**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number 2607357.Based on observation, interview and record review, the facility failed to prevent the development of pressure ulcers for one resident (Resident #1) of three residents reviewed for skin alterations, resulting in Resident #1 developing three facility-acquired pressures ulcers- one Stage 3 pressure ulcer ( full- thickness skin loss with exposure of the subcutaneous tissue layer beneath) to his coccyx: unstageable wound (full- thickness loss where the depth of the wound is obscured by necrotic tissue or eschar) to his left heel and a deep tissue injury (pressure related injury to subcutaneous tissues that appears as deep bruise under intact skin) to his left lateral malleolus and inconsistencies in classification of the wounds. Findings Include Resident #1:On 9/16/2025 at approximately 12:15 PM, Resident #1 was observed resting in bed watching television. He was well dressed in a knitted shirt and black slacks. His left lower leg was observed to be bandaged above his socks with the date of 9/11. When Resident #1 was asked if he had any other open areas on his body he pointed to coccyx area. CNA (Certified Nursing Assistant) G entered the room and when asked about the resident's wounds she expressed, he has three (pressures ulcers) - left ankle, left heel and coccyx and all were facility acquired. It can be noted Resident #1 did not have soft heel boots on and his bilateral heels were resting on the bed.On 9/16/2025 at 1:30 PM, Wound Nurse F was interviewed regarding Resident 1's three wounds. He stated they were all facility acquired but two they believe are vascular and they are awaiting testing. The three wounds were reviewed:Resident #1's left malleolus was discovered on 7/29/2025 with classification as stage 2 pressure ulcer; on 7/31/2025 it was classified as unstageable. Wound Nurse F expressed he was unsure what the true classification was currently as they are awaiting testing. Left heel opened on 8/7/2025 and was initially classified as pressure DTI (deep tissue injury) but around 8/28/25 is when it was changed to other as it appeared more vascular in nature. He reported the wound was worsening and now it appears to be healing.Coccyx was discovered on 8/7/2025 and the current treatment is triad cream. It is classified at MASD (moisture associated skin damage) which is due to incontinence related moisture. Nurse F stated the wound is associated from Resident #1 sweating or being urine.On 9/16/2025 at approximately 2:00 PM, a review was conducted of Resident #1's medical record and it revealed he was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, diabetes, dementia, hypertension, kidney disease and heart disease. Resident #1 was deemed incompetent but can express his needs to facility staff. Further review revealed the following:admission Skin Assessment 5/26/25:- No skin issues present on admissionCare Plan: .I have an ADL (Activities of daily Living) self-performance.ambulation. I am non ambulatory.Transfer: I require assistance by (1) staff to move between surfaces with use of sliding board. Bed Mobility: I require 1 assistance to turn and reposition in bed.Use of incontinence products-brief.daily skin inspections. Report abnormalities to the nurse.Kardex: Off-loading heels boots as I will tolerate.Bladder Continence and Toilet Use 30-day look back: Most of the lookback, Resident #1 was incontinent and changed about once on each shift, with 8+ hours between episodes and the resident being incontinent 95% of the time.MDS (Minimum Data Set Assessment) dated 8/27/2025 check MDS date for accuracyNumber of Stage 3 pressure ulcers: 1Number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar: 1Number of unstageable pressure injuries presenting as deep tissue injury:1Progress Notes:7/15/2025 04:39: Resident was observed expressing discomfort during check and change. Resident verbally complained of pain in both legs and refused to be touched during care.7/29/2025 10:45: Upon entering the patient's room this morning, stage 2 pressure ulcer was noted to left lateral malleolus, along with a DTI to left heel.8/1/2025 at 14:46:. Resident noted to have stage 3 coccyx, unstageable left lateral malleolus, DTI left heel.8/12/2025: 14:11: .Ulcer of sacral region, stage 3 Sacrum. Frequent incontinence checks. Pressure injury of deep tissue of left heel Left heel: Offload left heel Recommend NWB ( none weight bearing) to the left foot doppler ordered for left lower leg. Decubitus ulcer, ankle, left, unstageable Left lateral malleolus. Pt (patient) is bowel incontinent yes. Pt is urinary incontinent yes. Stage 3 pressure injury - Sacrum Wound Length x Width x Depth: 2.4cm x 1.8cm x 0.1cm. Deep Tissue Injury - Left HeelWound Length x Width x Depth: 2.4cm x 1.5cm x 0.1cm. Unstageable Pressure Injury - Left Lateral Malleolus Wound Length x Width x Depth: 1.4cm x 1.1cm x 0.1cm.9/9/25 at 10:48: .Recommend ordering CT angiogram to further evaluate vascular status given non-healing.foot ulcer.The wound service is consulted for evaluation and treatment of:- Moisture associated skin damage (MASD) to the sacrum, previously coded at Stage 3 Pressure injury. Surface area has decreased.- A diabetic ulcer to the left heel, previously coded as deep tissue injury. Surface area has decreased.- A diabetic ulcer to the left lateral malleolus, previously coded as unstageable pressure injury.Arterial doppler BLE 9/1/25: The common femoral arteries, superficial arteries, and popliteal arteries are well visualized bilaterally. They appear patent without evidence of obstruction to flow. There is no evidence of significance stenosis or atherosclerotic disease.Review was conducted of Resident #1 wound notes for all three wounds and the following was reviewed:Coccyx Wound:Facility acquired- opening on 7/26/2025:Stage 2 on 7/28/2025; MASD IAD Incontinence Associated Dermatitis on 7/31/2025; Stage 3 on 8/7/2025; MASD- IAD Incontinence Associated Dermatitis on 8/28/2025.7/28/2025: 2.13 cm x 2.61 cmx 1.16 cm, 60% slough and 40% epithelial and edges are fragile.7/31/2025: 1.71 cm x 3.09 cm x 0.91 width.light serosanguineous drainage, edges attached and surrounding tissue fragile .8/7/2025: No measurements were indicated on this wound evaluation. Light serous drainage and intermittent pain during care.8/15/2025: 2.73 cm x 2.41 cm x 1.84 cm, light serosanguineous drainage, attached edges ad fragile surrounding tissue with slight pain at dressing change.8/21/2025: 0.88 cm x 1.75 cm x 1.03 cm, islands of epithelium pink or red, light serosanguineous drainage.8/28/2025: 0.51 cm x 2.11. cm x 0.74 cm, sanguineous/bloody drainage, moderate pain at dressing change.There was inconsistency in the classification of the coccyx wound as the facility reclassified it multiple times.Left Heel Wound:7/31/2025: DTI.3.24 cm x 2.51 cm x 1.71 cm, surrounding tissue is fragile, slight pain at dressing change, wound bed is pink or red.8/7/2025:DTI.No measurements included on this assessment, resident reports pain during movement.8/15/2025: DTI.2.76 cm x 2.39 cm x 1.48 cm, edges attached and surrounding tissue is fragile.8/21/2025: DTI.7.17 cm x 4.24 cm x 2.22 cm, surrounding tissue is dry/flakey and fragile, slow to heel.8/28/2025: Consistent with vascular complicated by diabetes.1.78 cm x 2.03 cm x 1.34 cm.dry, flakey, fragile.9/4/2025: 4.01 cm x 3.44 cm x 1.62 cm, type- consistent with vascular complicated by diabetes, 80% slough, light serosanguineous drainage, fragile edges and moderate pain at dressing changes. progress: stalled.9/11/2025: 3.07 cm x 2.9 cm x 1.39 cm. consistent with vascular complicated by diabetes .80% slough, light serosanguineous drainage, moderate pain at dressing changing.It can be noted on 08/28/2025, Resident #1's wound was changed to reflect the facility's current impressions regarding the wound- they stated the wound was consistent with vascular complicated diabetes Left Lateral Malleolus- in house acquired Stage 2 - Unstageable (slough and/or eschar)7/29/2025: Pressure- Stage 2.1.47 cm x 1.63 cmx 1.3 cm, no drainage and intermittent pain.7/31/2025: Pressure- Unstageable (slough and/or eschar).1.3 cm x 1.62 cm x 1.17 cm, 100% slough, light serosanguineous drainage. 