**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake MI00138305. Based on observation, interview and record review the facility failed to prevent the development of a stage 4 pressure ulcer that included physician lead care for the evaluation and treatment for pressure ulcers and facility staff trained in the treatment of pressure ulcers for 1 of 5 residents (Resident #27), reviewed for pressure ulcers, resulting in an Immediate Jeopardy when Resident #27 developed a facility acquired pressure ulcer on the right gluteal (buttock) fold that worsened to an infected Stage 4 pressure ulcer that required hospitalization, IV antibiotics and surgical intervention. Findings include: On 8/2/23, the Nursing Home Administrator was notified of an Immediate Jeopardy that began on 6/7/23, when Resident #27 developed a facility acquired pressure ulcer, that worsened to a Stage 4 pressure ulcer, leading to hospitalization, IV (intravenous) antibiotics and surgical interventions. Review of a Face Sheet revealed Resident #27 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dorsopathies (diseases of the musculoskeletal system and connective tissue associated with degenerative diseases of the spine) of the cervical (neck) region. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 4/19/23 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #27 was cognitively intact. Review of the Functional Status revealed that Resident #27 required extensive assistance of 1 person for bed mobility, transfers, and toileting, and that Resident #27 could stand and bear weight with assistance of 1 person. Review of Resident #27's assessment Braden scale for predicting pressure sore risk dated 4/21/23, indicated that the document was not complete, and was void of answers to the questions. This was the most recent assessment prior to Resident #27 developing the Stage 4 pressure wound on Right gluteal fold. Prior to the assessment on 4/21/23, the most recent was completed on 11/3/22, which indicated that Resident #27 was at risk, and the current assessment completed on 7/20/23 indicated that Resident #27 was at high risk. Per the facility policy, Braden assessments are completed quarterly. Review of Resident #27's Pain Care Plan revealed, .at risk due to diagnosis of Stage 4 pressure ulcer (no location) .Created 7/25/23. There were no interventions related to prevention/worsening of pressure ulcers. Review of Resident #27's Skin Care Plan revealed, .at increased risk to develop skin breakdown, due to limited mobility, secondary to severe cervical spine disease, paraplegia, chronic pain, and a history of stage 4 pressure ulcer to sacrum. She has a history of choosing to not lay down at times, frequently requesting to get up when in bed, resorting to outburst of yelling loudly, and crying. She has been educated why laying down is important for her, she states that she understands, but does not care. She is at times incontinent of bladder. She developed a stage 4 pressure ulcer to right sacrum even with interventions. She was readmitted from hospital with stage 2 on sacrum. Edited on 7/25/23 by DON. INTERVENTIONS: Blue boots to bilateral feet while in bed, start date 7/25/23. May be up in chair for therapy and appointments, start date 7/25/23. Wedge cushion to help with turning and repositioning, start date 7/25/23. CNA to check skin daily and PRN (as needed) during care, start date 8/24/21. Nurse to check and document skin condition weekly with first bath of the week. Notify MD and wound care nurse if any problems arise, start date 8/24/21. Moisture barrier cream to any excoriation/irritation PRN. Notify physician if not effective, start date 8/24/21. Perform treatments per physicians order, start date 8/24/21. Provide and encourage supplements as ordered, start date 7/25/23. Assist and encourage with eating and drinking at meal time prn to ensure nutritional and fluid intake are sufficient to maintain healthy skin integrity and promote healing, start date 8/24/21. Ensure that water is within reach at bedside, start date 8/24/21. Alternating pressure mattress to bed and roho (pressure relieving) cushion to wheelchair, start date 7/25/23. Assist/encourage to keep heels elevated off bed. Assist and encourage to turn and reposition every 2-3 hours and side to side and PRN. May be on back for meals, start date 7/25/23, edited 7/25/23. During an observation and interview on 07/31/23 at 11:06 AM Resident #27 was lying in bed on her back, positioned slightly on her left side, with the head of bed (HOB) at 30 degrees. There was a wound vac (a type of therapy for wounds) powered on at the bedside on the night stand, leading to Resident #27's buttock area. Resident #27 reported that she was too weak and too tired to talk. During an observation on 07/31/23 at 01:47 PM Resident #27 was in the same position as the previous observation, lying in bed on her back, positioned slightly on her left side, with the HOB at 30 degrees. During an observation on 07/31/23 at 03:23 PM Resident #27 was in the same position as the previous observation, lying in bed on her back, positioned slightly on her left side, with the HOB at 30 degrees, and there was a visitor in the room. During an observation and