**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure 1 of 3 residents (R1) received necessary medical attention following a change in a left hip surgical incision. Additionally, the facility failed to comprehensively assess, monitor, and document skin changes. R1 sustained actual harm and required hospitalization, surgery, and insertion of a peripherally inserted central line catheter (PICC) for intravenous (IV) antibiotic treatment for sepsis. Findings include: R1's hospital Discharge summary dated [DATE], identified mechanical ground level fall after losing her balance and sustained a left subtrochanteric femur fracture. She required surgery that included an surgical open reduction and internal fixation (ORIF) of the left hip and tramedullary nailing of left femur. Surgical incision noted to left hip with dressing. R1's progress notes from 8/25/25 through 9/10/25, identified: -8/25/25 at 2:57 p.m. Weekly Skin Check: R1 continued with stapes to surgical incision on the left hip/thigh. No new skin issues noted. -8/25/25 at 3:06 p.m. Skilled Nursing Documentation: Surgical wound left hip/thigh, no drainage, surrounding tissue intact and no pain. Nursing interventions: surgical wound care. -8/26/25 at 1:42 p.m. Skilled Nursing Documentation: Surgical wound left hip/thigh, no drainage, surrounding tissue intact and no pain. Nursing Interventions: surgical wound care. -8/26/25 at 8:33 p.m. Staples to left hip/thigh removed per order. R1 tolerated well. Cleansed area with saline and applied steri strips. -8/27/25, 8/28/25, 8/29/26, 8/30/25, Skilled Nursing Documentation completed. No documentation in progress notes on left hip/thigh incision (4 days). -9/1/25 at 8:43 a.m. Surgical wound left hip scant amount of purulent (thick and milky discharge from a wound and almost always indicates an infection, should not be ignored, and needs treatment as soon as possible) drainage. Surrounding tissue erythema (redness that occurs when extra blood rushes to an area and often indicates inflammation or infection). Pain was present with tenderness to upper aspect of incision. Nursing interventions: proper positioning and surgical wound care. -9/1/25 at 8:43 a.m. Skin Assessment: Skin check done prior to shower. Surgical incision to left hip is red and warm to upper half of incision. R1 does report some tenderness to area. Scant purulent drainage noted to two areas of upper incision: bottom area measuring 1.3 centimeters (cm) along incision and top area measuring 3 cm along incision. Cleansed with wound wash and patted dry. Waterproof surgical post op bandage applied. -9/1/25 at 11:59 a.m. as needed (PRN) Tylenol given at 12:00 p.m. per her request for pain. -9/1/25 at 2:19 p.m. Surgical wound left hip scant amount of purulent drainage, surrounding tissue erythema, and no pain. Interventions to promote healing and prevent infection: proper positioning and surgical wound care. -9/2/25 at 2:19 p.m. surgical wound left hip scant amount of purulent drainage, surrounding tissue erythema, and no pain. Interventions used to promote healing and prevent infection: positioning and surgical wound care. -9/3/25 at 4:07 p.m. R1 had red and warm to touch right foot/toes. Charge nurse sent picture to primary provider medical doctor (MD) who ordered Bactrim double strength (DS) two times a day (BID) times 7 days. Orders updated. -9/3/25 at 11:18 p.m. Skilled Nursing documentation completed. Skin and/or left hip incision was not included in this entry. -9/4/25 at 6:24 p.m. Nurse was asked to check left hip as was noted to be red and swollen today with pain. Started on Bactrim yesterday. Area or [sic] erythema and edema marked earlier. There was a Mepliex surgical in place with 430% [sic] serous drainage present to foam. The area marked has not spread and is 37 x 34 cm. There is a peau d [sic] orange skin texture. Skin is warm and erythematous. R1 reported it throbs and aches. Temperature 100.0 (F). Report sent to MD. Further vitals checked at within proximity to last check. No response from MD yet. Did report to oncoming nurse no response yet and encouraged to monitor vitals more frequently throughout the evening. Told R1 she may need an evaluation through the hospital and possible increase in antibiotics and she said no. When asked further she stated she did not wish to go to the hospital. She was informed a message was sent to the provider and that they would continue to monitor. Instructed to report feeling of chills or sweats. -9/4/25 at 7:11 p.m. MD responded thinking of a resident transfer to higher level of care. Awaiting orders for transfer to local ER vs another hospital. R1 agreed with transfer stated, if she had to. Nurse on duty was aware of pending transfer. Hand off report had been given. -9/4/25 at 7:28 p.m. R1 was transferred to local hospital via son. Bed holds in place. -9/5/25 at 8:43 a.m. Discussed at interdisciplinary team (IDT): transferred to local hospital due to worsening of infection of left hip. -9/10/25 at 10:55 a.m. R1's planned arrival date back to facility 9/10/25 around 11:30 a.m. to 12:00 p.m. admission diagnoses: sepsis due to post surgical abscess. Cares: peripherally inserted central catheter (PICC) (a long flexible catheter goes into your upper arm vein, through the vein in the arm and into a large vein located by the