8/7/2025: Pressure- Unstageable (slough and/or eschar) .1.85 cm x 1.73 cm x1.39 cm.light serous drainage, edges intact, pain at dressing change.8/15/2025: Pressure- Unstageable (slough and/or eschar) .1.11 cm x 1.36 cm x 1.13 cm.50% slough, no drainage.8/21/2025:Pressure- Unstageable (slough and/or eschar).2.38 cm x 2.25 cm x 1.67cm, 100% slough, light serosanguineous drainage, moderate pain at dressing change.9/4/2025: Consistent with vascular complicated diabetes.6.87 cm x 5.44 cm x 2.45 cm.10% granulation, 90% eschar, light sanguineous/bloody drainage, moderate pain at dressing change.It can be noted on 9/4/2025, Resident #1 wounds were changed to reflect the facility's current impressions regarding the wound- they stated the wound was :consistent with vascular complicated diabetes.: On 9/1/2025 Resident #1's doppler of his bilateral extremities revealed the following, .The common femoral arteries, superficial femoral arteries, and popliteal arteries are well visualized bilaterally. They appear patent without evidence of obstruction to flow. There is no evidence of significant stenosis or atherosclerotic disease. Color doppler analysis reveals normal direction of flow. Doppler spectral analysis reveals normal arterial wave patterns without evidence of spectral broadening. There is no evidence of thrombosis. Overlying soft tissue tissues appear grossly normal.On 9/16/2025 at 12:25 PM, observation was made of Resident 1's left heel and lateral malleolus wound in the presence of CNA G and Nurse I.His heel was observed to be 90%-100% covered with eschar. Nurse I stated the left malleolus had eschar in the center, slough at the base, small amount of maceration with beefy redness surrounding the eschar center. A few inches down from the lateral malleolus wound was an approximately a dime size open area. The center was black/brown, and the surrounding area was red/pink. There was no documentation found related to this new skin alteration for Resident #1.On 9/16/2025 at 10:20 AM, the DON (Director of Nursing) reported Resident #1's three wounds were all discovered around the same time. The DON was asked why the coccyx wound was reclassified multiple times. The DON reported during their wound meeting they discussed what they thought the best course of treatment would be and that is when they decided the wound was MASD and not pressure. The results from the doppler were reviewed which indicated no arterial insufficiencies and the DON was asked as to why the wounds were reclassified at diabetic ulcers when the imaging refutes their stance. The DON stated she would research and provide further clarity. On 09/16/2025 at 11:15 AM, CNA G reported Resident #1 was unable to reposition himself with assistance and he favors laying on his back even when they change his position. The CNA added the residents left foot flares to the left when he is in bed. On 9/16/2025 at 2:06 PM, the DON and Clinical Support Nurse K were interviewed regarding Resident #1's wound. They explained his wounds were inconsistent with pressure and they were not healing. Once they looked deeper into the wounds they found the malleolus and coccyx appeared to have a vascular component to it, they completed the doppler which showed no issues. It was explained this was basic level imaging and after it resulted, they still wanted to image further to rule out vascular issues. They assert his wounds are consistent with vascular complicated diabetes and they are still in the rule out process.It can be noted the wound Nurse Practitioner notes recoded the sacrum wound from a Stage 3 Pressure Injury to MASD, left heel DTI was recoded to diabetic ulcer and left malleolus unstageable pressure injury was recoded to diabetic ulcer on 9/2/25 but during the interview process the facility reported they have not officially recoded the heel and malleolus yet as they wait or further testing. There are inconsistences from the inception of Resident 1's wounds with classification and subsequent diagnosis of the wounds. On 9/16/2025 at 3:15 PM, an interview was conducted with MDS (Minimum Data Set) Coordinator J. She reported she recently completed a significant change for Resident #1 based on his wounds. While she does not complete a physical assessment of the wound she does review the documentation, and the team discusses the wounds in their meetings. When coding the wounds for the MDS she goes off the ARD (Assessment Reference Date), and recent documentation closet to her seven day look back period. Review was completed of the CAA (Care Area Assessment) Worksheet dated 8/25/2025 and it stated the following, (Resident #1) is a long term care resident here at the facility. He requires assist with all adls (activities of daily living). He has three facility acquired pressure ulcers.he is incontinent of bowel and bladder and requires assist with incontinence care and toileting.He has a stage 3 pressure ulcer to his coccyx, a DTI to his left heel and an unstageable pressure ulcer to his left lateral malleolus. According to the National Pressure Injury Advisory Panel, dated 9/11/2025 . The heel is one of the most common anatomical sites for PI (pressure injuries.Review was conducted of the facility policy entitled, Skin Management Guidelines Prevention of Pressure Ulcers/Injuries, reviewed 11/2024. The policy stated, .Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Identify any signs of developing pressure injuries (i.e., nonblanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); Wash the skin after any episodes of incontinence, using pH balanced skin cleanser.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #58: During initial tour on 10/28/2024, Resident #58 was observed resting in bed laying on her back, with only a pillow under her head. Resident #58 was asked if she had any open wounds on her body and she shared she has a sore on her bottom. On 10/28/2024 at approximately 7:30 AM, a review was completed of Resident #58's medical record and it revealed she initially admitted to the facility on [DATE] with diagnoses that included, Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure, Pressure Ulcer of Sacral region, muscle wasting and atrophy and Acute Kidney Failure. Further review of Resident #58's records yielded the following: Progress Notes: 7/17/2024 at 15:17: When doing a skin assessment on this resident it was noted she has a new pressure wound to her coccyx .ordered an air mattress for the resident . 7/18/2024 at 12:38: .Wound #1 is an unstageable pressure to her coccyx . 8/7/2024 at 10:09: Assessed residents coccyx wound today, wound is draining purulent drainage. Wound bed 25% slough . 