 cm and debridement - autolytic. Review of R6's weekly skin assessment, dated 11/2/22, read in part, Right buttocks sore. *Documentation lacked wound measurements. Review of R6's weekly skin assessment, dated 11/9/22, read in part, Open sore inner glute. *Documentation lacked wound measurements. Review of R6's weekly skin assessment, dated 11/16/22, read in part, Open sore on right buttocks. *Documentation lacked wound measurements. *R6's right buttock/gluteal wound lacked wound observations and measurements from 9/7/22 through 12/30/22 by facility licensed nurses. Review of R6's wound observation, dated 12/30/22, revealed, a right buttock, pressure ulcer that measured - 2 x 2 x 0.4 cm - comments: Depth has increased, and NP CC is staging it as a stage 3 pressure ulcer. New orders given for calcium alginate and border foam 2 times a week. Review of R6's EMR progress note, dated 1/13/23, read in part, IDT a stage 3 to his R glute, previously this wound was considered a composite wound, but when wound Nurse Practitioner CC was in house this week she changed it to a stage 3. *R6's EMR lacked any wound observation documentation between 12/31/22 through 1/17/23. R6 should have had wound assessments completed on 1/6/23 and 1/13/23 for weekly wound measurements. Review of R6's MDS discharge assessment, dated 2/1/2023, revealed in section - M under skin conditions that R6 was at risk for developing pressure ulcers and had an unhealed or existing pressure ulcer stage 3, and under section E behavior - rejection of care - behavior not exhibited. Review of R6's Care plan history and review, dates 11/1/22 through 9/14/23, revealed, problem started date 1/2/21 - read in part, Problem: Resident is at risk for skin breakdown .Goal: Resident's skin will remain intact. Approach start date: 1/2/2021, conduct a systemic skin inspection every week by licensed nurse. Pay particular attention to the bony prominences. Low air loss alternating pressure relieving mattress setting at 320. Report any signs of skin breakdown (sore, tender, red, or broken areas). Provide incontinence care after each incontinent episode and as needed. Approach start date 11/28/22, Enhanced barrier precautions related to open wound (discontinued on 6/7/23). *Note - no documentation of open wound measurements in wound observations or healed wound for this approach. Problem: start date 12/30/22: Resident has a pressure ulcer .and history of pressure ulcers .approach start date 12/30/22, conduct a skin inspection every week by licensed nurse. Report signs of further skin breakdown (Sore, tender, red, or broken areas). *R6's EMR lack any documentation of a wound and lacked orders for wound care on R6's right foot 2nd toe. Review of R6's EMR, revealed a progress note, dated 7/7/23, read in part, Forwarded to primary care physician (PCP), as well as blood sugars from last week and medication list .Returned with the following abnormals: WBC (white blood cell count) 12.80 [elevated and out of normal range] . *Physician address blood sugars and did not address abnormal lab results. Review of progress note, dated 7/27/23, read in part, CNA informed writer that resident has redness and swelling to 2nd phalange on right foot. Fax sent to PCP for culture and is pending. Review of R6's census, revealed an admission to the hospital on 7/30/23 for cellulitis and osteomyelitis of the right foot second toe and later on 8/4/23 resulted in the right foot second toe amputation. On 9/14/23 at 11:00 AM an interview was conducted with Assistant Director of Nursing (ADON) F who was asked why R6 did not have any wound measurements prior to 12/30/22. ADON F replied, If R6 had an open area the floor nurses should have been documenting and measuring weekly under skin assessments and brought it to my attention. ADON F was asked how she was not aware of the open area if the progress notes indicated there was an open area on R6's skin of concern documented in the IDT notes in September 2022. ADON F replied, Well there were some things that we were missing in documenting the last time the Regional Director of Operations came and did a visit here. On 9/14/23 at 11:40 AM, ADON F was asked if the result of the culture mentioned in the progress note from 7/27/23 was resulted or obtain and replied, I would have to check. ADON F stated later that the culture was never obtained related to the fax being sent to the PCP on the next day and the PCP would have been out of the office then. ADON F was asked why the PCP was not phone verbally and replied, I am not sure, but R6 was sent out on 7/30/23 before the PCP could see him. ADON F was asked if the WBC was elevated on 7/7/23 and then the toe was being cultured on 7/27/23 why the PCP would not address the WBC being elevated and replied, That's the PCP for you. Resident R1 During an interview on 9/14/23 at 8:06 