**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficient practice #2. This citation pertains to intake MI00133600. Based on observation, interview, and record review, the facility failed to ensure skin treatments, PICC (Peripherally Inserted Central Catheter) line dressing changes and medications were provided in accordance with professional standards of quality were provided for three residents(R37, R40, and R333 ) reviewed for quality of care from a total sample of ten, resulting in dissatisfaction with care and delay in care and treatment. Findings include: Resident 37 (R37) On 3/6/2023 at 10:30 AM, R37 was observed sitting in their wheelchair. R37 stated that they were waiting for someone to look at their legs. Upon observation, R37 lower legs were red and flaky. R37 stated that they were red and itchy. A review of the medical record revealed that R37 admitted into the facility on 7/5/2022 with the following diagnoses, Dementia and Peripheral Vascular Disease. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 5/15 indicating an impaired cognition. R37 also required one-person extensive assist for transfers. A review of physician orders noted the following order, Order: BLE [Bilateral Lower Extremity]: apply bacitracin ointment to legs and apply tubi grips (elastic support bandage) q [every] day. Directions: Everyday shift for wound. Status: Active. Start Date:2/24/2023. On 3/6 and 3/7,no tubi grips were observed on R37. On 3/7/2023 at 11:00 AM, an interview was conducted with R37. R37 stated that no one put anything on their legs and that they did not know what tubi grips were. On 3/7/2023 at 12:56 PM, an interview was conducted with the Infection Preventionist (IP) who was also serving as the second floor Unit Manager. IP stated was interviewed regarding the care that was supposed to be provided to R37's legs. IP stated that the tubi grips should be applied everyday after the bacitracin is applied. IP was informed that the tubi grips had not been observed on R37 during survey observations. IP stated that they would look further into it. On 3/8/2023 at 1:02 PM, an interview was conducted with the Director of Nursing (DON) regarding following the order for Bacitracin and Tubi Grips. The DON stated that they expect for physician's orders to be followed. The DON stated that sometimes the resident will refuse, but they should follow the process when there is an refusal. Resident 40 (R40) On 3/7/2023 at 10:22 AM, R40 was observed in their bed. R40 stated that their PICC line site was itching a little. Upon observation the dressing was dated 2/27/2023. R40 was asked when does their dressing get changed. R40 stated that it is usually changed every Monday, however the nurse yesterday stated that they would not be able to get to it. A review of the medical record revealed R40 admitted into the facility on [DATE] with the following diagnoses, Urinary Tract Infection and Hypertension. A review of the Minimum Data Set assessment dated [DATE] did not assess cognition. R40 also required one person supervision with bed mobility and transfers. A review of the physician orders did not reveal an order for a PICC line dressing change. On 3/7/2023 at 12:50 PM, an interview was conducted with IP regarding the order not being in and R40's dressing not being changed. IP stated that the dressings are usually changed every Monday or as needed. IP was asked if there are usually orders for the dressing change. IP stated yes there is usually a order for the dressing change and that they would be entering one for R40. Resident 333 (R333) A review of complaint called into the State Agency noted the following, .1. Failing to properly review the medication list and provide [R333] with all prescribed medications. The result was [R333] went into severe withdraw (Effexor - anti-depression medication). A review of the medical record revealed that R333 admitted into the facility on [DATE] with the following diagnoses, Muscle Weakness and Acute Myeloblastic Leukemia, Not having achieved remission. A review of the Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13/15 indicating intact cognition. R333 also required extensive assistance with bed mobility and transfers. A review of R333's hospital discharge paperwork revealed the following, Continue to take these medications: Venlafaxine 150 MG (milligram) 24. Commonly known as: Effexor XR. Take one capsule (150 mg total) by mouth daily. A review of physician orders noted the following order, Order: Effexor XR Oral Capsule Extended Release 24 Hour 150 MG .