interview on 07/31/23 at 03:55 PM Resident #27 was lying in bed on her back in the same position as observed since 11:00 AM. Family Member (FM) J reported that Resident #27 had a large wound on her right lower buttock, and FM J was notified of the wound the first part of June, and informed that it was an abrasion (skin damage from scraping or wearing away) from the elastic of her incontinence brief. FM J reported was never updated that Resident #27's wound was worsening, until she was in the room during a wound dressing change on 7/8/23 and observed it herself. FM J reported that Resident #27 had ultimately became ill and required transfer to hospital on 7/8/23, then was sent to another hospital for surgery for an infected Stage 4 pressure ulcer. FM J reported that Resident #27 had drastically declined from her normal self since developing the wound, requiring her to be bedridden and have a urinary catheter, but that prior to was very active, regardless of being wheelchair bound. Review of Resident #27's Hospital Summary admission on [DATE] revealed, .Chief Complaint: Right gluteal decubital (relating to laying down) ulcer with possible infection. History of present illness: .transferred from (other hospital) to (this hospital) for possible gluteal ulcer infection. CT (imaging) at the outside hospital found irregular tissue with pockets of gas concerning for infection or abscess in the upper posterior right thigh extending to the level of the buttock. She was then transferred to (this hospital) .Plan: .will be admitted to hospital .Chronic right gluteal decubital ulcer, likely Stage 4, possible superimposed with infection with pockets of gas on CT .Vancomycin (antibiotic), Cefepime (antibiotic), and Metronidazole (antibiotic) .Operative Summary: .A scissor was used to cut away necrotic (dead) tissue overlying (covering) the wound .1.8 cm diameter wound with 5 cm undermining, unstageable, necrotic devitalized tissue debrided (removed), wound class dirty, PATOS (present at time of surgery). Excisional debridement with scissors down to level of subcutaneous (fat) tissue .Culture tissue/bone: Peptoniphilus asaccharolyticus (bacterial infection sometimes resistant to antibiotic treatment), Finegoldia [NAME] (bacteria) Hospital Course: .presented .from an outside hospital for a possible gluteal ulcer infection .General surgery consulted. Debridement, irrigation and Wound Vac placement was recommended .She was treated with antibiotics which were transitioned to p.o. (oral) antibiotics. Foley catheter placed to help with wound care . In an interview on 08/01/23 at 01:06 PM, Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound on Resident #27's right buttock fold was noted by staff initially on 6/7/23, and that it looked like the top layer of her skin had pushed away from the surface and stated, .I thought it was from her incontinence brief being too tight .Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she notified FM J at that time, but did not notify the physician of the new wound. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the wound was not improving, and started getting worse on 6/22/23, with odor and slough (dead skin cells that accumulate in the wound bed) starting in the wound, and continued to deteriorate. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that the only notification to the physician would have been the written order changes that Licensed Practical Nurse Wound Nurse (LPN-WN) C made and stated, .he (MD D) had to sign them .I don't know if he physically assessed the wound .Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that Resident #27's wound got much worse on 7/6/23, and at that timeliest Practical Nurse Wound Nurse (LPN-WN) C notified the DON, and changed the wound treatment orders again. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that over the next couple days, nurses had to change the bandages frequently because of them becoming saturated with wound drainage. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that FM J was visiting during a wound treatment on 7/8/23 and insisted that Resident #27 be taken to the hospital due to the condition of the wound. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that Resident #27 had preferred to be up in her chair during the day and didn't like to lay in her bed, and that was the reason that MD D completed the unavoidable wound form on 7/21/23, after Resident #27 returned from the hospital. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she did not document Resident #27's refusals to lay down and/or the efforts they had made to encourage her to lay down. Licensed Practical Nurse Wound Nurse (LPN-WN) C was not able to describe any additional interventions that were attempted to relieve pressure when the resident declined to lay down in bed, other than asking Resident #27 to lay down. Licensed Practical Nurse Wound Nurse (LPN-WN) C reported that she did not involve Resident #27's responsible party for additional suggestions, when Resident #27 declined to lay down. In an interview on 08/02/23 at 03:47 PM, Registered Nurse (RN) Q reported that Resident #27 was compliant and the CNA's had not ever reported any trouble with refusing cares. RN Q reported that just prior to going to the hospital, Resident #27's wound dressing was completely saturated, the area around the wound was red and warm, she had spiked a fever, was confused and stated, .