a.m., when asked if R1 had a dressing applied to their Stage IV pressure injury, Registered Nurse (RN) G said R1 had only cream applied to their pressure ulcer wounds and that no dressings were applied to the skin of R1. Review of R1's Face Sheet retrieved from the Electronic Medical Record (EMR) on 9/12/23 at 1:30 p.m., revealed R1 was admitted to the facility on [DATE], and had diagnoses that included: multiple sclerosis, pressure ulcer of right buttock, stage 4 (present on admission), dementia, and paraplegia. Review of R1's MDS assessment, dated 5/2/23, revealed R1 scored 9 of 15 on the BIMS, reflective of moderately impaired cognition. The MDS also revealed R1 had one Stage IV pressure injury that was present on admission. Review of R1's Physician Order Summary, retrieved 9/14/23 at 2:18 p.m., revealed the following, in part: Pressure relief air mattress. No settings. (On & Off), Start Date 7/13/2023 - Open Ended, and Cleanse wound to right ischium with wound cleanser. Apply 50/50 zinc/Lantiseptic ointment to areas in a thin layer. Ensure being changed BID and prn with incontinent episodes. Twice A Day, 5/10/23 - Open Ended. Observation of R1's stage IV wound care occurred on 9/14/23 at 10:33 a.m. RN G, assisted by Certified Nurse Aide (CNA) H donned gowns and gloves prior to beginning wound care. R1's feet/heels were observed resting directly on the bed mattress. CNA H washed the zinc/[NAME] septic cream from the outside of the wound dried to the buttocks and the outside surface of R1's stage IV wound. CNA H did not doff his dirty gloves or perform hand hygiene prior to assisting with positioning R1 in the bed. CNA H held their dirty gloves up in the air, while supporting R1's body with his upper arms. RN G applied wound cleanser to wound with a spray bottle. The interior of the wound was not held open and was not fully cleansed. RN G touched the top of the garbage clan lid with their gloved hand and then picked up a clean 4 x 4 gauze to dry the surface of the wound with the same hand used to touch the garbage can. CNA H's dirty gloves were observed to touch the back of the resident's shirt and R1's thighs. RN G put a very thin layer of the zinc/[NAME] septic cream on the outside of the wound using her gloved fingers, with nothing applied to the interior of the stage IV pressure injury. RN G used her dirty, gloved hands to pick up the zinc/[NAME] septic bottle and the bottle of wound cleanser, contaminating the outside of both bottles with cream applied directly to R1's skin. RN G exited the room, leaving the dirty wound cleanser bottle and wound cream bottle in R1's room. During an interview on 9/14/23 at approximately 10:45 a.m., CNA H was asked if his hands were clean or dirty as he touched R1 during wound care. CNA H confirmed he continued assisting with wound care with dirty gloves. CNA H said he should have washed his hands and donned clean gloves after completion of peri care for R1. RN G was asked if she had partially opened the stage IV pressure injury to cleanse the interior of the wound. RN G stated, No I don't open the wound and look inside. All I know is that there is a thin layer (of Lantiseptic cream) to the exterior of the wound. RN G was unaware of any dressing being required for the wound. The pressure relief air mattress machine at the end of the bed was observed with the button in the off position upon entry to the room with facility staff during the wound care observation on 9/14/23 at 10:33 a.m. The pressure relief air mattress remained off during the entire procedure. RN G and CNA H were in the process of exiting the room when this Surveyor asked RN G if the pressure relief air mattress was supposed to be off for R1. RN G then examined the pressure relief air mattress controls on the footboard of R1's bed on 9/14/23 at 10:58 a.m., confirmed the machine was off, and turn the air mattress back on. A sign on wall by R1's bed revealed the following instructions: Make sure mattress pump is on. During an interview on 9/14/23 at 12:54 p.m., the DON was asked how the interior of R1's stage IV pressure injury should be cleaned. The DON stated, I would use a sterile Q-tip to clean the interior of the wound with wound cleanser. I would attempt to open that wound so that the wound cleanser could get inside. (It is) not acceptable to not go inside the wound (to clean the wound). The DON was informed of the observation details related to R1's pressure injury and confirmed there was a potential for both wound and environmental contamination. Resident R30 During a telephone interview on 9/8/23 at 2:03 p.m., Complainant V expressed concern with skin concerns identified during an emergency room Visit on 6/1/2023. Complainant V stated, [R30] had open wounds. Complainant V said photographs were available that documented the skin concerns. Review of R30's Face Sheet