(Venlafaxine HCL). Directions: Give 1 capsule by mouth one time a day for depression. Start Date: 12/12/2022. A review of the progress notes revealed the following, 12/12/2022 13:00 [1:00PM]. Note Text: Notified [Nurse Practitioner] about resident missing transfusion appointment today and about missing doses of Effexor from admission until this morning. On 3/8/2023 at 1:02 PM, an interview was conducted with the facility's Director of Nursing (DON). The DON stated that they do not know what happened with R333's admission medications orders. A review of a facility policy titled, Physician Orders did not address quality of care. This citation has two deficient practices. Deficient practice #1. This citation pertains to Intake MI00134465. Based on interview and record review, the facility failed to adequately assess and monitor a skin alteration for one resident (R283) of two reviewed for quality of care, resulting in an unmonitored infection, gangrene, and ultimately, amputation of the right great toe. Findings include: A complaint filed to the State Agency was reviewed and included the following: .On 01/25/23 a podiatrist came to clip [R283's] toe nails. He had an ingrown toe nail that was infected on his right foot, big toe. Antibiotic cream was use (sic) and a dressing applied. On 02/04/23 the resident's [family] visited .[R283's] big toe was blue and dark black .On 02/08/23 the resident had his big toe amputated because he had gangrene. A review of R283's record revealed that the resident was admitted into the facility on [DATE] and discharged on 2/5/23. A review of R283's Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was cognitively intact and required extensive assistance from staff for activities of daily living (ADLs). R283's medical diagnoses included Right Femur Fracture, Cerebrovascular Disease, Peripheral Vascular Disease, Hemiplegia/Hemiparesis Affecting Left Side, and Type 2 Diabetes Mellitus. A review of R283's medical record revealed a photo taken on 2/5/23 of the resident's right toe, along with an incomplete (unsigned) skin assessment. The photo showed R283's right foot with the top of the right toe discolored black/purple and appearing leathery (indicating gangrene) down to the bottom of the nail bed. A review of R283's hard copy chart from the facility revealed documentation from a podiatry visit at the facility on 1/25/23. The podiatrist documented the following: -Chief Complaint: Painful dystrophic toenails, Painful lesion - R (right) hallux nail . R Hallux (R1, or Right Great Toe)- medial border - Erythema, Incurvation, Painful Nail Boarder (sic), Breakdown, Paronychia (an infection of the skin that surrounds a toenail or fingernail) . Treatment: Podiatic E/M (evaluation/management) & Hx (history), Debrided mycotic toenails 1-5 B, I & D (incision and drainage) of infected toe - R1, Antibiotic Ointment and Dsg (dressing) applied - R1. A review of R283's electronic medical record and progress notes did not reveal any documentation related to the visit from the podiatrist, nor indicate that there was an issue with R283's feet/toes prior to the podiatry visit. A review of R283's physician orders did not reveal any related to the treatment of the resident's right foot/toe until 2/4/23, and did not reveal an order to send R283 to the hospital at any point for further evaluation of the toe. Continued review of R283's progress notes revealed the following: -2/4/2023 19:01 (7:01 PM) General Progress Note Note Text: Resident observed with redness to upper back, swelling and discoloration to right big toe during shower. MD (Physician), Unit Manager, and son informed of finding. Daughter admitted to cutting residents toe nails multiple times since January 23rd. Family very rude to nurse and unit manager on phone. Family demanded resident be sent out 911. Residents family then changed their mind. Writer inserted order of TOA (topical antibiotic) and dry dressing BID . Written by Licensed Practical Nurse (LPN) H. -2/4/23 19:40 (7:40 PM) General Progress Note Text: .writer was informed by nurse on duty with family concerns to residents right great toe, resident is seen and followed by outside podiatrist and was seen recently, daughter .admitted to cutting residents toe nails several times during the residents stay without having staff awareness. Talked to son on phone about concerns, he was rude, verbally aggressive, and upset the physician would not sent resident out 911, resident and family refused to leave and remained at the hospital. TX (treatment) order was applied to toe by nurse, resident will be followed by wound NP (Nurse Practitioner) on 2-6-2023. Physician aware of current plan of care. Written by LPN I. -2/5/2023 11:04 (AM) General Progress Note Text: Yesterday (2/4/23) medical doctor (MD) gave order to go to hospital, pt (patient) refused to leave, Transportation offered and set up, PT taken by family out of facility, instructed to go straight to emergency room. All risks discussed and understood. Written by Licensed Practical Nurse (LPN) H. A review of the facility provided, hard-copy Skin Worksheets