8/15/2024 at 12:42: Resident sent to the hospital . for further evaluation due to pressure on the coccyx and risk for infection . Care Plan: (Resident #58) has actual impairment to skin integrity r/t (related to) abrasions Stage 2 right buttocks .If the resident refuses treatment, confer with the resident, IDT and family to determine why and try alternative methods to gain compliance. Document alternative methods .The resident needs assistance to turn/reposition at least every 2 hours, more often as needed as she will allow .I have impaired cognitive function or impaired thought processes r/t mild cognitive impairment .Bed mobility: 1 require extensive assist of 1. Dressing: I require extensive assist of 1 .Transfers: mechanical lift 2PA (person assist) . July 2024 TAR (Treatment Administration Record): Review was completed of the TAR, and it indicated on 7/2/2024, 7/9/2024 and 7/16/2024 (one day before the pressure injury was discovered) a body audit was documented as completed on Resident #58, that stated no new skin breakdown. On 7/17/2024 an unstageable pressure injury to Resident #58's coccyx was discovered. August 2024 TAR: Resident #58 did not receive scheduled wound treatments on the following days: 8/10/24 8/13/24 8/23/24 8/24/24 8/26/24 Furthermore, Resident #58 was sent to the hospital on 8/15/2024, but nursing staff did not indicate that on the TAR so it appeared the resident missed multiple wound treatments. Cleanse coccyx wound with wound cleanser, pat dry apply calcium alginate with silver, cover foam dressing, change daily and prn. Started on 7/25/2024 and discontinued on 8/19/2024. Cleanse coccyx wound with wound cleanser, pat dry apply calcium alginate with silver, cover foam dressing, change daily and prn. Started and discontinued on 8/23/2024. Resident #58 never received this treatment to her wound. September TAR 2024: Resident #58 did not receive scheduled wound treatments on 9/8/2024, 9/17/2024 and 9/25/2024. October TAR 2024: Resident #58 did not receive scheduled wound treatments on 10/2/24 and 10/7/24. On 10/30/2024 at 2:10 PM, an interview was conducted with Unit Manager/Wound Care Nurse M regarding Resident #58's facility acquired coccyx wound. Nurse M expressed the resident will not turn and reposition and prior to development of the wound she refused the specialty mattress. Nurse M was queried on what the facility has trialed to offload the resident from her back. When asked about a wedge pillow or body pillow or other unique way to offload her. Nurse M reported they had not tried anything of that nature to her knowledge. Nurse M was asked when the last time the resident has been out of bed, and she reported it had been a while. Nurse M expressed once she was alerted to the wound it was already progressing and its highly unlikely the wound was not present the day prior when the body audit was completed. Nurse M explained given the presentation of the wound there would have been the presence of skin impairment in this area prior to facility staff alerting her to the wound. The wound developed due to the resident positioning in bed. Nurse M was asked to provide any evidence that showed facility staff were attempting other methods to offload the resident and/or get her out of bed since wound inception. On 10/29/2024 at approximately 8:00 AM, Resident #58 was observed laying in bed on her back. Further review was conducted of Resident #58's wound documentation from inception on 7/17/2024: 7/17/2024: 0.87 cm (centimeter) x 2.13 x 0.52cm: Unstageable pressure, 100% slough, periwound is non-attached. 7/24/2024: 1 cm x 1.92cm x 0.76cm; Unstageable pressure, 100% slough, moderate serous exudate . 7/31/2024: 1.21cm x 1.91xm x 0.78; Unstageable pressure, 100% slough, non- attached edges, progress -deteriorating . 8/7/2024: 8.84cm x 4.36cm x 2.94cm; Unstageable pressure, 30% granulation, 70% slough with increased drainage, seropurulent exudate with faint odor, stated on Doxycycline for suspected wound infection. 8/14/2024: 15.99cm x 5.52cm x 4.15cm: Unstageable pressure ,50%granulation, 50% slough with redness and inflammation; moderate serosanguinous exudate; induration 2-4 cm extending >50% around the wound. 8/28/2024: 12cm x 4.95cm x 3.31cm: Stage IV pressure: 50% slough, moderate serosanguinous exudate with faint odor. 9/11/2024: 32.72cmx 7.04cm x 6.19cm; Stage IV pressure, 80% granulation with 20% slough; purulent exudate with faint odor; rolled edges. 9/24/2024: 17.09cm x 5.3cm x 4.16cm; Undermining:1.5 cm from 1 to 2 o'clock- 2.0 cm from 10 to 12 o'clock, Stage IV pressure, 90% granulation and 10% slough, sanguineous/bloody exudate. 10/1/2024: 13.24xm x 4.79cm x 3.89cm; undermining 2.0 cm from 10 to 5 o'clock. Stage IV pressure, 90% granulation and 10% slough, sanguineous exudate, progress: deteriorating. 10/29/2024: 28.96cm x 7.86cm x 5.11 cm, deepest point-0.3cm, 0.5cm from 7 to 11 o'clock, Stage IV pressure, 100% granulation, serosanguinous exudate. It can be noted the wound documentation stated Resident #58 will only lay on her buttocks and they educated her regarding offloading. There was no evidence presented of other interventions attempted with the resident to offload her, encouragement provided or any other efforts to assist in their feet. On 10/30/2024 at approximately 6:30 AM, Resident #58 was observed laying flat on her back. There were pillows observed in the room to reposition her. On 10/31/2024 CNA (Certified Nursing Assistant) H was asked when the last time Resident #58 had been out of the bed. The CNA stated she has not been out of the bed since summer, and she just lays on her back as she won't allow staff to reposition her. There was no other evidence provided by the facility regarding substantial interventions utilized to prevent the development and worsening of Resident #58's coccyx pressure injury. This Citation Pertains to Intake Numbers MI00147625, MI00147548, and MI00147423 Based on observation, interview, and record review, the facility failed to implement and operationalize policies and procedures to ensure pressure ulcer prevention and management for five residents (#5, #56, #58, #60, and #76) of eight residents reviewed. This deficient practice resulted in a lack of implementation of meaningful, appropriate, and planned interventions for pressure ulcer prevention, multiple residents developing pressure ulcers, unnecessary pain, and the likelihood for a decline in overall health status. Findings include: Resident #56: On 10/28/24 at 11:10 AM, Resident #56's room door was observed to be closed. Upon knocking and entering the room, a pungent, foul odor with overwhelming putrid qualities was immediately noted. The smell grew stronger closer to the Resident. The Resident was lying in bed on their back with their knees bent and heels/feet directly against the mattress. Resident #56 was wearing a hospital style gown. When queried if they had any wounds or open areas on their skin, Resident #56 revealed they have an open area on their back. With further inquiry, Resident #56 revealed the wound developed at home. When queried regarding wound care provided at the facility, Resident #56 revealed dressing change times are not consistent due to staffing but indicated staff usually change the dressing. When queried if staff remind and/or assist them to turn and reposition in bed every two hours, Resident #56 responded they do not and revealed they do not always see a staff member that frequently. At 11:18 AM, Certified Nursing Assistant (CNA) U entered Resident #56's room. CNA U assisted the Resident to roll to their right side to provide care. After rolling onto their side, a wound on the Resident's upper left back was visualized. An undated was dressing was in place but did not cover the entire wound bed. Dark colored wound drainage was present on the bedding where the Resident had been laying. Record review revealed Resident #56 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD), diabetes mellitus, pressure ulcer (wound caused by pressure), and lower extremity contractures. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the Resident was cognitively intact and required supervision/touching assistance for rolling and moderate to total assistance for transferring, bathing, and toileting. The MDS further detailed the Resident had a stage three (full thickness tissue loss pressure ulcer). Review of Resident #56's Electronic Medical Record (EMR) revealed a care plan entitled, I have impaired skin integrity related to admitted with . Stage III pressure ulcer to back . (Initiated: 8/3/24; Revised: 10/22/24). The care plan included the interventions: - Daily skin assessments (Initiated: 8/28/24) - Float my heels while in bed (Initiated: 8/3/24) - Treatments as ordered . (Initiated: 8/4/24) - Turn and reposition q (every) 2 h (hours) (Initiated: 8/3/24) - Weekly wound measurement and evaluation (Initiated: 8/3/24) On 10/30/24 at 5:17 AM, 7:39 AM, and 8:14 AM, Resident #56 was observed in their room in bed. For all three observations the Resident was positioned on their back with the heels and feet positioned directly against the mattress. An observation of wound care for Resident #56's left upper back pressure ulcer was completed on 10/30/24 at 11:49 AM with Licensed Practical Nurse (LPN) G. LPN G removed the dressing from the wound bed and a small amount of dark reddish colored drainage was observed. The wound bed was red in color and irregularly shaped. Resident #60: On 10/28/24 at 12:14 PM, Resident #60 was observed lying in bed in their room with their eyes open wearing a hospital style gown. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. The room lights were off, the blinds were closed, and there was no visual and/or audio sensory stimulation. When queried regarding the care they receive at the facility, Resident #60 stated, I got a sore spot on my butt it ain't going away. Resident #60 then stated, Been waiting to talk to nurse about my butt. When asked if the area hurt, Resident #60 responded that it did. An observation of the Resident's room revealed no positioning devices and/or additional pillows for pressure relief. When queried if staff assist them to turn and reposition in bed, Resident #60 shook their head to indicate no. When asked if they are able to turn themselves in bed, Resident #60 repeated that there was a sore spot on their buttocks but did not provide a response to the question. When queried regarding getting out of bed and staff assistance, Resident #60 replied that they cannot walk and do not get up. Record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included dementia, malnutrition, arthritis, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was moderately cognitively impaired and required substantial to total assistance to complete all ADL's with the exception of eating. The MDS further detailed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Upon request for a list of Residents with wounds and pressure ulcers, the facility provided a list entitled, Wound Report for 10/23/24. The report detailed Resident #60 had Shearing to right and left buttock that was present upon admission. Review of Resident #60's Healthcare Provider (HCP) orders and Treatment Administration Record (TAR) revealed the Resident had the following active wound care order in place, Cleanse open areas to BL (bilateral) buttocks with wound cleanser. Pat dry. Apply calcium alginate (wound dressing indicated to treat moderate to heavily draining partial to full thickness draining wounds including full thickness tissue loss pressure ulcers, tunneling wounds, and some burns) to wound beds. Cover with a foam dressing. Change every 3 days and PRN (as needed) every night shift every 3 day(s) for wound care (Start Date: 10/9/24). A second active PRN order for the same treatment was present for if dressing missing or soiled Review of Resident #60's Completed, Discontinued, On hold, Pending Clinical Review, Pending Confirmation, and Struck out HCP orders revealed the following: - Cleanse open area to left buttock with wound cleanser. Pat dry. Apply Selan cream to open cleanser. Pat dry. Apply Selan cream to open area. Cover with a foam dressing. Change daily and PRN (as needed) . if dressing soiled or missing (Ordered: 9/19/24; Discontinued: 10/9/24) - Cleanse open area to left buttock with wound cleanser. Pat dry. Apply Selan cream to open cleanser. Pat dry. Apply Selan cream to open area. Cover with a foam dressing. Change daily and PRN every night shift . Review of Resident #60's EMR revealed the following Wound Evaluation assessment documentation: - 9/19/24 - 4:07 PM . Coccyx . Present on admission . Length: 13.21 cm (centimeters). Width: 6.41 cm. Deepest Point: 0.1 cm . Describe: Type Other . Shearing (a contributing factor in pressure ulcers, a wound caused solely by sufficient pressure and force to keep the body moving in one direction - friction) . Wound Age Unknown . Staged by In-house nursing . Wound Bed . Granulation . 100% . Exudate . None . Treatment . Primary Dressing . Selan (zinc oxide barrier cream) Secondary Dressing: Foam . Additional Care: Incontinence management, Mattress with pump, Moisture barrier . Turning/repositioning program . Education Educated resident on the importance of turning and repositioning every 2 hours as tolerated . The wound picture included with the assessment and used to measure the wound showed a large open wound on the right buttocks with irregular borders and a pink/red colored wound bed with areas of black tissue within the wound bed. Two separate, smaller wounds were proximal to the larger wound on the right buttocks. A separate wound was present on the coccyx and left buttocks. The wound bed was irregularly shaped and approximately 45% of the wound bed being composed of dark black and purple tissue, approximately 5% of the wound bed being visible deeper and deep red in color and the other areas of the wound bed pink in color. - 9/24/24 - 1:25 PM . Coccyx . Length: 9.26 cm .Width: 4.46 cm . Deepest Point: 0.1 cm . Describe . Shearing . Granulation . 100% . Exudate . None . Treatment . Primary Dressing . Selan . Secondary Dressing: Foam . Additional Care: Incontinence management . Moisture barrier . Nutrition/dietary supplementation . Turning/repositioning program . Educated resident on the importance of turning and repositioning every 2 hours as tolerated . The wound picture included was taken from a different angle and the wound on the right buttocks was not entirely captured in the picture/measurement. The picture showed the wound on the right buttocks and the coccyx/left buttocks to be completely separate areas not connected by a skin bridge. The two separate, smaller wounds proximal to the wound on the right buttocks were not visible in the image. A white colored substance was present around the coccyx/left buttocks wound edges in the picture. The wound bed was a milky white/pink color with darker area of tissue present at approximately the 7 to 8 o'clock position of the wound bed. - 10/22/24 - 11:23 AM . Coccyx Length: 7.5 cm . Width 1.93 cm . Shearing . Wound Bed . Epithelial 50% . Granulation 50% . Exudate: Light . Serous . Treatment . Dressing Appearance: (Prior) Missing . Primary Dressing: Calcium alginate Secondary Dressing: Foam . Additional Care: Cushion, Heel suspension/protection device, Incontinence management, Moisture barrier, Moisture control. Nutrition/dietary supplementation, Turning/repositioning program . Notes resident noted to be lying on right side most of the day and does not like to reposition off the right side; attempts to float heels off bed declined. Education attempted; resident not able to retain information . The attached wound picture included in the assessment was from a different angle than previous pictures. The entire coccyx/left buttocks was not included in the image. The open wound on the right buttocks appeared to have a skin bridge but the wound bed was unable to be completely seen for description due to the angle of the image. The Resident was visibly soiled, and bowel movement was present in the image. - 10/29/24 - 9:22 AM . Coccyx . Length: 7.02 cm . Width: 2.18 cm . Describe . Shearing . Granulation . 