revealed the Resident was admitted to the facility on [DATE] with diagnoses that included the following, in part: functional quadriplegia, congestive heart failure, anxiety disorder, and impaired vision in the left eye. Review of R30's Minimum Data Set (MDS) assessment, reference date of 6/16/23, revealed a Brief Interview for Mental Status (BIMS) score of 15/15 reflective of intact cognition. Record review on 9/13/23 at 9:14 a.m., found no facility documentation in the electronic medical record showing R30 had a sacral/buttock pressure injury prior to transfer to the emergency department on 6/1/23. Observation on 9/12/23 at 11:30 a.m., found R30 lying flat on her back in bed. Bilateral feet were without foot coverings and were positioned directly on the bed mattress. R30 did not respond to verbal communication with this Surveyor. R30's family member answered all questions related to R30's care in the facility. Review of R30's weekly Skin Body Assessments beginning 4/2/23 through 9/10/23, revealed the following, in part: 5/21/23: Areas of Skin Impairment, describe below (was checked) . sore on right anterior shin, redness to abd (abdomen) and breast folds, (and) sore on bottom. No location of the sore on the bottom of R30 or measurements were documented in the facility EMR for R30 prior to emergency room visit on 6/1/23. The area of impairment for R30 was only documented on this Skin Assessment. No other documentation was present in the EMR to record or detail the sore on bottom for R30. 5/28/23: No Areas of Skin Impairment. 6/4/23 and 6/11/23 . Out to Hospital. 6/12/23: Areas of Skin Impairment . open reddened area to the upper left gluteal cheek measuring 1 cm (centimeter) x (by) 3.25 cm. Review of skin photographs documented with the 6/1/23 admission to the emergency department showed purplish/red bruising to both buttock cheeks, with a larger pressure injury, with serosanguinous (blood mixed with clear drainage) exudate (wound drainage) on the left buttock, and a smaller open area on the right buttock cheek. The photograph showed a barrier cream had been applied to the wound area. During a telephone interview on 9/14/23 at 9:36 a.m., RN W was asked about Skin Body Assessments that did not detail all wounds present on R30. RN W stated, If it was not a new opening (wound), sometimes they (facility nursing staff) did not document the open areas. If the wound was previous identified in a Skin Body Assessment staff may not document the wound again on following skin assessments. Resident R51 During an interview on 9/14/23 at 8:06 a.m., RN G said R51 only had a cream applied to her pressure injury, and that no dressings were applied to the skin of R51. Review of R51's Face Sheet revealed Resident R51, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: dementia and need for assistance with personal care. Review of R51's MDS assessment, with a reference date of 7/7/23, revealed a BIMS score of 3 of 15, reflective of severe cognitive impairment. R51 was receiving Hospice care. During wound care observation on 9/14/23 at 11:18 a.m., R51 was observed lying in bed slightly on her right side. R51 winced in apparent pain as they removed her pants. R51 was positioned onto her right hip, and a pressure injury was observed on the inside of the right buttock cheek near the coccyx. Wound cleanser was applied, and the area dried with sterile 4x4 gauze. A small, sealed package of periguard ointment was placed directly on R51's over bed table. RN G used her clean gloves to pick up the Periguard Ointment. RN G opened the potentially contaminated package and used the now dirty gloves to apply the periguard directly onto the entire wound bed on R51's buttock/coccyx pressure injury. During an interview on 9/14/23 at 11:29 a.m., when asked if the surface of the bedside table had been disinfected, RN G acknowledged it had not been cleaned. Placement of clean supplies on a Resident's dirty over bed table was discussed. CNA H, also present during wound care nodded his head up and down in understanding. RN G confirmed the potential environmental contamination to the gloves used to apply the periguard cream directly onto R51's wound had the potential for contamination of R51's wound. No wound dressing was applied to the stage II pressure injury to R51's inner right buttock cheek. Review of the hospice visit documentation provided by the Hospice agency to the facility on 9/13/23, revealed the following electronic discussion related to R51's pressure injury on the interior right buttock cheek near the coccyx, in part: - Hospice Licensed Practical Nurse (LPN) I, 8/15/23 at 1:28 p.m. (CDST), .Assisted the CNA to change the patient' brief and look at her bottom. It is open to air with only her brief over it. CNA states she has many diarrhea-like stools in a day so the nurses do not put the foam on it