**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures to ensure comprehensive pressure ulcer assessment, care and management per professional standards of practice including documentation, diligent infection control practices, implementation of personalized interventions and monitoring of interventions to prevent the development of pressure ulcers for one resident (Resident #21) of four residents reviewed. This deficient practice resulted in a lack of pressure ulcer identification, assessment, and documentation. Resident #21 developing five pressure ulcers including four unstageable, Deep Tissue Injuries (DTI) [dark colored, non-blanchable area over a bony prominence due to a pressure-related injury to underlying tissue with unknown depth] and one Stage Three pressure ulcer (full thickness tissue loss), unnecessary pain, and the likelihood of infection, and an accelerated deterioration in overall health status. Findings include: Resident #21: On 6/21/22 at 12:01 PM, Resident # 21 was observed in their room in bed, positioned on their back. Resident #21 made eye contact when spoke to but did not respond verbally. The Resident's lower legs were bent at the knees and positioned outward, in a crisscrossed fashion, with the lateral (outside) aspect of their legs positioned directly against the mattress. The Resident was receiving oxygen therapy via nasal cannula. The nasal cannula tubing was visibly tight and appeared to be digging into the skin on the left side of Resident #21's face and ear. An alternating air mattress was in place on the Resident's bed. The mattress controller was set at 3. The mattress was hard when touched. Record review revealed Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Down's Syndrome, urinary retention, dysphagia (difficulty swallowing), seizure disorder, and quadriplegia (total or partial paralysis of all four extremities). Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive assistance to perform all ADLs. The MDS further revealed the Resident was at risk for pressure ulcer development but did not have any pressure ulcers. Review of Resident #21's admission MDS assessment dated [DATE] revealed the Resident did not have any pressure ulcers. On 6/21/22 at 3:20 PM, Resident #21 was observed in their room in the same position in bed. Resident #21's eyes were closed, and their lateral lower legs remained positioned directly on the mattress. The oxygen tubing remained visibly tight and pressing into the skin on the left side of their face and ear. Review of Resident #21's care plans revealed an active care plan entitled, The resident has [potential or actual] impairment to skin integrity of the following location coccyx and left elbow (Initiated and Revised: 1/28/22). The care plan included the interventions: - Check and change every 2 hours; float heels off bed; turn every 2 hours as resident allows (Initiated: 2/1/22; Revised: 6/3/22) - Encourage good nutrition and hydration in order to promote healthier skin (Initiated: 2/1/22) - Identify/document potential causative factors and eliminate/resolve where possible (Initiated: 2/1/22) - Keep skin clean and dry. Use lotion on dry skin. Do not apply on skin impairment area(s) (Initiated: 2/1/22) - Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physician/provider (Initiated: 2/1/22) - The resident uses the following devices to relieve/prevent friction/sheer/pressure; alternating low air loss mattress; cushion in chair (Initiated and Revised: 2/1/22) - Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (Initiated: 2/1/22) - Use lifting device to move resident (Initiated and Revised: 2/1/22) - Weekly skin assessment (Initiated: 2/1/22) - Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations (Initiated: 2/1/22) Review of the facility provided CMS-802 Resident Matrix form, dated 6/21/22, indicated Resident #21 did not have any pressure ulcers. Review of Resident #21's Health Care Provider Orders and Medication Administration Record (MAR) for June 2022 detailed the following active and discontinued wound care treatment orders: - Cleanse bilateral heels with wound cleanser, apply skin prep to heels twice daily (Ordered: 4/14/22) - Cleanse coccyx with wound cleanser, apply Dermafilm lite (hydrocolloid wound dressing for management of partial and full-thickness pressure ulcers and wounds) in the morning every 3 day (s) for skin healing (Start: 6/1/22; Discontinued: 6/7/22). The treatment was not documented as completed on 6/7/22. - Cleanse coccyx with wound cleanser, apply Dermafilm lite in the morning every 3 day (s) for skin healing (Ordered: 6/7/22; Start: 6/9/22). The initial treatment was completed on 6/9/11. The treatment was not documented as completed on 6/21/22. - Cleanse bilateral buttocks with soap and water; dry well; apply Dermaseptin (non-prescription cream to treat skin irritations) TID (three times a day) every shift for skin healing (Start: 2/16/22). The treatment was not documented as completed on 6/2/22 Evening, 6/11/22 Evening, 6/13/22 Day, and 6/21/22 Day. Review of discontinued orders revealed Resident #21 had prior orders for wound care treatments on their coccyx, left elbow, left heel DTI, right buttocks, and bilateral heels. Review of documentation in Resident #21's Electronic Medical Record (EMR) revealed the following progress notes: - 2/8/22: Wound Care (Provider) . Chief Complaint Wound care . resident is seen for wound care . open areas on left elbow and coccyx. We had these areas documented as an abrasion to the left elbow and moisture damage to his coccyx, while the hospital had these areas as pressure area. Resident is a functioning quadriplegic with a history of down syndrome who lived at home with (family) . Resident is dependent on staff for cares and is unable to reposition self frequently. Residents Foley was discontinued one week ago, and these areas have since resolved. Resident skin is intact at this time but frail and easily damaged. It is unsure at this time if the resident will be able to discharge back home . - 3/16/22 at 8:25 AM: SOC-Skin . New DTI left lateral heel; measures 1.5 cm (centimeters) x 1.5 cm . History . Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Care plan (current/revised/new) interventions: New . Comments: Monitor weekly . Cleanse with wound cleanser, apply skin prep BID (twice a day) - 3/24/22 at 11:21 AM: SOC-Skin . Existing; DTI left heel; measures 1.5 cm x 1.5 cm . History: Falls; Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Care plan (current/revised/new) interventions: Current . Comments: Monitor/measure weekly . Cleanse with wound cleanser, apply skin prep BID - 4/1/22 at 3:16 PM: SOC-Skin . Existing; DTI left heel; measures 0.7 cm x 0.6 cm . Background . Pressure injury left buttock; Pressure injury left elbow . Contributing deficits: Limited mobility; dependent on staff for ADL's; changes position slightly; incontinent of bowel; chairbound/bedbound; dependent on staff for fluids/nutrition . Contributing lab results: None . Stable . Cleanse with wound cleanser, apply skin prep BID - 4/7/22 at 12:22 PM: SOC-Skin . Existing; DTI left heel; measures 0.8 cm x 0.6 cm . Comments: Continue to monitor x 2 weeks . Skin prep to heels BID - 4/14/22 at 11:24 AM: SOC- Skin . Existing; DTI left heel; measures 0.7 cm x 0.6 cm . Comments: Stable; heel firm . Skin prep to heels BID; preventative - 5/2/22: Health Care Provider Progress Notes . Visit Type: Acute . resident is seen for hypotension (decreased blood pressure) . Skin: no itching or burning . Skin: warm and dry . - 5/5/22: Physician Progress Notes . Visit Type: 30-Day Follow Up . General: Patient for routine 30 day follow up . in sub-acute rehab for falls, sacral pressure injury . staff relates no concerns regarding patient . dependent in 5/6 ADL . no issues with intake . Skin: warm and dry. noted with continued L (left) heel deep pressure injury that is > 90% resolved . - 5/26/22 at 1:43 PM: SOC-Nutrition/Hydration . Resident is being reviewed in SOC r/t (related to) nutritional risks. Mitigating factors . Wound care nurse is following skin status . Recommendations- Increase med plus 2.0 (nutritional supplement) 120 mL (milliliters) BID . and Prostat (nutritional supplement) 30 mL QD (every day) . - 5/31/22 at 1:35 PM: Skin & Wound Evaluation . Type (Blank) . Location (Blank) . Acquired (Blank) . How long has the wound been present? (Blank) . Wound Measurements . Length: 1.9 cm . Width: 0.8 cm . Edges . Attached . Cleanse with wound cleanser, apply Dermafilm thin . - 6/2/22 at 11:17 AM: SOC-Nutrition/Hydration . Resident is being reviewed in SOC r/t nutrition risk. CBW (Current Body Weight) is 107.4 (on) 6/2/22 . Mild weight loss noted. BMI class is WNL (Within Normal Limits) . pureed textures diet is provided with fortified foods QD, med plus 2.0 120 mL BID and Prostat 30 mL QD. Supplements were increased on 5/26/22 per recommendations to aid in weight loss prevention . Impaired skin integrity noted. Tx (treatments) are in place. Supplements are in place which may aid in healing . - 6/14/22 at 3:26 PM: Skin Assessment . Are there any new abnormal skin areas? No . site(s) of any existing abnormal skin areas . Tip of penis red from chronic foley . Buttocks excoriation . - 6/20/22: (Provider) Progress Notes . Chief Complaint: Increased secretions/altered Skin Integrity . recently signed onto hospice services . multiple areas of altered skin integrity, these areas come & go continuously . Skin: multiple areas of redness, some blanchable and some are not . - 6/21/22 at 7:17 AM . Skin & Wound Evaluation . Type: Moisture Associated Skin Damage (MASD) . Location: Left Buttocks . In- house acquired . New . Length: 0 cm . Width: 0 cm . On 6/22/22 at 10:40 AM, an observation occurred of Resident #21 in their room. The Resident was in bed, positioned on their back. The Resident made eye contact and smiled when spoke to. Resident #21's legs were in the crisscross position with the lateral aspect of their legs directly against the mattress. Resident #21's oxygen tubing remained visibly tight on the left side of their face and ear as observed on 6/21/22. An observation of Resident #21 occurred on 6/22/22 at 1:16 PM in their room in bed The Resident was positioned on their back with both of their lower extremities in a crisscrossed position and the lateral aspect of their lower extremities directly against the mattress. The oxygen tubing remained visibly tight and pressing into the skin on the left side of the Resident's face and ear. When spoke to, Resident #21 would smile but did not provide meaningful responses when asked questions. On 6/22/22 at 1:44 PM, an interview was completed with Licensed Practical Nurse (LPN) D. When queried how frequently facility nursing staff monitor residents' oxygen tubing to ensure it is positioned properly, LPN D implied staff should check the tubing when they are in a Residents room. LPN D was then asked if Resident #21 had any wounds and/or pressure ulcers and indicated they were not aware and would need to review the Resident's medical record. When queried if floor nursing staff complete