100% . Scab . Exudate . Light . Serosanguineous . Treatment . (Prior) Dressing . Missing . Primary Dressing: Calcium alginate Secondary Dressing: Foam . Additional Care: Cushion, Heel Suspension/protection device, Incontinence management, Mattress with pump . Repositioning device(s), Turning/repositioning program . Notes Shearing has improved. One small, superficial scab to left buttock and superficial excoriation to right buttock remains . Education: Attempted but resident cognition is poor . The attached wound picture included in the assessment was from a different angle than previous images and the entire coccyx/left buttocks was not included. The coccyx/left buttocks wound visible in the image was pink in color with an oblong area on dark yellow/light brown colored tissue in the center. The open wound on the right buttocks was unable to be completely visualized due to the angle but appeared to have a skin bridge but the wound bed was unable to be completely seen for description due to the angle of the image. Review of Resident #60's EMR revealed a care plan entitled, I have impaired skin integrity skin impairments to bilateral buttocks r/t mobility and incontinence of bladder and bowel . HX (history) of PI (Pressure Injury) with scar tissue . Risk for friction and shearing . (Initiated: 9/19/24; Revised: 10/15/24). The care plan included the interventions: - Weekly wound measurement and evaluation (Initiated: 9/19/24) - Remind me as needed to move feet and legs to offload pressure (Initiated: 9/19/24; Revised: 10/15/24) - APM mattress (Initiated: 9/19/24; Revised: 10/15/24) - I prefer to not offload pressure as recommended (Initiated: 9/19/24) - Daily skin assessments (Initiated: 9/19/24) - Encourage and assist me to turn and reposition as I tolerate, If I decline attempt small shifts of body. If I decline both reapproach at later time (Initiated: 9/19/24; Revised: 10/15/24) Review of Resident #60's care plans revealed the Resident did not have a care plan and/or intervention in place On 10/30/24 at 5:13 AM, Resident #60 was observed in their room from the hallway of the facility. They were uncovered and their brief was visible. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. Upon entering the room, there were no additional pillows and/or positioning devices in place on the bed, floor, or in the room. The Resident did not have heel suspension/protection devices in place nor were there any observed in the room. An interview was completed with Licensed Practical Nurse (LPN) G on 10/30/24 at 7:34 AM. When queried regarding Resident #60's wounds and treatments, LPN G reviewed the Resident's EMR and stated the only treatment they had for the Resident was skin prep to heels. When queried regarding the wound on the Resident's coccyx/buttocks, LPN G reviewed the Resident's EMR again and verbalized they were unaware of the area because the treatment is completed on the night shift. LPN G revealed the wound care treatment on the Resident's coccyx/buttocks was not due to be completed. At 7:36 AM on 10/30/24, Resident #60 was observed in their room. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. On 10/30/24 at 8:27 AM, Resident #60 was observed in their room in bed. The Resident was laying on their back and slightly on their right side with their lower legs and heels positioned directly against the mattress. An interview was completed with RN CC on 10/30/24 at 8:29 AM. When queried regarding observation of Resident #60 being in the same position, lack of positioning devices, and lack of heel boots (suspension/protection devices), RN CC revealed they would need to review the Resident's EMR. No further explanation was provided. Resident #76 On 10/28/24 at 12:19 PM, Resident #76 was observed laying on their back in bed in their room. Their legs and heels were positioned directly against the mattress and both of their feet were pressed against the footboard of the bed. The knee section of the bed was observed to be elevated positioning their feet lower than their knees. Resident #76 was taller than average height for a male and their bed did not have a length extension in place. The Resident's left hand was in a fist and their left arm was visibly edematous and positioned flaccidly by their side directly on the mattress. When queried, Resident #76 revealed they had a stroke which effected their left side and had minimal movement in their left arm and hand. When queried if they were able to turn and reposition themselves in bed, Resident #76 verbalized they could not. When queried if the staff assist them to turn and reposition them in bed, Resident #76 verbalized they do not. When queried regarding the care they receive, Resident #76 stated, This place is terrible. When asked why, Resident #76 replied, The aides have attitude. Resident #76 was asked how the aides have attitude and replied, They tell me it's not their job when ask for help. Resident #76 further revealed there are rarely staff present on the unit and it takes an hour or two for staff to answer their call light when they do need assistance. Resident #76 specified there are two Certified Nursing Assistants (CNA) who check on them, but the rest do not. When queried if they had any open areas and/or wounds, Resident #76 relayed they had something on their buttocks but did not think it was open. On 10/29/24 at 8:16 AM and 10:57 AM, Resident#76 was observed laying in bed positioned directly on their back with their legs and heels positioned directly against the mattress. The knee area of the Resident's bed remained bent, and their feet lower than their knees and pressed against the footboard. Record review revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included left sided hemiplegia and hemiparalysis (one sided paralysis) following cerebral infarct (stroke), heart failure, diabetes mellitus, and weakness. Review of the MDS assessment dated [DATE] revealed the Resident was cognitively intact and required maximum/substantial assistance for rolling/turning, bathing, and hygiene and total assistance for transferring. The MDS further revealed the Resident was at risk for, but did not have any pressure ulcers. Review of Resident #76's EMR revealed a care plan entitled, I have impaired skin integrity related to admission with shearing of the sacrum area (Initiated and Revised: 9/6/24). The care plan included the interventions: - Float my heels while in bed (Initiated: 6/22/24) - Turn and reposition q2h (Initiated: 6/22/24) - Weekly skin assessments (Initiated: 6/22/24) - Weekly wound measurement and evaluation (Initiated: 6/22/24) A second care plan entitled, I am at risk for altered skin integrity related to decreased mobility (Initiated: 9/6/24) was noted in Resident #76's EMR. The care plan included the intervention, Apply house stock barrier cream to skin prn to protect from moisture (Initiated: 9/6/24). On 10/30/24 at 5:10 AM, 8:35 AM, and 10:14 AM, Resident #76 was observed in their room in bed. The Resident was positioned on their back with their legs and heels positioned directly against the mattress. The knee area of the bed remained elevated causing the Resident's feet to be lower than then their knees. There were no additional pillows for positioning on the Resident's bed. An interview was completed with CNA C on 10/30/24 at 10:36 AM. When queried, CNA C confirmed they were assigned to care for Resident #76. CNA C was then asked if Resident #76 is able to turn and reposition themselves in bed and revealed they could not. When queried if the Resident was supposed to be turned and repositioned by staff, CNA C replied, Yeah. CNA C was asked when Resident #76 had last been turned and repositioned, CNA C stated, Well, I ain't done (Resident #76) yet this morning. It was last night. When asked what time, CNA C was unable to recall. When queried what time they started work, CNA C replied that they were doing a double. When asked what they meant, CNA C stated they worked days yesterday then came back for night (shift) and were now working day shift. When asked how they reposition Resident #76, CNA C replied, Turn and put a pillow under (Resident #76) if they ask for it otherwise (Resident #76) just lay on their back and raises the head of the bed. When asked if they were saying they only repositioned and offloaded pressure with a pillow if Resident #76 asked, CNA C confirmed and reiterated Resident #76 is able to raise the head of their bed with the bed controls. An observation of care and Resident #76's skin was completed with CNA C and Registered Nurse (RN) CC on 10/30/24 at 10:39 AM. On the ball area of Resident #76's left foot, under the great toe, a darkened and discolored area of skin, circular in shape and approximately the size of a nickel was noted. When asked if the area was blanchable, RN CC pressed on the area and blanching was not observed. When asked, RN CC confirmed the tissue was non-blanching. On Resident #76's distal left heel, a dark