because they can't change it frequently due to case load. Spoke directly to the nurse and she states the same. This nurse questioned if they need an MD order for something to be put on her wound to help heal it and not cause more breakdown . - Hospice LPN I, 8/30/23 11:20 a.m. (CDST), Patient continues to have the open area to the coccyx area. CNA (Certified Nurse Aide) in nursing home states they are using the barrier cream that was ordered 2 weeks ago but she has not had a foam to that area ever since. The area is not any better and looking at it, looks very sore. Can we get an order for the foam to that area, or do you have another suggestion? Please advise. Thank you. - Hospice LPN I to Hospice RN J, 8/30/23 at 3:41 p.m. (CDST), Can you call this order to [Name of Facility] The wound looks terrible, and they aren't doing anything for pressure relief . During an interview on 9/14/23 at 12:25 p.m., Hospice Supervisor RN J agreed the hospice visit documentation should be available to the facility floor nurses. When asked about the current order for R51's right buttock/coccyx pressure injury, RN J stated, The order said sacral foam daily and PRN (as needed) for Stage II pressure relief. That is the order I believe is in place now. RN J said the order was sent to the facility on 8/31/23 at 9:34 a.m. and said that is the treatment that should be done to R51's coccyx pressure injury currently. RN J stated, I am not aware that they have not been doing the sacral dressing . During an interview on 9/14/23 at 12:47 p.m., the DON was asked to verify the current physician order for R51's coccyx pressure injury. The DON said the current order for R51's coccyx wound was barrier cream. The DON confirmed Hospice had faxed an order to the facility for a foam dressing on 8/31/23 but said an unidentified hospice nurse verbally said the facility could go back to just barrier cream on the wound. When asked for the new physician order for just application of barrier cream to R51's wound, the DON stated, I probably don't have it. I changed the order when the nurse told me, because we could not keep the patches on anyways. When asked if the DON had a physician order for the change to barrier cream, the DON stated, Not right in front of me. The DON acknowledged she had changed the physician order for a foam dressing to be applied to R51's coccyx pressure injury based on the verbal comments of a hospice nurse, not on a new physician order. No physician order was provided to show a change in treatment for R51's coccyx pressure injury. Review of the Pressure Injury Prevention and Care policy, revised 03/2023, revealed the following, in part: Pressure injuries will be assessed and documented upon admission, readmission, upon discovery, and weekly thereafter. Assessment may include the size, location, category/stage, odor (if any), drainage (if any), peri-wound condition, wound edges, undermining, tunneling, exudate, pain, and current treatment order . 7. Physician/provider will be notified if pressure injury shows signs of deterioration, infection, or no improvement for further evaluation and recommendations regarding treatment and interventions. 8. Potential/suggested procedure with pressure injury identification: A. Notify the physician/provider and the resident's responsible party. B. Initiate treatment in accordance with facility protocols, standing orders, or physician orders. C. Document the appearance of the pressure injury (e.g.: size, location, appearance, odor (if any), drainage (if any), condition of peri-wound, wound edges, stage, etc.) D. Implement pressure-relieving or pressure-reducing interventions as appropriate E. Notify the Director of Nursing Review of the undated Dressing Change Competency revealed the following, in part: Establish a clean field: A barrier (paper towels, dressing kit wrapper, etc.) is used. Supplies are opened using clean technique. Indicated ointment/solutions are poured over gauze . Review of the Hand Washing/Hand Hygiene policy, reviewed 04/2023, revealed the following, in part: Practicing Hand Hygiene is a simple effective way to prevent infections by preventing the spread of germs. Wash hands and other skin surfaces when: 1. After immediate contamination with blood, other body fluids or potentially contaminated articles. 2. After removing gloves or other personal protective equipment. 3. After care of each resident. 4. Before and after nursing treatments or procedures (dressing changes, catheter insertion, eye drop instillation, etc.). 5. After handling urinals, bedpans, catheters, sputum, or any other body fluid .