wound care treatments, LPN D specified the facility has a wound care nurse who is primarily responsible for wound care and the majority of treatments are completed on night shift. Upon request, an observation of Resident #21 was completed with LPN D at this time. Upon entering the room, Resident #21 was observed on their back in bed, in the same position as previously observed, with their legs bent and lower extremities directly against the mattress. The oxygen tubing remained noticeably tight on the left side of their face and ear. LPN D was queried regarding the position of Resident #21's oxygen tubing. LPN D did not respond verbally but began to adjust and reposition the tubing. When LPN D loosened the adjuster under the Resident's chin and lifted the oxygen tubing, a dark colored, significantly indented line was present along on the left side of the Resident's face from their chin to their ear where the tubing had been pressing into their skin. When LPN D went to remove the tubing from around Resident #21's left ear, they indicated it was stuck at the top. Closer inspection revealed the tubing was dug into the skin on the top portion of the Resident's left ear. A thick yellow/off-white colored drainage was present on the tubing and the gray colored foam wrap in place on the section of the tubing wrapped around the ear. LPN D proceeded to remove the tubing and an open, draining pressure ulcer was observed on the top of the fold between the helix (top part of the external ear) and the skin on the head. The wound bed was white/gray in color, slightly smaller than a dime with a distinct foul odor present. The Resident's hair was visibly dirty with observable wet and dried drainage present near the wound on their ear and multiple chunks of unknown substances present throughout their hair and on their scalp. LPN D was asked if the wound was caused by pressure and replied, Yes. LPN D revealed they were going to have Wound Care Nurse P come to Resident #21's room to evaluate and treat the wound. LPN D was then asked if they remove Resident #21's oxygen tubing routinely to monitor skin integrity as part of the nursing skin assessment and revealed they did not. When queried if they observe all areas of the skin when completing skin assessments, including all bony prominence's, LPN D indicated facility CNA staff typically notify nursing staff if there are any skin concerns. With further inquiry, LPN D revealed they did not comprehensively observe and assess areas of the skin for potential breakdown, including all bony prominence's, when completing skin assessments. At 2:12 PM on 6/22/22, Certified Nursing Assistant (CNA) R and CNA S entered Resident #21's room to provide ADL care and Wound Care Registered Nurse (RN) P entered the room to evaluate the pressure ulcer on the Resident's left ear. An observation of Resident #21's skin was requested to be completed at this time. A dark colored area, approximately the size of a quarter was observed on Resident #21's right lateral (outside) heel. The area was directly over a bony area of their heel, where their lower extremity had been positioned directly against the mattress. Wound Care RN P was asked if the area was blanchable. RN P proceeded to press on the wound and the tissue was observed to not blanch (no color change indicating lack of blood flow and underlying tissue damage). RN P stated, Non-blanchable. Wound Care RN P was then asked if the wound was caused by pressure and replied that it was. Another area, approximately the size of a dime and dark in color was observed on Resident #21's left lateral heel. The area was noted to be where the Resident's lower extremity had been positioned directly on the mattress and over a bony prominence. When queried, RN P pressed on the wound bed and the area was observed to be non-blanchable. When asked, RN P stated the wound was non-blanchable. CNA R and CNA S then repositioned Resident #21 on their side. Observation of the Resident's buttocks/coccyx revealed a dark colored discolored area, circular in shape, and approximately the size of a golf ball. There was no dressing in place over the coccyx wound. Blanching was not observed when RN P assessed the wound. When asked, RN P stated the wound was non-blanchable and caused by pressure. RN P was queried regarding the stage of the pressure ulcers on the Resident's right and left lateral heels and coccyx and stated, All DTI so unstageable. Wound Care RN P exited the room at this time to obtain supplies. Upon returning, RN P was asked to assess the condition of the skin on the bony prominence of Resident #21's left elbow. A dark area, approximately the size of a nickel was observed on the bony prominence over the Resident's elbow. When queried, RN P indicated it was non-blanchable. RN P revealed the wound was also an unstageable, DTI pressure ulcer. RN P donned gloves at this time, without washing their hands, and proceeded to complete wound care treatment on Resident #21's coccyx pressure ulcer. When asked to measure the wound, RN P stated, The Internet is down and revealed the facility utilizes an electronic wound measurement system for pressure ulcers and do not complete manual measurements. When asked if the pressure ulcer was approximately the size of a golf ball, RN P replied, I agree, golf ball size. RN P indicated they had forgot to bring an Allevyn (wound care dressing) and proceeded to doff their gloves and exit the room. RN P returned with the dressing, donned new gloves without performing hand hygiene, and applied to the