heart and allowed for long term access to infuse IV fluids, medications, and draw blood) line/antibiotic (Abx) for six weeks and wound vac/Prevena (not to be removed until batteries die) left hip. -9/10/25 at 12:35 p.m. R1 admitted from hospital in stable condition. -9/10/25 at 4:22 p.m. Skin assessment: left hip incision swollen and redness noted with wound vac in place. Left posterior calf open area 4 x 1 cm and 0.5 cm deep with clear drainage. Meplix dressing over Silvadene gauze ordered. R1's treatment administration record (TAR) August 2025, identified:-Change Mepilex dressing daily to left hip, start dated 8/19/25. Dressing change was signed off as being completed on 8/20/25, 8/22/25 through 8/26/25, 8/29/25, through 8/31/25. Dressing was signed off as not completed on 8/21/25 (not administered: due to condition), 8/27/25 (dressing changed at appointment) and 8/28/25 (did not want dressing on). -Complete weekly skin check observation and record vitals once a day on Monday. Documented on 8/4/25, not administered, no bath. Documented completed on 8/11/25, 8/18/25, and 8/25/25. R1's TAR September 2025, identified: -Change Mepilex dressing daily to left hip, start dated 8/19/25. Dressing changed was signed off as being completed on 9/1/25, 9/2/25, and 9/4/25. On 9/3/25, dressing change was documented as not completed. -Complete weekly skin check observation and record vitals once a day on Monday. Documented on 9/1/25 completed. -R1 was being treated for diagnosis abscess of left leg. Document every shift (3 times a day) in progress notes if these signs and symptoms are noted: temperature, pus present at wound skin or soft tissue site, new or increase in heat, redness, swelling, tenderness/pain, serous drainage at the affected site, changes in mental status and/or increase in ADL assistance. Start dated 9/12/25. Signed off not completed on 9/12/25 (1 time) (will administer when awake), 9/16/25 (1 time) (resident unavailable), and 9/24/25 (1 time) (did not get done in a.m.). R1's admission to hospital dated 9/5/25, identified admitted to hospital for post-surgical abscess and overlying abscess or previous left subtrochanteric femur fracture due to ground level fall status post ORIF with intramedullary nailing of left femur. Sepsis and increased left hip pain was due to the above. Orthopedics consulted, plan for surgery in a.m. Given her sepsis started on IV antibiotics Vancomycin and Rocephin. Today brought in by her son as over the last several days had noticed around her incision drainage and redness. Has noted a yellowish color to the drainage. Fever developed over the last 24 hours. She is also noted pain had increased in the left hip over the past few days to the point where she was unable to walk. It sounded like prior to this she was doing well. In the emergency department (ED) she had chills along with a fever of 100.0 degrees Fahrenheit (F), heart rate 114. Lab work completed shower elevated white blood cells (WBC) of 13.4 with left shift, stable hemoglobin, elevated C-reactive protein (CRP) (measures level of a protein in your blood that indicates inflammation) of 166 milligrams per liter (mg/L) (normal range less than 2.0 mg/L) and elevated erythrocyte sedimentation rate (ESR) (measures inflammation in the body) of 67 millimeters per hour (mm/hr.) (normal less than 30). CT scan showed abscess. Notable erythema over the proximal medial thigh extending over the lateral thigh midway down with increased erythema pronounced on the incision site. A bacterial culture with gram stain (laboratory test that helped diagnose harmful bacteria) of the left thigh tissue on 9/5/25, identified a rare staphylococcus aureus (a bacterial infection that can cause serious illness and become deadly if found in the blood stream, joints, bones, lungs, or heart, moderate white blood cells and treated with antibiotics), moderate white blood cells (WBC) ( body produces more to fight an infection by attaching and destroying invading pathogens), and many red blood cells (RBC). A bacterial culture with gram stain dated 9/5/25, specimen taken from deep left thigh fluid identified rare staphylococcus aureus and corynebacterium aurimucosum (a nosocomial (occur in healthcare settings) pathogen infecting hard-to-heal peripheral wounds, such as skin wounds, soft tissue abscesses and osteomyelitis) and many WBC. R1's care plan dated 9/10/25, identified at risk for skin alteration of skin due to limited/decreased mobility and pain. Staff were directed to observe skin integrity daily with cares, bathing, report any reddened, irritated, bruised or open areas and any new skin concerns taken to the nurse to address. The skin risk assessment with Braden scale/tissue tolerance completed per guidelines. She had a PICC to deliver fluids/medications due to a diagnosis of abscess of left leg and directed staff to administer medications/antibiotics as ordered. She required wound care treatment plan as follows: keep wound vac in place for 7 days or until battery dies and dressing changes to surgical site. R1's 5-day Minimum Data Set (MDS) dated [DATE], identified she was admitted on [DATE], hospitalized , and readmitted on [DATE]. Cognition was intact with no behaviors. Diagnoses included fracture of the hip, peripheral vascular disease (PVD) (narrowed blood vessels