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI00139217. All observations and interviews are recorded in Eastern Standard Time (EST). Based on observation, interview and record review, the facility failed to safely transfer one Resident (R56) of three residents reviewed for accidents. This deficient practice resulted in actual harm when R56 fell to the floor and sustained a right hip fracture with subsequent hospitalization, and surgical intervention. Findings include: A review of R56's Narrative and Impression Report, dated 8/29/2023, revealed the following result: 1. Mildly displaced right hip intertrochanteric fracture A review of R56's Emergency Department (ED) Note, dated 8/29/2023 at 12:19 p.m , revealed the following: .Patient has a great deal of chronic debility, lives in a local skilled nursing facility. She had some type of fall 4 days ago. Was seen in the ER by myself 3 days ago, but at times complaining of pain in her right ribs and right knee. X-rays of the right knee were negative for any sign of fracture. Per mother, since then she has developed pain in her right hip and is unwilling to try to bear weight on the leg .X-rays of the right hip show minimally displaced right intertrochanteric hip fracture. No orthopedic surgeon is available. Patient has had surgery previously at [Hospital Name]. Spoke with the orthopedic team there, they are willing to accept the case. Will transfer via EMS (Emergency Medical Services). On 9/12/23 at approximately 12:00 p.m., R56 was observed sitting in her wheelchair near the nurse's station. R56 was beginning to be agitated with staff members attempting to assist her to the main dining room for her meals. An interview was conducted with Registered Nurse (RN) S who was also R56's guardian who stated that R56 was currently have symptoms of a UTI (urinary tract infection) and was normally not so agitated. An interview was conducted with RN S who confirmed R56 had fallen due to an improper transfer and fractured her right hip. R56 was transferred to the local hospital, but they were unable to perform the surgery, so she was transferred again to a hospital where her hip was able to be repaired and sent back to the facility. RN S stated R56 still was upset with the staff who did the improper transfer. R56 was admitted to the facility on [DATE] and had diagnoses including benign neoplasm of cerebral meninges, hemiplegia affecting left nondominant side, and congenital malformation syndromes predominantly associated with short stature. A review of R56's Minimum Data Set (MDS) assessment, dated 6/29/23, revealed she required extensive, two people assist for bed mobility, transfers, and toileting. Further review revealed R56 scored a 99 on the Brief Interview for Mental Status (BIMS), and staff noted R56 had severely impaired cognition. A review of R56's electronic medical record (EMR) revealed the following: 8/25/23 21:40 (9:40 p.m.) written by Licensed Practical Nurse (LPN) N. Resident was lowered to the floor by writer and another CNA (Certified Nurse Aide). Resident was unsteady during transferring. CNA called writer, writer went into room immediately and gently lowered resident to the floor with no injuries. Writer than called charge nurse into the room and resident was lifted back into her chair with no issues. Vital signs revealed to be unremarkable, Resident also denies any pain or discomfort, Resident is sitting in the hallway eating a snack and chatting with other residents at this time. Will continue to carefully monitor and assist. 8/26/23 5:14 Resident stated her leg feels sore. Writer asked if resident would want to take some Tylenol and she said, 'No I just want to sleep.' Resident VSS (Vital Signs Stable). Resident slept well throughout the night. 8/26/23 8:00 Res (Resident) with a noted right leg external rotation and on a pillow. Writer asked res to try and move leg, and res unable to do so. Res with swelling to right knee and dark area around knee cap. Res with c/o (complaints of) pain and shaking noted. Ice pack applied, and on-call paged with V.O. (Verbal Order) from (Physician T) to send res via (transport name) for eval (evaluation) and Tx (treatment) to ER (Emergency Room) . 8/26/23 10:44 Res returned via private vehicle with POA (Power of Attorney). Res with no issues r/t (related to) being lowered to the floor. Res with some c/o pain to knee that was relieved with PRN (as needed) Tylenol. WCTM (will continue to monitor). 8/26/23 21:12 (9:12 p.m.) Resident being monitored after being lowered to floor on 8/25. Writer asked if res has any pain to right leg and res stated a little bit. Res was slow to lift right leg up and writer asked if it was pain that made it difficult to raise leg, res stated 'no, I'm just scared. Writer asked again if she has any pain to the right leg and she shook her head no but stated 'just a little bit. PRN Tylenol was given to help with any pain, scattered redness noted to R (right) knee with no defined edges, size difficult to determine. Res had no c/o pain with writer touching knee. Per CENA, res did fine with transferring this shift, however when res was toileting, she had an episode of shaking. After taking a few deep breaths resident stopped shaking. 