black colored area of tissue was observed. The area was circular, slightly smaller than a dime, and located directly over a bony prominence. RN CC was asked if the area was blanchable and applied pressure. The area directly over the darkened black area was observed to be non-blanchable. When queried, RN CC confirmed the area was non-blanchable. When queried, Resident #76 stated their left heel had been hurting. A follow up interview was completed with RN CC and Unit Manager Licensed Practical Nurse (LPN) P on 10/30/24 11:07 AM. When queried regarding observations of the Resident on their back in bed with their lower extremities positioned directly against the mattress and feet pressed against the foot board of the bed as well as staff statement related to repositioning, both RN CC and LPN P confirmed Resident #76 should be turned and repositioned every 2 hours. When queried regarding observations of Resident #76's heels not being elevated and/or floated in bed as indicted on their care plan, RN CC and LPN PP verbalized understanding but did not provide further explanation. When asked if the Resident had heel boots in place due to their lack of mobility and pressure ulcer risk, RN CC and LPN P revealed they did not. When queried if the area identified on the ball area of Resident #76's left foot under the great toe may have been caused from where the Resident's foot was pressing against the footboard, both staff revealed that may be the cause. When queried if the area was a pressure injury, RN CC affirmed it was. When queried if the area identified on the Resident's heel was also caused from pressure, the staff indicated it was. RN CC and LPN C were then asked what the areas would be classified as and revealed a Deep Tissue Injury (DTI- pressure ulcer with unknown depth due to intact skin and underlying tissue damage) or a suspected Deep Tissue Injury (sDTI- localized area of discolored intact skin with underlying tissue damage of unknown depth caused by pressure). On 10/30/24 at 11:30 AM, an interview was completed with the facility Administrator. When queried, the Administrator verified the Resident was unable to turn/reposition themselves and that their heels were supposed to be elevated off the mattress. The Administrator revealed they were surprised the Resident did not have heel boots in place. An observation of Resident #76 and their room was completed with the facility Administrator at this time. The Resident was observed lying in bed, positioned on their back upon entering the room. When queried regarding Resident #76's feet being pressed against the footboard of their bed, the Administrator confirmed Resident #76 is tall and the bed is short for them. When queried regarding the knee section of Resident #76's bed being elevated, causing their feet to be lower than their knees and the controller not working, the Administrator asked Resident #76 what happened, and the Resident confirmed the bed was stuck. The Administrator verbalized they would get a longer and functioning bed for them. The Administrator asked Resident #76 if they had heel boots in their room and Resident #76 informed them that they did not. On 10/31/24 at 12:03 PM, Resident #76 was observed laying in in bed on their back with their legs and heels positioned directly against the mattress. An interview was completed with RN HH on 10/30/24 at 2:00 PM. RN HH indicated wound images were obtained of Resident #76's feet and verbalized they did not see the areas identified with RN CC. A review of the images obtained by the facility revealed the areas identified were not included. A second skin observation of Resident #76's left foot was completed on 10/31/24 at 11:00 AM with RN CC. The darkened and discolored areas were present the Resident's left heel and the ball area under great toe. The ball area under the great toe was less pronounced. When [NAME][TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This Citation pertains to Intake Number MI00131408 Based on interview and record review the facility failed to order a critical lab on 08/27/22 and administered three doses of Coumadin (medication used to treat blood clots) without laboratory results reviewed by a physician for one resident (Resident #125), resulting in Resident #125 stat PT (prothrombin time)/ INR (international normalized ratio) not being ordered on 08/27/22 as directed by the facility provider, being administered three doses of Coumadin without laboratory results and review, an INR of greater than 9.95, PT greater than 99 with blood noted in the resident's stool and subsequent evaluation at the emergency room with a Vitamin K infusion. Findings Include: Resident #125: On 11/15/22 at approximately 10:15 AM, review was completed of Resident #125's medical records and it revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Paroxysmal Atrial Fibrillation, Rheumatoid Arthritis, Major Depressive Disorder and Anxiety Disorder. Resident #125 required assistance with her ADL's and was assessed of having a mild cognitive impairment. Further review of her chart yielded the following: Hospital Discharge Records: Discharge Diagnosis: Paroxysmal atrial fibrillation/AFIB on Coumadin: rate controlled; INR therapeutic . Discharge Medications: .Warfarin 3 MG (milligrams) tablet; Take 1 tab (tablet) by mouth in the evening . Physician orders: - Warfarin Sodium Tablet 3 MG give 1 tablet by mouth one time a day for anticoagulation. Ordered on 8/5/2022 Care Plan: Focus: (Resident #125) is on Anticoagulant therapy r/t: Atrial fibrillation . Initiated on 8/30/22 about three weeks after her admission date. Hospice Progress Notes: 8/30/22: .Pt (patient) had critical INR level and was having active GI (gastrointestinal) bleeding, facility NP (Nurse Practitioner) and Pt's daughter wanted her sent to the hospital for treatment . 8/31/22: .Was recently rehospitalized to treat critical INR levels and bleeding d/t (due to) Coumadin therapy, which has been discontinued . On 11/15/22 at 9:30 AM, an interview was conducted with Nurse AA regarding Resident #125's Coumadin administration and PT/ INR laboratory results. Nurse AA reported she worked night shift on Saturday (8/27/22) and was never informed in report by Nurse CC that a stat lab had been ordered for the resident. Nurse AA further reported she was not aware Resident #125's Coumadin was on hold for 2 days prior. Nurse AA continued prior to administering the residents Coumadin she searched for the PT/INR results on both medications carts, medical records and other places but was not able to locate it. She reported at that time there was not a specific form dedicated to residents who were prescribed Coumadin for a quick reference for staff and added all facility staff did not have access to the lab portal to view laboratory results. Nurse AA reported she does take responsibility for administering Resident #125's Coumadin without having the PT/INR results and contacting the provider. After this incident the facility began to implement procedures and processes for residents prescribed Coumadin. Nurse AA reported while she takes responsibility for her actions no other staff members were reprimanded for the systemic failures. She continued she was informed by management that she would take blame for the totality of the incident when there were multiple failures. Nurse AA reported the nurse that initially took the order from the physician or Nurse Practitioner did not input the order, this pertinent information was not passed off in report and there was no streamlined process. On 11/15/22 at approximately 2:05 PM, Nurse CC was interviewed regarding the process for ordering labs. The nurse reported they receive the initial order from the provider, and they usually input it into their electronic medical records. Once the order is in the system a facility nurse must confirm the order in the record and then put the order into the laboratory system Nurse CC reported if it's a stat lab the process is the same, she clarified if the