dressing to the Resident's coccyx. Without doffing/donning new gloves and/or performing hand hygiene, RN P proceeded to clean the pressure ulcer on Resident #21's left ear. When queried regarding the wound, RN P indicated it was caused from pressure and stated, It's a stage two (partial thickness tissue loss without slough). When asked if slough (dead tissue that is white or yellow in color) was present on the wound bed, RN P revealed there was. RN P was queried why the pressure ulcer was not a stage three due to the presence of slough but did not provide an explanation. RN P applied calcium alginate (wound care treatment) and covered with a dressing. RN P did not perform hand hygiene after cleansing the draining wound bed and applying the dressing. RN P then applied skin prep the Resident #21's left elbow and left heel using the same skin prep pad. When CNA R and CNA S lifted the Resident's left lower extremity for RN P to apply the skin prep, another pressure wound was noted on the Resident's left mid lateral foot area. The area was approximately the size of a nickel and directly over the bony area on the lateral side of the foot. When asked about the area, RN P assessed and stated, non-blanchable. RN P revealed the area was a DTI pressure ulcer and applied skin prep to the area. During wound care evaluation, treatment, and repositioning, Resident #21 made moaning sounds and cried out while displaying facial grimacing and non-verbal signs and symptoms of pain. CNA staff were observed attempting to verbally calm and comfort the Resident. RN P did not assess the Resident's pain at any time prior, during, and/or after wound assessment and treatment. After completing skin assessment and treatment application, RN P exited the Resident's room. An interview was completed with CNA R and CNA S at this time. When queried how frequently Resident #21 is turned and repositioned in bed, both CNAs indicated they do their best. With further inquiry, CNA R revealed the Resident did not get out of bed anymore and was receiving Hospice services. The staff were then asked about the settings on Resident #21's alternating air mattress and both revealed they were unaware of what the settings are supposed to be and do not monitor the mattress. When queried regarding observations of Resident #21's lower extremities being positioned directly on the mattress and if the Resident had pressure reduction devices, both CNA R and CNA S revealed Resident #21 did not have any repositioning devices for pressure reduction/prevention. An interview was completed with CNA U and CNA V on 6/22/22 at 2:45 PM. When queried regarding the frequency in which Resident #21 is supposed to be turned and repositioned, both CNAs indicated the Resident is supposed to be repositioned every two hours. CNA U then stated, We try but we cannot. With further inquiry, CNA U and CNA V revealed they were unable to turn Resident #21 and other residents every two hours due to the needs of the residents in the facility and staffing levels. The staff explained that there are multiple residents who require two-person assistance, need assistance to eat, and have multiple, time-consuming care needs. Both CNA's indicated they provide the care they are able to provide but are not able to turn residents every two hours, especially when the resident requires two assist, as the residents need to be. When asked if they had discussed this with facility leadership, the staff indicated leadership told them the staffing numbers were adequate. An interview was conducted with Wound Care RN P on 6/22/22 at 2:54 PM. When asked what interventions were in place to prevent pressure ulcer development for Resident #21, RN P replied, Alternating air mattress. RN P was then questioned regarding the alternating air mattress settings including what the mattress controller settings are supposed to be set at and who monitors the mattress. RN P revealed they were unsure of what the settings were supposed to be and/or if it is monitored by staff. When queried who initially installs the mattress on the bed and sets up the controller, RN P stated, Maintenance. When queried regarding Resident #21's alternating air mattress feeling very hard when touched, RN P stated, I bet it is. RN P was asked how they knew the mattress was providing effective pressure reduction and fluctuation of pressure when they were not aware of what the settings needed to be and when the mattress function was not being monitoring by facility staff, RN P was unable to provide an explanation. When asked about observations of Resident #21's lower extremity position, identification of new pressure ulcers, and interventions in place to prevent pressure, RN P indicated staff were supposed to keep the Residents heels elevated. When asked why their heels had not been elevated, RN P was unable to provide an explanation. When queried if any alternative interventions had been attempted such as heel boots, RN P replied, I was instructed to not use heel boots. When queried who had instructed them to not use heel boots, RN P replied the DON (Director of Nursing). With further inquiry, RN P revealed the reason they were instructed to not use heel boots was because there was an issue with a (heel) boot causing a pressure ulcer because the staff did not remove it and check (skin under boot). RN P continued, They (heel boots) all got thrown away. When queried regarding staff stating they were unable to turn and reposition Resident #21 every two hours due to staffing and the Resident not getting out of