8/27/23 23:23 (11:23 p.m.) Resident with some c/o left leg pain. PRN Tylenol given with some relief. 8/28/23 11:24 slight bruising to R knee, c/o pain in knee, not wanting to walk on leg with PT (physical therapy) WCTM. 8/28/23 15:27 (3:27 p.m.) IDT (interdisciplinary team) met during morning meeting to discuss resident's fall over the weekend. Witnessed fall and resident was lowered to the floor in the bathroom after her knees buckled. No injuries although later did have c/o pain and had an ER visit r/t same. No apparent fx (fracture) or other injury noted at the ER> Investigation revealed resident was being transferred onto toilet with 1 CNA, Therapy has been recommending transfer Ax2 (assist times two). Staff education to CNA. 8/29/23 4:20 Staff reported to nurse that res was combative with last rounds and requesting pain medication. Writer entered room and asked res if she was experiencing any pain. Res replied 'Just my leg, just my leg' . 8/29/23 8:08 PCP (Primary Care Provider) gave verbal order to send resident out to [Hospital Name] for evaluation. POA aware and is in agreement. 8/29/23 11:25 Writer notified per POA that res had fractured right hip and is surgical. Res to be sent to [Hospital] for surgery. DON (Director of Nursing) and administrator notified. Resident with continued c/o of right hip/leg pain. Post fall from 8/25/23. Is combative with cares, crying out with movement. POA would like resident sent out for evaluation r/t same. 9/1/23 14:47 (2:47 p.m.) IDT met with discussion of res who was being transferred, her knee buckled, and she was lowered to the floor by staff. Initially appeared to have no injuries, did get sent to ER on 8/26 as she was offering complaints of pain to right knee and ribs, X-rays done which indicated no fractures and she was transferred back to the facility. She did have mild complaints of pain on Sunday and Monday. She started to complain of increased pain to her right hip early Tuesday morning. She was sent back to the ER r/t these complaints, and it was noted that she had a fracture. She then went to [hospital Name] where she underwent surgery to her hip. She returned to the facility post this hospital stay a short time ago. Intervention was for staff education. Care plans reviewed and are appropriate. An attempted phone interview was conducted with LPN N on 9/14/23 at approximately 9:10 a.m. A message was left with no return call prior to the exit of the survey. Review of LPN N's witness statement dated and signed on 8/30/23 read, in part, . (LPN N reports she was at her med cart outside the door of room where (R56) resides. At approximately 2100 (9:00 p.m.) (LPN N heard CNA U call out for help from the bathroom . (LPN N immediately entered the bathroom and observed (R56) on the floor and (CNA U) stated to (LPN N) that (R56's) knees buckled and she had to be lowered to the floor . Further review showed that this witness statement was different than the nurse progress wrote LPN N wrote on 8/25/23 where she stated she helped lower R56 to the floor. An attempted phone interview was conducted with CNA U on 9/14/23 at approximately 9:15 a.m. A message was left with no return call prior to the exit of the survey. Review of CNA U's witness statement dated and signed on 8/29/23 read, in part, .At approximately 2100 (9:00 p.m.) (CNA U) asked resident (R56) if she would like to get her pajamas and get ready for bed. (R56) agreed so (CNA U) brought (R56) in her wheelchair into the resident's bathroom. (CNA U) and (R56) prepared for the transfer. (R56) reached for the grab bar in her bathroom and (CNA U) was beside her. (R56) then used the grab bar to rise out of her chair and stood up. (CNA U) then was assisting (R56) to pivot to the toilet and at that time (R56's) knees buckled. (CNA U) was unable to keep (R56) from falling, she assisted her to the floor in the bathroom as safely as she could . A review of R56's Physical Therapy PT Evaluation & Plan of Treatment dated 6/30/23 revealed the following: .Reason for Therapy .(R56) presents with significant functional decline after prolonged, complicated hospital stays for brain tumor resection. She demonstrates decreased LE/core (Lower Extremity/core) strength impacting ability to perform transfers. She is unable to ambulate and requires assistance from 2 caregivers currently for safety . A review of R56's care plans read, in part, Problem Start Date: 6/30/23 AT RISK FOR FALLS .Approach Start Date: 8/25/23 Increased assistance with transfers .