for R283 revealed: -1/11/23 worksheet, marked as abnormal, with the right foot/leg circled and two areas on the resident's back marked as abnormal. No details regarding the skin concern circled on the right foot/leg were present on the sheet, nor in the resident's medical record upon review. No corresponding progress note to the skin worksheet dated 1/11/23 was found, however, a progress note for a body audit on 1/12/23 noted, No new skin concerns. No Skin Worksheets for R283 were provided by the facility after 1/18/23, although the resident remained in the facility until 2/5/23. A review of R283's medication/treatment administration records (MAR/TAR) revealed the order, Body Audit every night shift every Wednesday, Saturday for Body Audit. There was no documentation present indicating that the body audit was completed per the order on Saturday, 1/28/23, and no corresponding progress note was found. It was documented that a body audit was completed on Wednesday, 2/1/23, however, no corresponding progress note nor skin assessment/worksheet was found. A review of R283's hard copy chart from the facility revealed that the resident's family member signed the resident out AMA (against medical advice) on 2/5/23 at 11:00 AM. On 3/6/23 at 2:13 PM and 3/7/23 at 10:38 AM, Confidential Witness J was interviewed via phone. When queried regarding what occurred over the weekend prior to R283 leaving the facility, Witness J explained, February 4th my [family member] was visiting [R283] . [The resident's] toe was completely black - not bruised - it was black. Ten days prior, a podiatrist had come in per the facility and clipped [R283's] toenails, he had an ingrown toenail - the paperwork went into a binder and didn't get put into the computer system. No one was paying attention to [R283's] feet. [R283] has bad blood circulation to his feet and diabetes. Witness J explained that photos were sent to the supervising nurse of the toe LPN I (who was not working in the building when the issue with the toe was discovered, but was corresponding over the phone). Witness J stated, The nurse (LPN I) said the doctor was saying just to put cream on it and would have someone look at it on Monday. We were telling them [R283] needed to go to the hospital. When asked if family had cut the resident's toenails, Witness J stated that family cut the resident's toenails on the smaller toes but, Not the big toes, because there was an ingrown toenail .We asked the facility if they could do it and they said they would get podiatry set up. Witness J explained that is why R283 ended up being seen by the podiatrist in the facility in the first place. Witness J stated the resident's family wanted R283 to go to the hospital on 2/4/23 but the facility would not send him out. When asked if any of the family or R283 ever changed their mind about wanting to send the resident to the hospital, Witness J stated, No. Witness J continued and stated, I went there on Sunday (2/5/23) morning and looked at the toe myself and talked to the nurses and supervisors. They said it's okay, someone will look at it tomorrow (2/6/23). I asked them to override the doctor. When queried regarding the documentation in R283's record by LPN H and LPN I from 2/4/23 and 2/5/23, Witness J stated it was incorrect. Witness J stated that R283's family was adamant on the resident needing to be sent to the hospital, and added, That's absolutely not what happened at all. Why would [family] sign AMA paperwork if the doctor had given an order to send [R283] to the hospital? They did absolutely nothing for [R283] as it related to that toe .We saw the toe on the 4th (February), and it was done on the 25th (January) .[R283] supposedly had four showers between those two dates, no one was paying attention during his showers as to having an open wound on his toe and no one said anything to us. R283's hospital documentation was obtained, reviewed, and revealed the following: -Note From Your admission on [DATE] .ED (Emergency Department) Provider Notes .Chief Complaint: Foot discoloration . Physical Exam: .Skin: .Right great toe has partial nail evulsion with necrotic region around right first toe distal nail bed. Right dorsal foot erythema. +1 bilateral lower extremity edema . Medical Decision Making: I am concerned about osteomyelitis and necrosis of the patient's right great toe. Patient will be given vancomycin and Zosyn (antibiotics) and will admit for podiatry evaluation and IV (intraveneous) antibiotics. X-ray indicates no fracture. -OR (Operating Room) Brief Operative Note .Date of Surgery: 2/8/2023 11:07 AM .Preoperative Diagnosis: gangrene right great toe, Postoperative Diagnosis: Same, Procedure(s): amputation of the great right toe . On 3/8/23 at 8:32 AM, Licensed Practical Nurse (LPN) H was interviewed regarding her involvement in the discovery of the deterioration of R283's right great toe. When queried regarding conflicting information about whether the resident was ordered to be sent to the hospital versus being signed out AMA, LPN H stated that R283's family wanted the resident to be sent out. LPN H further explained that R283's [family member], Was rude and didn't want to talk to me because I'm not a RN (Registered Nurse) .and was upset there was no RN in the building. [R283's family member] was talking with the Unit Manager (LPN I) on the phone but she wasn't here to see it, she just talked to [family member], it was after hours .