(FM J) was adamant that she be sent to the hospital . RN Q reported that she had called MD D and left a message for him regarding Resident #27's condition and that the on-call physician gave the orders to sent to the hospital. Review of Resident #27's Determination of Unavoidable Pressure Wound dated 7/21/23 (3 days after return from hospital) revealed, 1. Was a risk assessment completed upon admission? Yes - 9/12/19 and quarterly .3. Were nutritional interventions implemented and routinely evaluated? (no answer) .Does resident have 2 or more primary risk factors? Yes - Continuous urinary incontinence or chronic voiding dysfunction, Paraplegia (paralysis) .8. Did resident develop malnutrition and/or dehydration .NO .9. The physician has documented unavoidable pressure wound based on residents condition? (no answer). 10. List prevention and treatment implemented despite unavoidable criteria: turn side to side, elevate heels off bed, offer naps at 10:00 AM and 2:00 PM, alternating air mattress, pressure relief cushion, WC (wheelchair) block to rest foot off put pressure to right gluteal fold. The pressure wound located on the right gluteal fold, stage 4, is determined to be unavoidable due to choosing not to lay down, she becomes very angry when even asked. (signed by MD D) In an interview on 08/02/23 at 09:49 AM, MD D reported that Resident #27 did not have a wound until she returned from the hospital and stated, .they found it at the hospital . MD D reported that new wounds may have orders started verbally over the phone, but that a physical assessment would be done the next time the physician was in the facility. MD D reported that he would expect the nurse to notify him of new wounds, but that if he saw an order for a wound treatment, MD D would question the order and stated, .but only if the order catches my eye .because I look at a lot of orders . MD D reported that he did not remember Resident #27 having any orders for wounds. MD D reported that Resident #27 is at very high risk to develop pressure ulcers due to her not cooperating with staff and stated, .I did not know about the wound, so no, I could not say that it was unavoidable . Review of Weekly Meeting notes provided by the DON indicated that Resident #27's right gluteal fold wound was discussed on 6/22/23 and 6/29/23. There was not a physician present for these meetings. In an interview on 08/01/23 at 02:42 PM, DON reported that she had saw the wound about 1 week after it was first identified and at that time agreed that it was an abrasion from the incontinence brief. DON reported that Licensed Practical Nurse Wound Nurse (LPN-WN) C was not certified in wound care, and to have a doctor look at new wounds was not part of their process and stated, .the doctors are usually ok with the orders that (LPN C) writes DON reported that Resident #27's wound was discussed in meetings every week, it was known that the wound was not improving and stated, .we normally have a doctor look at it if its changing .this fell through the cracks . DON reported that she did not think Resident #27's wound had been assessed but a physician, and that there was no documentation to indicate that it was. Review of Resident #27's Wound Sheets revealed the following nursing documentation: 6/7/23: Right gluteal fold, wound type-abrasion, facility acquired, 0.4 cm length x 0.3 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/15/23: Right gluteal fold, abrasion, facility acquired, 0.7 cm length x 0.5 cm width x 0.1 cm depth, no undermining, no tunneling, red, small amount of drainage, no odor. 6/22/23: Right gluteal fold, abrasion, facility acquired, 1.0 cm length x 1.1 cm width x 0.2 cm depth, no undermining, no tunneling, red, small amount of drainage, mild odor. 6/28/23: Right gluteal fold, abrasion, facility acquired, 1.8 cm length x 1.7 cm width x 0.7 cm depth, no undermining, no tunneling, 1/4 of wound yellow and red, medium amount of drainage, mild odor. 7/3/23: Right gluteal fold, (no type noted), facility acquired, 3.0 cm length x 3.2 cm width x 0.5 cm depth, no undermining, no tunneling, yellow, saturated with drainage, mild odor. 7/7/23: Right gluteal fold, (no type noted), facility acquired, 3.4 cm length x 3.8 cm width x 0.6 cm depth, no undermining, no tunneling, yellow, saturated with drainage, strong odor. Surrounding skin with hard edges and bruising. Review of Resident #27's Written Orders revealed the following orders for wound dressings: 6/7/23: Cleanse right gluteal fold with NS (normal saline) pat dry, apply Mepilex (foam bandage), change every 5 days/PRN (as needed). signed by MD D. 6/15/23: DC (discontinue) Mepilex, new order: Cleanse right gluteal fold with NS pat dry, apply Xeroform (bandage that maintains moist environment) change daily and PRN. signed by MD D. 6/16/23: DC Mepilex. Cleanse right gluteal fold with NS pat dry, apply Xeroform change daily. This was the same order as on 6/15/23. signed by MD D. 6/23/23: DC Xeroform. Cleanse right gluteal fold with NS pat dry, apply Calcium