This citation pertains to intake MI00130021. All times are recorded in Eastern Daylight Time (EDT). Based on observation, interview, and record review, the facility failed to prevent a fall with fracture resulting in harm for one Resident (#29) of two residents reviewed for falls. This deficient practice resulted in decreased mobility, hospitalization, and pain. Findings include: Resident #29 Resident #29's facility incident report, dated 6/14/22, revealed she had an unwitnessed fall on 6/14/22. Orders were received for x-rays from the physician on that same day. Resident #29 expressed discomfort and complaints of pain and was sent to the local hospital. The local hospital contacted the facility and notified the facility of the x-ray results, which indicated that Resident #29 had sustained a right hip fracture. Resident #29's facility incident summary, dated 6/14/22, revealed during a shift-to-shift report the resident had increased pain in her right hip and she was unable to reposition. Resident #29's facility event report, dated 6/14/22, revealed the resident was observed sitting on the floor, weeping, with complaints of pain in the right hip. Pain level 10/10 and described as excruciating pain, worst possible, and interferes with ability to carry on with daily routines, socialization, or sleep. Pain with range of motion in the right hip and inability to move right hip. Facility event report, dated 6/14/22, revealed risk factors to medications as antipsychotic, antidepressant, narcotic, cardiovascular, and diuretic. The electronic medical record (EMR), revealed medical diagnoses that included: dementia, altered mental status, mixed obsessional thoughts and acts, and need for assistance with personal care and difficulty in walking. The Minimum Data Set (MDS) assessment, dated 5/27/22, revealed a Brief Interview for Mental Status (BIMS) for Resident #29 which indicated severe cognitive impairment. Resident #29's progress note, dated 1/29/22, read in part, An unwitnessed fall in the evening where she was found on the floor .Certified Nurse Assistant (CNA) instructed to check on frequently and assist with transfers for the next 24 hours. After this fall there was no new fall risk assessment completed. Review of Resident #29's progress notes revealed the following: 6/5/22 .She does request assistance with ADL's (Activities of daily living). The tasks she does performs on her own are slow process for her and she does stop or not complete them . 6/7/22 .OT (Occupational Therapist) had called writer into the room to talk about the resident confusion / speaking being odd . 6/14/22 - Resident [#29] had uncontrollable pain to right hip after fall .Resident unable to bend right leg and refusing to reposition. 6/14/22 .Local emergency room called with update that resident has a right hip fracture and that they would be transferring her to another facility as they do not have ortho in house right now . 6/17/22 .Resident returned from out of state hospital via wheelchair .Transferred on to her bed with assist of four . 6/17/22 .She expressed discomfort in her right hip .she came back to the facility for a right hip fracture that cannot be surgically repaired .hospital recommended hospice . Resident #29's local hospital records, dated 6/14/22, revealed an x-ray report with findings of acute, displaced intertrochanteric fracture of the right femur (area where the top of the thigh bone meets the pelvic bone). Resident #29's out of state hospital records, dated 6/15/22, revealed medication administered for pain management was given intravenously (medication added directly to the blood stream) Morphine (an opioid) one milligram (a scheduled two class drug) and was given on 6/15/22 twice and on 6/16/22 twice to manage Resident #29's pain caused by her hip fracture. Resident #29's out of state hospital records, dated 6/17/22, revealed orthopedic discharge patient instructions to be non-weight bearing on her right lower extremity. Review of facility CNA Care Sheet, dated 8/1/22, revealed that Resident #29 required a mechanical lift for transfers. Resident #29's quarterly fall risk assessments, revealed no quarterly fall risk assessments were completed between 1/4/21 and 6/17/22 on Resident #29. Resident #29's quarterly fall risk assessment, dated 1/17/21, revealed a fall risk score of 3 (A score of 5 or greater = High Risk. Score of 4 or less = Not a High Risk). Three months later another quarterly fall risk assessment was completed on 3/30/21 and revealed an increased fall risk score of 11. After the quarterly fall risk assessment was completed on 3/30/21, Resident #29's care plan did not include any added interventions to ensure she remained free of injury. Resident #29's fall risk assessment, dated 6/18/22, from the critical admission assessment, revealed a fall risk score of 18. Resident #29's Care Plan, date printed 8/3/22, read in part, Problem: Resident at risk for falling related to fall at home .Goal: Resident will remain free from injury. Approach: Grip strips next to bed. (dated 6/14/22), Provide increased assistance with transfers x 24 hours (dated 1/29/22), Assure resident is wearing eye glasses .