order is not put in the lab portal it will not be drawn, as their electronic medical record and lab system are not integrated. Nurse CC reported Monday and Thursdays are standing lab order days for PT/INR's and the orders would be added at admission or when they medication was began. Nurse CC was asked if residents on Coumadin and their PT/INR results were discussed during shift report, and she reported it is. Nurse CC was queried if she recalled caring for Resident #125 on 8/27/22. Nurse CC stated there were two nurses working on the Bay until 2 PM. At 2 PM she took report from Nurse DD as she was providing care for Resident #125 until she left at 2 PM. Nurse CC expressed she cannot recall if she was aware of the stat lab that was ordered or if this information was passed off in report to her. Nurse CC stated she does not believe she reported on anything regarding Resident #125's Coumadin and PT/INR when she gave report to Nurse AA. Nurse CC continued the stat lab would have been completed on night shift prior to their arrival. On 11/16/22 at 11:00 AM, an interview was conducted with Nurse DD regarding Resident #125's labs. Nurse DD was not able to recall the resident or anything to do with the incident. Nurse DD reported typically in report they would discuss pending PT/INR lab and all residents that are prescribed Coumadin. Further review was completed of Resident #125's medical records and the following was found: Provider Progress Notes: 8/26/22 at 00:00: Patient is [AGE] year-old female with a past medical history of Paroxysmal A. Fib on Coumadin . Patient was seen today to follow-up on fall and PT/INR results regarding anticoagulant management. INR returned therapeutic at 4.32. New orders given . Patient has no evidence of bleeding. Patient denies bloody nose or blood in the stool. No reports of hematuria or hematochezia. No overt bruising is noted . Long term (current) use of anticoagulants: INR 4.32. HOLD Coumadin x 2 days. No active signs of bleeding. Recheck INR on Saturday, 8/27/2022 INR goal range 2-3 . 8/30/22 at 00:00: Patient is [AGE] year-old female with a past medical history of Paroxysmal A. Fib on Coumadin . Patient was seen today to follow-up on PT/INR results regarding anticoagulant management. INR results reviewed this morning, noted with supra-therapeutic at greater than 9.95. Nursing reports blood in stool, started this morning, no other active bleeding .New orders given for patient to be sent out to the emergency room for further evaluation and treatment for elevated INR . Nursing Progress Notes: 8/30/22 at 10:11: Coumadin placed on hold for elevated INR . 8/30/22 at 16:41: Resident returned from ER (Emergency Room) via stretcher. Assisted to bed by RN (Registered Nurse). MAR (Medication Administration Record): - Resident #125's Coumadin was held on 8/25/22 and 8/26/22. It was administered on 8/27/22, 8/28/22 and 8/29/22. Laboratory Orders: 8/25/22: - The INR: 4.32 and a note at the bottom of the lab that stated, Hold Coumadin x 2 day & (today and Friday) recheck on Sat 8/27/22). It was signed by Nurse Practitioner BB on 8/26/22. 8/29/22: - The INR was greater than 9.95 and PT was greater than 99.10. The laboratory result indicated therapeutic range for PT is 9.6-12.2 and INR is 2.50-3.50. It can note noted there are no progress notes from facility nurses on 8/26/22 indicating Resident #125's Coumadin was placed on hold and stat PT/INR was ordered by Nurse Practitioner BB. Additionally, Resident #125's stat INR lab was never ordered by facility staff and her Coumadin was restarted on 8/27/22 with the scheduled lab being drawn on 8/29/22. Resident #125 was administered three doses of Coumadin without lab results and review by facility providers. On 11/17/22 at 1:55 PM, an interview was conducted with Nurse Manager C regarding access to the laboratory portal for facility staff. Manager C reported she does have admin access for the laboratory portal to provide access to facility nurses. Manager C expressed all licensed nurses have access and they did have a universal log in for agency staff but was unsure if it is active currently. Manager C explained agency staff would rely on facility nurses if they needed to search the laboratory site. It was explained to Manager C that during interviews it was reported all staff do not have access to the laboratory website. She was queried if after the incident with Resident #125 if an audit was completed to ensure all facility staff log in credentials are active and if they have the link for the laboratory website. Manager C reported there was no audit completed for current access nor did they check if facility staff had the website for the lab portal. On 11/17/22 at approximately 2:30 PM, a review was completed of the Human Resource files of Nurse AA and Nurse X. Nurse X: Was hired on 10/21/2019 and ended her employment with the facility on 10/1/2022. Nurse X had two disciplinary actions in 2022. -One on One Educational Opportunity on 8/4/22: Completing assessments before leaving shift. Reporting change in condition to on call manager . -Corrective Action on 8/11/22: Dressing change orders were not completed .Dressing monitoring orders were not completed .charge nurse falsified documentation . Charge Nurse Skills Checklist: -The checklist indicated Nurse X was competent in nurse-to-nurse shift report, Coumadin procedures, lab draw procedures, how to contact the lab and how to contact physician with lab results. This competency was completed on 6/15/22. Nurse AA: Corrective Actions: - Dressing change orders were not completed .Dressing monitoring orders were not completed .charge nurse falsified documentation . This was presented to Nurse AA on 8/31/22. -8/31/22: Resident was given Coumadin on 8/27/22, 8/28/22 and 8/29/22 without knowing most recent INR. 8-25-22 INR was 4.32. Anyone getting Coumadin has scheduled INR checks. It is expected that a nurse know the most recent INR level before administering Coumadin .When you administer a medication without knowing required results, the resident could be given medication that is not needed. This incident, the resident received 3 doses of Coumadin and the most recent INR result was 4.32. Continuing to administer Coumadin when the INR is elevated can lead to internal bleeding and increased risk of bleeding and decreased clotting ability . Charge Nurse Skills Checklist: -The checklist indicated Nurse AA was competent in Coumadin procedures, lab draw procedures, how to contact the lab and how to contact physician with lab results. This competency was completed on 5/27/22. The facility was asked to provide their policies and procedures on PT/INR Monitoring, Stat/Routine Labs and Anticoagulant. The polices provided were newly formed polices with the date of 11/28/22 when the incident with Resident #125 was discovered on 8/30/22. It is unknown what procedures Nurse's AA and Nurse X were deemed competent when their Charge Nurse Checklist was completed. Additionally, these policies were implemented upon request from this writer not during investigation and training related to the deficiency. Review was completed of the FRI (Facility Reported Incident) investigation, and it yielded the following results: Investigation Summary: .On 8/30/22 during morning rounds it was noted that (Resident #125) had an INR of greater than 9.95 and a PT of greater than 99 with some noted blood in her stool .