bed, RN P indicated they believed the Resident was not repositioned as frequently as they should be. RN P was then asked how Resident #21's pressure ulcers could have been prevented. RN P indicated the Resident's nutritional status had changed and stated, As far as turning and repositioning, there is nothing I can say. RN P was queried regarding dietary documentation in Resident #21's medical record indicating the Resident's BMI remained within normal limits on 6/2/22 and 6/9/22, RN P did not provide a response. When asked if turning/repositioning and elevation of their lower extremities would have prevented the pressure ulcers from developing, RN P replied that it would have helped to prevent development. When queried what interventions were in place to prevent pressure ulcer development on Resident #21's elbow, especially considering their history of a pressure ulcer on their elbow, RN P reviewed the Resident's EMR and revealed there were no specific interventions in place to prevent development of pressure ulcers on the Resident's elbow. RN P was queried regarding the drainage from the pressure ulcer identified on Resident #21's left ear and replied, I think it (oxygen tubing) dug right in there (skin). When queried regarding the size of the pressure ulcer on Resident #21's left ear, RN P stated, Estimate 2 centimeters (cm) by 2 cm. When asked about the chunks of substance on the Resident's head and hair, RN P replied, It is some sort of buildup but did not elaborate further. RN P was then queried why they did not perform hand/hygiene and/or change gloves during wound care including following cleansing and application of a dressing to the open, draining wound on Resident #21's ear. RN P stated, You are correct, I did not. When asked why they did not, RN P replied, I should have. No further explanation was provided. RN P was questioned regarding Resident #21's pressure ulcer risk and revealed the Resident had prior pressure ulcers and was at risk for pressure ulcer development. When asked why other interventions and more resident specific interventions had not been attempted and implemented such as more frequent turning and repositioning and positioning devices, RN P was unable to provide justification. A follow-up interview was completed with Wound Care RN P on 6/22/22 at 3:46 PM. RN P revealed they had information regarding Resident #21's alternating air mattress. RN P stated, Per maintenance, it is set to (the Resident's) comfort level. RN P was asked how facility staff were able to ask/determine Resident #21's comfort level when they are non-verbal and replied, You can't. When queried regarding wound documentation on 5/31/22 being incomplete and not including the wound site and/or type, RN P reviewed the documentation and revealed they had authored the documentation but did not complete it (wound assessment). When asked where the wound was located, RN P was unable to provide documentation of the wound. When queried regarding facility policy/procedure related to wound treatment completion and assessment documentation, RN P stated, Weekly wound evaluation is (completed) by me. RN P further revealed that staff nurses document in the daily skilled assessment, progress notes, and/or TAR. When queried regarding why weekly wound assessments were not noted in Resident #21's medical record, RN P indicated the assessments should have been completed. The Residents medical record was reviewed by RN P at this time. After review, RN P confirmed the assessments had not been completed weekly and stated, They should have been. Resident #21's TAR was reviewed with RN P at this time. When queried regarding the blank areas on the TAR, RN P confirmed that meant the treatment was not completed. RN P was asked why the treatments were not completed but did not provide an explanation. When asked if the treatments should have been completed, RN R indicated they should have been. RN P was then queried regarding the different treatments in place for Resident #21's coccyx/buttocks wound and replied, Use Dermaseptin when it (skin) is pink or looks red depending on the person. When asked, RN P revealed Dermafilm dressings are used for open pressure wounds. RN P was then asked about the Skin & Wound Evaluation they completed and documented on 6/21/22. When asked if they had removed the Resident #21's oxygen tubing and assessed their ears, RN P replied, No. When asked if they had assessed all of Resident #21's skin and areas of potential pressure, RN P revealed they did not. When asked why they did not, RN P indicated the CNA staff will let the nursing staff know if there are any issues related to skin integrity. RN P was then queried regarding the lack of consistent and comprehensive weekly wound assessment documentation in Resident #21's EMR, RN P revealed that was an area which could be improved but did not provide further explanation. When queried regarding documentation of Resident #21's pressure ulcers and treatments completed today, RN P stated they would do their best to document the assessment but revealed they were retiring and today was their last day of work. An interview was conducted with the facility Administrator on 6/22/22 at 4:30 PM. When queried regarding Resident #21 including identification of multiple pressure ulcers, lack of comprehensive assessment and documentation by nursing staff, lack of treatment completion as ordered, and lack of implementation of interventions to prevent pressure ulcer development, the Administrator did not provide further explanation. Review of facility provided Incident and Accident Reports for Resident #21 revealed the Resident developed a facility acquired DTI pressure injury in March 2022. The report detailed, 3/15/22 . 