(dated 1/21/20), Encourage resident to assume a standing position slowly (dated 1/21/20), Encourage resident to use environmental devices . (dated 1/21/20), Provide proper, well-maintained footwear (dated 1/21/20), and Provide toileting assistance every 2-3 hours and PRN (as needed) (dated 1/21/20). Note fall mat not indicated on care plan, bed rail on right side of bed not present but on care plan, Resident #29 now a Hoyer lift and not indicated, and grip strips on care plan and not on the floor next to bed as indicated per care plan. Review of Resident #29's MDS, section G functional status, dated 5/27/22, revealed a functional status for ADL's for walking in room - score 8 indicating the activity did not occur during a seven-day period. Walk in corridor - score 3 indicating extensive assistance. Mobility devices walker and wheelchair. Functional limitation in range of motion - no impairment. Review of Resident #29's MDS, section G functional status, dated 6/28/22, revealed a functional status for ADL's for walking in room - score 8 indicating the activity did not occur during a seven-day period. Toileting use - score 3 indicating extensive assistance. Walk in corridor 8 - indicating the activity did not occur during a seven-day period. Mobility devices wheelchair. Functional limitation in range of motion - score one = impairment on one side. On 8/3/22, an observation was made of Resident #29, at approximately 7:30 AM, resting in bed, with a fall mat on the floor next to bed. There were no grip strips noted under fall mat as indicated by the care plan. On 8/2/22, at 5:15 PM, an interview was conducted with Resident #29's Family Member K. Resident #29's Family Member K was asked if she had any concerns regarding the care Resident #29 was receiving at the facility and responded, The only concern I have is her falls. She has had a decline since her fall in June. On 8/3/22, at 7:30 AM, an interview was conducted with CNA J. CNA J was asked if Resident #29 was care planned for a floor mat and a right-sided enabler bar and responded, I'm not sure. CNA J was asked how long Resident #29 has had her urinary catheter and responded, She has had it ever since she came back from the hospital after she fell in June. On 8/3/22 at 7:40 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. LPN C was asked if Resident #29 was care planned for a floor mat and if she had grip strips on the floor next to her bed and responded, I would have to look at the plan of care. On 8/3/22 at 9:00 AM, an interview was conducted with the Director of Nursing (DON). The DON was asked how often fall risk assessments were to be conducted on residents and responded, Quarterly and if a fall occurs as needed. The DON was then asked when Resident #29 had her last fall risk assessment completed and responded, I have to check. It was last done on 11/4/21. The [NAME] was asked if she was able to identify an increase in a fall risk or a decrease in a fall risk if the quarterly assessments were not being completed on Resident #29 and responded, No. I do not think so. The DON was asked if she knew what Resident #29's real fall risks were and responded, No. The DON was then asked if she felt that the interventions in Resident #29's care plan prior to her fall on 6/14/22 were adequate for being a high fall risk and responded, No. The DON was asked if the grip floor strips were applied to Resident #29's floor next to her bed to prevent further falls and responded, Probably not. On 8/3/22, an interview was conducted with Occupational Therapist Assistant (OTA) I, at 10:30 AM. OTA I was asked what kind of assistance Resident #29 needed prior to her fall on 6/14/22 and responded, She was a standby assistance / supervision, used the front two wheeled walker, and with a gait belt and one staff. OTA I was then asked what kind of assistance she needed after her fall on 6/14/22 and responded, She is wheelchair dependent and non-weight bearing on her right hip related to her fall with a fracture and non-surgical repair. Review of facility policy titled Fall Prevention and Management, date revised 2/20/2020, read in part, Purpose: to assess resident risk for falls and implement interventions to reduce the incidence of falls and / or mitigate the risk of injury related to falls. Procedure: 1.) Licensed nurses will complete fall risk assessments on residents upon admission, quarterly, and prn (as needed), 2.) When a fall event occurs .4.) The Director of Nursing or clinical leader will review the fall, events surrounding the fall, intervention, and post-fall documentation with the IDT (Interdisciplinary Team) during morning clinical meeting to elicit IDT input and recommendations and determine if additional investigation is needed.