(Nurse Practitioner BB) ordered for resident to be transferred to the ER for a Vitamin K infusion .It was noted that on 8/25 (Resident #125) had an INR of 4.32. The Coumadin was ordered to held for two days and an INR was to be obtained on 8/27/22. The lab was not drawn, and the Coumadin was restarted on 8/27/22. The next scheduled INR was to be obtained on 8/29/22 with the results being an INR greater than 9.5 and a PT greater than 99 . Incident and Accident Report: Lab results for PT/INR not relayed to facility staff and Coumadin given to resident without lab results reviewed by PCP .Resident sent to ER, daughter updated. Witness Statements: Nurse AA Interviewed (Nurse AA) regarding the INR not being rechecked and giving Coumadin. (Nurse AA) stated she didn't know that I needed to be rechecked and she stated that she did understand what the Coumadin number was and that she normally wouldn't have to give Coumadin .She stated normally there is a box that it should be entered into. When asked about there being a box she said no and she didn't look back at the prior number. Medication error was explained to (Nurse AA) and verbal education given regarding the risk of administering Coumadin without knowing the INR and verifying the order. (Nurse AA) also stated she did not see the lab come in on 8/29 and did not know that a lab was supposed to be redone that day. Nurse X Interviewed (Nurse X) and she stated (Nurse Practitioner BB) put the Coumadin on hold on 8/25 but did not enter for a new lab to be done. Did not remember if there was an order. It can be noted there were only two witness statements for the FRI investigation. The statements were not signed nor dated by Nurses X and AA. Furthermore, the statements were not in depth to understand the system error. Nurse AA statement revolved on educating and questioning if she knew the policies and procedures. Nurse X was not reprimanded for not inputting the stat order as directed by Nurse Practitioner BB nor was she questioned as to why she did not order it, put in a subsequent progress note and provide the information in shift report. The statements did not provide much insight into what occurred. Furthermore, there were many more nurse that could have been interviewed to gain insight into the deficiencies and Nurse Practitioner BB was not interviewed to gather who she provided the order to and the conversation that ensued. A timeline was not present it he investigation that indicated where the drop in communication was nor was there a root cause analysis to overhaul the systemic failure. On 11/21/22 at approximately 11:00 AM, an interview was conducted with Nurse Practitioner (NP) BB regarding Resident #125. Practitioner BB reported Resident #125's PT/INR came back elevated, and she placed her Coumadin on hold for two days (8/25/22 and 8/26/22) with a stat lab ordered of 8/27/22. Practitioner BB reported the nurse should have waited to administer her Coumadin until the lab resulted or contacted on call for further instruction. Practitioner BB reported she communicates any new orders with the nurse for that unit but on this day she does not recall who she informed. Practitioner BB reported many times she will input her own orders in the electronic medical records and other times will verbally tell the nurse. She further explained that nurse will them have to input the order in the lab portal to ensure it is completed. Practitioner BB reported on 8/30/22 Resident #125 was sent to the emergency room for evaluation as her PT/INR was above 9 and blood in her stool. Practitioner BB continued their lab is not consistent and while the Vitamin K treatment could have been administered at the facility, she was not confidant they would respond timely. Practitioner BB expressed there are concerns with the communication between the nurses and ensuring lab orders are acutely inputted. On 11/21/22 at 1:47 PM, phone call was placed to Nurse EE, there was no answer and voicemail was left requesting return phone call. Nurse EE was the 3rd shift nurse on 8/26/22 into 8/27/22 that should have been provided with report regarding the stat lab and ensured her lab was completed. On 11/21/22 at 1:53 PM, phone call was placed to Nurse X, there was no answer and voicemail was left requesting return phone call. Nurse X was the nurse that took the verbal order from Nurse Practitioner BB for the stat PT/INR lab to be drawn on 8/27/22 for Resident #125. On 11/21/22 at 2:42 PM, an interview was conducted with the DON (Director of Nursing) regarding the procedure to order labs. It was explained the laboratory comes between 4 AM-6 AM, Monday- Friday and its always the same person and in his absence the company does not send anyone else. If a lab is ordered, it has to be entered into the electronic medical record and the lab portal. The DON reported agency staff do not have access to the lab portal. The DON stated once their providers give an order for a lab, it is inputted into the medical record and the nurse then must confirm the order. The provider will either input the lab themselves into the medical record or give a verbal order to a facility nurse. Either way, the lab still must be confirmed in the system and then put into the lab portal. The DON was queried if during their investigation if they ascertained why the stat lab was never ordered. The DON reported the nurse that was provided with the order did not input the order into the lab portal or the resident's medical record. At the time this occurred the nurse (Nurse X) was not disciplined, and the DON was uncertain why she was not disciplined as she did not follow the process. This writer and the DON reviewed the staff assignment sheet from 8/26/22 and 8/27/22 and found that on 8/26/22 Nurse DD worked from 6 PM-12 AM and then returned from 6 AM -2 PM. Nurse EE (worked night shift on 8/26/22 into 8/27/22) and would have given report to Nurse DD and Nurse CC upon their morning arrival. The DON was queried if they were interviewed regarding the incident and DON reported she thought she did. The DON was not able to locate any witness statements from Nurse's CC', DD and EE, to find if they were aware of the stat lab order for Resident #125 and where the breakdown occurred. It was further discussed with the DON the concerns regarding the missing interviews, review of the process of inputting labs once provided, administering Coumadin without laboratory results and contacting the providers, integrating their providers to ensure a streamlined process going forward, reviewing laboratory access for the facility staff, holding all culpable staff responsible and completing a root cause analysis to effect systemic change. The DON expressed understanding of the concern and stated they had nothing else to add to the file. On 11/17/22 at 11:30 AM, an interview was held with Staff Development Nurse G regarding education provided after Resident #125 stat PT/INR was not ordered as directed and Coumadin given for 3 days without the most recent PT/INR results. Staff Development Nurse G stated they began training with staff in early September on the new process. Nurse G was queried if they included the process to order labs and ensuring staff had active lab portal account. Nurse G stated this was not included in their training. She was further queried if discussion was held with their Nurse Practitioner and Medical Director regarding the lab process and better ways to streamline it and if the report process was addressed. Nurse G reported their IDT (interdisciplinary team) determined communication was a concern amongst their staff and developed a new 24-hour report system for staff (this was not included in the FRI investigation) and the Nurse Practitioner and Medical Director were not integrated on the laboratory process as that was not apart of their education to facility staff. Nurse G reported the nurses input the order for PT/INR's outside of their standing PT/INR lab days. She reported whomever the provider verbally gave the order to is who should have it into the lab portal and the medical record. On 11/30/22 at 4:00 PM, a review was completed of the facility policy entitled, Provision of Quality of Care, dated 10/19/22. The policy stated, Based on comprehensive assessments, the facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents choice .1. Each resident will be provided care and services to attain and maintain his/her highest practicable physical, mental and psychosocial well-being. 2. A comprehensive care plan will be developed for each resident in accordance with procedures for development of the care plan .