[Family] signed [the resident] out AMA the next day. LPN H explained that she and the aide on duty on 2/4/23 did what they were supposed to do by noticing the toe when taking the resident for a shower and completing a skin assessment. LPN H stated that she didn't work for days before the condition of R283's toe was noticed so, Can't say what happened between then because I wasn't here. When queried regarding a treatment being in place for R283's right great toe after the podiatrist had seen the resident on 1/25/23, LPN H explained that doctors are, Supposed to put orders in a book and flag it so the nurses can see it on the rack and it can get put in .But I don't believe the podiatrist put an order in .He treated the toe but we looked for an order and couldn't find one. On 3/8/23 at 9:53 AM, the Director of Nursing (DON) was interviewed. The DON was asked to review the podiatry note for R283 dated 1/25/23 that noted the I&D, inflammation, and skin breakdown of the resident's right great toe. When asked about orders being put into place to treat the toe after said visit, the DON stated she didn't believe the podiatrist put any orders in, To do anything extra at that point .[The] nurses didn't know anything concerning about the toe until days later. When asked about how R283's toe was being monitored after the visit from podiatry, the DON explained that staff does body audits and is confident that staff reports things that they see. The DON stated, For it to not be noticed .I'm not sure if [R283] had a shower in-between. When queried regarding the skin worksheet dated 1/11/23 with the circled area on the right foot/leg, the DON responded that there was a 1/12/23 note indicating no new skin issues. The DON reviewed a 1/25/23 practitioner note and stated she was hoping it would have acknowledged the podiatry visit, however, it did not. When queried regarding the missing MAR/TAR body audit documentation on 1/28/23, the DON acknowledged the missing information. The DON was unable to locate an accompanying note to the documented 2/1/23 body audit checked off on the MAR/TAR. A review of the facility's policy/procedure titled, Skin Management Guidelines, dated 03/2022, revealed, .Skin alterations and pressure injuries are evaluated and documented by the licensed nurse: .Using the Skin Alteration Record or Skin/wound application in PCC (if enabled) weekly by the licensed nurse for non-pressure injuries - Whenever there is a significant change in condition or clinically indicated .Body audits are completed: By the licensed nurse daily for patients with pressure injuries and documented on the eTAR; new findings are documented in a progress note; By the licensed nurse weekly for patients without pressure injuries and documented on the eTAR; new findings are documented in a progress note; By the nursing assistant during scheduled baths/showers, and if indicated during routine daily care and documented on the Skin Worksheet .The Skin Worksheet is used by the nursing assistant to document skin observations. The worksheet is completed at least twice/week with the patient ' s bath/shower. Completed worksheets are given to the licensed nurse for validation and action planning as indicated . A review of the facility's policy/procedure titled, Change of Condition Protocol, dated 06/2021, revealed Purpose: To provide guidance in the identification of clinical changes that may constitute a change in condition and require intervention and notifications .Nurse ' s Responsibility: .Identify the resident involved and the issue - ask when the incident/change began and/or when was it identified? Is the resident known to the nurse? Has this occurred before .Review previous condition and current medication orders .Decision Phase: Determine whether this is an unusual incident for this resident; Evaluate whether additional information is needed; Evaluate the seriousness of the issue; Determine whether a call to 911 is indicated; Determine whether the physician needs to be consulted; Determine whether the issue is within the confines of the Nurse Practice Act; Evaluate whether a physician visit to the community is indicated or whether the resident needs to be sent out for an evaluation .