1:30 PM . Brief Description: Purple area lateral L (left) heel. Low loss mattress noted . tx (treatment) ordered. Care plan in . Injury Type . DTI left heel . An interview was completed with the Director of Nursing (DON) on 7/11/22 at 2:46 PM. When asked if they were aware of Resident #21's pressure ulcers and surveyor observations, the DON indicated they were made somewhat aware by facility staff. When queried regarding Resident #21 including identification of multiple pressure ulcers, lack of comprehensive assessment/documentation by nursing staff, lack of treatment completion as ordered, and lack of implementation of interventions to prevent pressure ulcer development, the DON stated, Oh wow, okay. The DON revealed they were not made aware of the number and/or severity of the concerns regarding Resident #21's pressure ulcers. When queried regarding the lack of documentation of wounds, including consistent assessment, the DON revealed they can't argue with the documentation or lack of documentation. No fu[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to operationalize policies and procedures to ensure that indwelling urinary catheter care was conducted according to professional standards of practice, for one resident (Resident #21) of four residents reviewed, resulting in Resident #21's catheter being maintained in an unsanitary matter, a lack of documentation of care and monitoring per the Health Care Provider's (HCP) order, repeated Urinary Tract Infections (UTI), hospitalization for a UTI with sepsis (infection throughout the body), and the likelihood for a decline in the resident's overall health status. Findings include: Resident #21: On 6/21/22 at 12:01 PM, Resident # 21 was observed in their room in bed. The Resident made eye contact but did respond verbally when spoke to. Resident #21's mouth was slightly open, and their mucous membranes and tongue were markedly dry. There were no beverages present within the Resident's reach. An indwelling urinary catheter drainage bag was noted on the right side of the Resident's bed. The drainage bag was not contained, nor covered in a dignity bag, and positioned directly on the floor. The urine in the tubing and drainage bag was dark in color with significant amounts of sediment noted. A thick, off white colored coating was present on the inside of the drainage tubing. Record review revealed Resident #21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Down's Syndrome, urinary retention, dysphagia (difficulty swallowing), and Urinary Tract Infection (UTI). Review of the MDS assessment dated [DATE] revealed the Resident was rarely/never understood and required extensive assistance to perform all ADLs. Review of Resident #21's care plans revealed a care plan entitled, The resident has (indwelling) catheter . r/t (related to) retention (Initiated: 2/1/22; Revised: 4/5/22). The care plan included the interventions: - Change per order (see TAR [Treatment Administration Record]) and PRN (as needed) (Initiated: 2/1/22; Revised: 4/5/22) - Monitor and document output as per facility policy (Initiated: 2/1/22; Revised: 4/5/22) - Monitor/document for pain/discomfort due to catheter (Initiated: 2/1/22; Revised: 4/5/22) - Monitor/record/report to MD for s/sx (signs/symptoms) UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns (Initiated: 2/1/22; Revised: 4/5/22) - Position catheter bag and tubing below the level of the bladder and away from entrance room door (Initiated: 2/1/22; Revised: 4/5/22) - Provide for gravity drainage (Initiated: 2/1/22; Revised: 4/5/22) At 3:20 PM on 6/21/22, another observation occurred of Resident # 21. The Resident was in their room, in the same position in bed. Their indwelling urinary catheter drainage bag remained not covered and/or contained and positioned on the right side of the bed directly on the floor. Resident #21's urine within the tubing and drainage bag remained dark in color with visible sediment. The off-white-colored sediment build-up remained within the tubing. An interview was completed with Licensed Practical Nurse (LPN) D on 6/22/22 at 1:44 PM. When queried regarding the rationale for Resident #21's indwelling urinary catheter, LPN D specified the Resident's catheter was due to urinary retention. LPN D was then queried regarding Resident #21's catheter drainage bag being observed directly on the floor. LPN D revealed catheter drainage bags should always have a barrier and should not touch the floor. When asked about the color and sediment of Resident #21's urine including the cloudy, off white colored coating in the drainage tubing, LPN D did not provide further explanation. When queried regarding nursing care and management of the Resident's catheter, LPN D revealed they would need to review the Resident's orders. An observation of incontinence/daily ADL care for Resident #21 was completed with Certified Nursing Assistant (CNA) R and CNA S on 6/22/22 at 2:12 PM. During daily care, the Resident was noted to not have a urinary catheter securement device in place. When asked, both CNAs indicated Resident #21 pulls at their catheter when they have a securement device. With further inquiry regarding the type of securement devices used by the facility, the staff revealed the facility utilizes the securement devices which attach (stick) to the skin. CNA R continued that Resident #21 has