Alginate and border gauze change daily. signed by MD D. 7/3/23: DC Calcium Alginate. Cleanse right gluteal fold with NS pat dry, apply Hydrofera Blue (bandage that provides protection and addresses bacteria and yeast) 4 x 4 gauze, cover with border gauze and change every 3 days/PRN. signed by MD D. 7/6/23: DC Hydrofera Blue, Cleanse right gluteal fold with NS pat dry, apply Collagen (healing) Powder and cover with 4 x 4 border gauze. There was no physician signature on the order. All of these orders were written by Licensed Practical Nurse Wound Nurse (LPN-WN) C . Review of Resident #27's Physician Notes dated 6/23/23, indicated no documentation of a wound and or a skin assessment. Review of Resident #27's Dietary Notes dated 4/19/23 indicated that appetite was usually good, the skin was intact and that there were no supplements in place. There were no further notes until 7/12/23, which indicated appetite was good, skin wound, and resident in the hospital. Review of Resident #27's Hospital Dietician Consult dated 7/9/23 revealed, .PU (pressure ulcer) right buttock .does not meet criteria for malnutrition .maintaining weight. During an observation on 08/01/23 at 09:09 AM Resident #27 was lying in bed on her back, positioned slightly on her right side with the HOB at 30 degrees. During an observation and interview on 08/01/23 at 09:35 AM Resident #27 was lying in bed on her back, positioned slightly on her left side with the HOB at 30 degrees. Certified Nursing Assistant (CNA) P reported that she had just repositioned Resident #27 onto her right side and stated, .we try to turn her every 2 hours .it was supposed to be at 9:00, I was a little late . CNA J reported that she did not know how bad Resident #27's wound was until she saw the soaked bandage just prior to her hospitalization a few weeks ago. CNA J reported that CNA H is Resident #27's regular CNA, so she would know more about her. In an interview on 08/02/23 at 01:58 PM, CNA H reported that Resident #27's wound started small, like an abrasion, the incontinence briefs were not too small, but when Resident #27 was sitting, her buttocks pressed on the edge of the brief. CNA H reported that Resident #27 preferred to be up in her chair during the day, but understood that she needed to get off her bottom, and did not decline laying down for CNA H. CNA H reported that she had been Resident #27's aide for a long time and Resident #27 could stand up, with help to relieve pressure off her bottom and would ask to stand longer to stretch her legs. CNA H reported that she (CNA H) would toilet Resident #27 multiple times a day, just to relief the pressure and stated, .but I was off work a lot during the time her wound started and have been until today . CNA H reported that Resident #27 did drink supplements, but needed encouragement. During an observation on 08/01/23 at 10:40 AM in Resident #27's room, CNA P performed incontinence care on Resident #27. Resident #27's buttocks were observed with a wound vac covering the right lower buttock and a large bandage covering the coccyx (tailbone) area. In an interview on 08/01/23 at 10:57 AM, CNA F reported that she was not aware that Resident #27 had a wound until she went to the hospital for it a few weeks ago. CNA F reported that Resident #27 was very different before she was hospitalized and stated, .she could stand up .could use the bathroom .she liked to go to the dining room .always brushing her hair . Review of the facility policy Skin Assessment and Ulcer Prevention revealed, .Goal: To assess each resident upon admission and at least quarterly for the potential for skin breakdown utilizing the standardized scale (Braden). To assess each resident with wounds for changes and determine proper wound treatments .When a wound is identified the physician will be notified, the resident will be added to the weekly physician wound rounding sheet with wound details. Physician will sign and document that each resident was seen in (electronic health record). The policy was complied by DON on 8/2/23 and approved by NHA on 8/2/23. On 8/2/23, the survey team verified the facility completed the following to remove the Immediate Jeopardy. 1. Resident #27 will be seen by the attending physician and will have a consultation with the wound clinic on August 2, 2023. 2. Any resident with a Stage 1 pressure ulcer or higher will be seen by the attending physician to assess the wound and document review on August 2, 2023. 3. The Pressure Ulcer policy and procedure has been updated as of August 2, 2023, to include immediate notification of physician when a wound is identified and that the resident will be added to the physician's weekly rounds. All licensed nursing staff will be trained in person or over the phone on the updated policy and procedure and acknowledgement of the training will be tracked by signature of the nurse or documentation from the trainer on August 2, 2023. Although the immediate jeopardy was removed on 8/2/23, the facility remained out of compliance with a scope of isolated and severity of actual harm due to all nursing staff had not received training for wound care/skin prevention program and sustained compliance had not been verified by the state agency.