sensitive skin and they were unsure if the device caused skin irritation. The staff were then asked if the wrap around, non-adhesive, Velcro style catheter securement device had been tried and both indicated it had not. Review of Resident #21's Medication Administration Record (MAR) for May 2022 revealed the Resident was started on Cephalexin (Keflex- antibiotic) 500 mg (milligram) three times a day for seven days due to a UTI on 5/28/22. Review of Resident #21's Treatment Administration Record (TAR) for May 2022 revealed the following: - Change catheter drainage bag monthly and as needed. Label with date in the morning every 28 day(s) (Start Date: 4/6/22). The TAR indicated the catheter drainage bag was due to be changed on 5/4/22. There was no documentation of completion. - Change indwelling catheter as needed one time a day every 28 day(s) (Start Date: 4/6/22). The TAR indicated the catheter was due to be changed on 5/4/22. There was no documentation of completion on 5/4/22. - Change indwelling catheter as needed as needed (Start Date: 4/5/22). Documented as completed on 5/12/22 at 2:42 AM. - Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date 3/8/22). The TAR included documentation sections for completion three times per day. There was no documentation of completion on: 5/4/22 Day, 5/5/22 Day, 5/9/22 Day, 5/16/22 Night, 5/23/22 Evening, 5/25/22 Day, and 5/29/22 Night. Review of progress note documentation in Resident #21's medical record revealed the following: - 2/21/22 at 4:15 AM: Nurses' Notes . On call notified: Upon admit resident did have a Foley for urinary retention, was discontinued over a week ago. Has milky discharge from penis frequent urination without being able to empty bladder fully. After moderate urine inct (incontinent) episode did bladder scan still has 500 cc + of urine. - 2/21/22 at 4:32 AM: Nurses' Notes . Order received: Obtained 650 cc of cloudy urine with foul odor. Resident had visual relief and tolerated well. UA sent . - 2/27/22 at 6:43 AM: Nurses' Notes . HX (History) of urinary retention had a Foley upon admission, after removed over a week ago had retention and is being treated for UTI at this time. Today Resident was a no void for 8 hrs. Procedure done straight cath'ed obtained 1000 cc of clear dark yellow urine, tolerated well and showed signs of relief. Due to this resident has a cogitative deficit is unable to verbalize urge to void and has difficulty alerting staff of discomfort . - 5/12/22 at 3:00 AM: Nurses' Notes . Resident was showing s/s (signs/symptoms) of discomfort, reaching for genitals. This writer attempted to flush Foley catheter but was unsuccessful. A standing order for Foley catheter change PRN (as needed) is for a 14 F (French) 10 mL (milliliter). This was unavailable. On call (provider) approved a 16 F . 10 mL of sterile water was used to inflate the balloon. New collection bag was attached . 250 mL of clear amber colored urine return noted in bag . - 5/14/22 at 3:55 AM: Nurses' Notes . Noted that resident has indwelling cath 16 fr was [incontinent] of large amount of urine around the cath [insertion] site. (Registered Nurse [RN] Q) in to assess resident. Deflated cath balloon only had 5 cc (cubic centimeters) in, replaced with 10 cc. draining to gravity urine in tubing. Noted this resident has had issues like this in the past and replacing entire cath is very difficult . - 5/14/22 at 10:54 PM: Nurses' Notes . Resident has had continuous issues with Foley not draining well even after being replaced earlier today with 16 french. Urine is coming out both penis and Foley tubing and resident is experiencing lower abd (abdomen) discomfort and retention. Bladder scanner not working correctly get inconsistent numbers each time scanned consecutively. - 5/14/22 at 11:27 PM: Nurses' Notes . Notified on call said that a different size Foley may be used. Also noted has moderate amount of discharge from tip of penis and urine cloudy. - 5/14/22 at 11:31 PM: Nurses' Notes . Inserted 20 fr (French) Foley per ok from on call. Resident tolerated well and it is draining well to gravity. Drank 350 at dinner and had out so far after change 250 cc. - 5/22/22 at 4:04 AM: Nurses' Notes . No urine in tubing after 8 hrs. Inserted 20 fr Foley per ok from on call. Resident tolerated well and it is draining well to gravity. - 5/23/22 at 4:54 AM: Nurses' Notes . For the last 24 hrs have been encouraging fluids and output for 8 hrs has been consistently low in Foley around 300 cc each 8 hr period. Discharge from penis and urine dark with foul odor. Remains afebrile. HX (history) of recurrent UTI's. Notified on call. - 5/24/22 at 5:28 PM: Nurses' Notes . resident spiked a temperature, administered Tylenol and cold compress applied to forehead, tested for Covid results = neg, np (Nurse Practitioner)/dr (Doctor) notified Note: A Health Care Provider order and/or Urinalysis (UA) laboratory testing was not ordered and/or completed at the facility. - 5/31/22: Health Care Progress Note: Visit Type: Acute . Chief Complaint Hypotension (low blood pressure) /UTI/fever . seen for hypotension, UTI, fever. Nursing reports this patient has had decreased oral intake of food & fluids and problems with Foley cath 3 days ago . was sent to the ED to have Foley reinserted r/t (related to) urinary retention . was dx (diagnosed) with a UTI and returned on an antibiotic . Patient does better at meals when assisted. Nursing reports appears to be doing better today than yesterday . is more alert & interactive . Review of Resident #21's MAR and TAR for June 2022 revealed documentation of the Resident's catheter and drainage bag was changed on 6/1/22, twenty days after it was last changed. Resident #21's May 2022 TAR further revealed the task, Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date: 3/8/22) was not completed on during the Evening on 6/2/22 and 6/11/22, the Day on 6/21/11, and the Day, Evening, and/or Night shifts on 6/22/22, 6/23/22, 6/24/22, 6/25/22, 6/26/22, 6/27/22, 6/28/22, 6/29/22, and 6/30/22. Further review of Resident #21's medical record revealed the Resident was transferred to the hospital on 7/3/22 due to a change in condition. Review of hospital record documentation for Resident #21 detailed the Resident was diagnosed with sepsis (infection throughout the body) secondary to pneumonia and a Urinary Tract Infection (UTI) at the hospital on 7/3/22. A review of Resident #21's hospital ED (Emergency Department) Provider Note dated 7/3/22 at 6:40 AM, specified, (Resident #21) is nonverbal and unable to communicate . present to the emergency room by EMS after nursing home called believing that (the Resident) was getting ready to die. Apparently (Resident #21) was diaphoretic (sweating) and had a decreased level of responsiveness. EMS arrived to find the patient alert and looking around and in no obvious distress . presented to the emergency room awake and alert but tachycardic (rapid heart rate) with a heart rate in the 120's (elevated) . General . somewhat pale and malnourished appearing . lips are dry and cracked and oral mucosa is dry . tachycardic . ED Clinical Course . does appear . septic and the source is most likely urine. (Resident #21's) Foley (indwelling) catheter was changed out and had a significant amount of pus noted in urine . Problem/Assessment/Plan . Sepsis . HAP (Healthcare Acquired Pneumonia) . UTI . Review further revealed Resident #21 was readmitted to the facility on [DATE]. Review of facility medical record documentation following their readmission revealed: - 7/5/22 at 2:29 PM: Nursing Evaluation Summary . Note Text: resident readmit . lethargic (Resident) baseline, new abx (antibiotic) orders for uti (Urinary Tract Infection), notified NP/MD/on call provider NP . - 7/5/22 at 7:13 PM: Nurses' Notes . Resident came back from brief stay at hospital, all prior orders to resume, new orders for severe UTI amoxicillin (antibiotic) 875/125 mg (milligram) bid (twice a day) x 10 days, Bactrim DS 800-160 mg (antibiotic) bid x 10 days, resident is lethargic . baseline, (hospital) reinserted Foley . was low on magnesium and potassium (treatment provided at hospital) . Review of Resident #21's MAR and TAR for July 2022 revealed no documentation of the Resident's indwelling catheter and/or drainage bag being changed. The MAR/TAR further revealed no documentation during the day of completion for the task, Monitor urine from indwelling catheter for color, cloudiness, odor, and decreased output. Notify provider as needed of any changes every shift (Start Date: 3/8/22) on 7/3/22, 7/5/22, 7/8/22, and 7/9/22. On 7/11/22 at 2:47 PM, an interview was completed with the Director of Nursing (DON). When queried regarding Resident #21's recent discharge the DON stated, (Resident #21) was sent out for a UTI and came back. When asked if catheter drainage bags should be positioned directly on the floor, the DON revealed drainage bags should be off the floor and contained/covered. When queried regarding observations of Resident #21's urine, catheter tubing and drainage bag, the DON stated they were not pleased. With further inquiry, the DON implied they were unable to refute observations and would address with staff. A review of the Resident's medical record was completed with the DON at this time. When queried regarding the lack of documentation of completion of monitoring, assessment, observation, and timely care in response to symptoms, the DON was unable to provide an explanation. When asked if there was a correlation between the lack of documentation of monitoring, assessment of the Resident's catheter care/urine, surveyor observations of the catheter, transfer to the ED and subsequent diagnosis with sepsis as well as the Resident's history of UTI's, the DON revealed they were unable to provide any information and/or documentation to dispute the lack the monitoring/care and subsequent UTI with sepsis. The DON then stated that Resident #21's health status had been declining and was recently transferred to Hospice. When asked the correlation between Hospice and a UTI, the DON did not provide further explanation. Review of facility provided policy/procedure entitled, Catheter Care Procedure - Urinary (Implemented: 1/1/21) revealed, Policy: It is the policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections. Catheter care will be provided by the nursing assistant and/or nurse. Details: 1. Residents who have indwelling urinary catheters will be provided catheter care in accordance with current clinical standards. This may include a. Every shift b. With each bowel movement (incontinence or continence) c. As needed and per request 2. Catheters should be maintained to provide gravity drainage, without kinks or loops 3. Catheters should be secured to prevent pulling and damage to the urethral meatus. This may be accomplished by: a. Utilizing the appropriate drainage device (leg bag or catheter bag) b. Leg strap c. Velcro strap d. Linen/clothing clamp e. Adhesive securing device 4. Catheters should be emptied every shift or as needed 5. Urinary output should be recorded per facility protocol. 00