reducing blood flow to the limbs), chronic obstructive pulmonary disease (COPD), surgical site incision infection with cares, and cellulitis to right lower limb. She was at risk for pressure ulcers. She required substantial/maximal assistance with roll left to right in bed, sit to lying, and lying to sitting, dependent for toileting hygiene, lower body dressing, sit to stand, and all transfers. R1's orders from 8/1/25 through 9/13/25 identified: -8/3/25, leave occlusive dressing intact for: comments- keep Prevena (purple) dressing in place until wound vac dies. Remove and throw away. Replace with Mepilex. Change every 7 days with occlusive dressing. If incision is draining, ok to change dressing sooner. Keep covered until staple removal at 2 weeks pos-op. Nursing communication: if she is doing well, ok to remove staples at 2 weeks post-op at skilled nursing facility (SNF) and cancel follow-up appointment. -8/3/25, ice to affected area: ice to lower extremity, cold packs as needed for swelling a pain. Alternate 20 minutes on and 20 minutes off. Assess skin every 2 hours. Do not apply directly to skin. -8/19/25, change Mepilex dressing daily to left hip. May shower, cover incision with waterproof dressing so it does not get wet. -8/26/25, ok to remove staples on 8/26/25 if no drainage. If concerns call orthopedics. -9/10/25, cefazolin (Ancef) (antibiotic) 2,000 milligrams (mg) in sodium chloride 0.9%/50 millimeters (ml) administer IV every 8 hours for post op infection. -9/10/25, left hip incision/surgical site, abdominal (ABD) pad, secure with tape. Special instructions: incision has significant amount of drainage. Change as needed. -9/12/25, complete the weekly skin check observation.-9/12/25, Document in progress notes if these signs and symptoms are noted: temperature, pus present at wound skin or soft tissue site. New or increase in heat, redness, swelling, tenderness/pain, serous drainage at affected site, and change in mental status. Every shift: days/evening/nights. -9/13/25, Skill Charting: Pain-site/level/intensity/pharmacological/non-pharmacological interventions, medical doctor (MD) appointments, . special instructions: skilled charting should be therapy, IV antibiotic and skin. R1's Hospital Discharge summary dated [DATE], identified two days prior to admission to hospital she was noted to have redness and drainage at incision site. She was admitted to the hospital for surgical cellulitis, orthopedic surgery and infectious disease physician was consulted. Her intraoperative culture showed Morganella Morganii (an unusual opportunistic pathogen belonging to the Enterobacteriaceae (microorganisms that can grow in absence of oxygen such as gram-negative) family, primary associated with post-operative wound and urinary tract infections and known for its resistance to multiple antibiotics and evolving virulence. This bacterium often results in a high mortality rate with some infections) and a few peptoniphilus species (gram-positive, anaerobic (requiring absence of free oxygen) causes infections). She had been treated with broad-spectrum IV antibiotics during hospitalization and recommended to complete 6 weeks course of antibiotic discharging on IV Ertapenem per infectious disease physician recommendation. She also received wound VAC during this hospitalization and orthopedic surgery recommended to keep in place for 7 to 14 days or until battery dies, then place Mepilex over incision. Interagency Handoff Report dated 9/10/25, identified R1 was admitted to the hospital on [DATE], hospital events: presented to emergency department (ED) with complaints of left hip skin changes and drainage from surgical incision. ORIF of left hip with intramedullary nail placement on 7/29/25. Computerized tomography scan (CT) (imaging test that uses x-rays and a computer to create detailed pictures of your organs, bones, and tissues), showed large fluid collection. Intravenous (IV) fluids and antibiotics administered, orthopedics consulted, planned for incision and drainage (I&D) (procedure to drain pus from an abscess and clean it out to promote healing) tomorrow. Blood cultures completed and PICC inserted. During an observation /interview on 9/19/25 at 10:08 a.m. R1 sat in her wheelchair in her room fully dressed. She stated she had fallen at home and fractured her hip, had surgery, and then admitted to the nursing home. Her incision was healing pretty good, stitches were taken out but had a hard time when the nurse attempted to remove the two top stiches. The NA saw my incision was getting red on my upper thigh and told then nurse. She had also informed the nurse it was red, increased pain and drainage after the stiches came out. She had to be sent into ER, started on antibiotics and surgery to open it up twice to see where the infection was located. During an observation on 9/19/25 at 12:01 p.m. RN-D was in bathroom with R1 on the toilet. A clean brief was applied and pulled up to her thighs. She was lifted off the toilet with the PAL machinal lift with her feet placed on the platform. There was a Mepilex dressing approximately 1 inch wide located over her left hip incision dry and intact with small amount of shadow drainage with no redness on the surrounding skin or signs of infection per RN-D. R1 was getting ready to leave facility for a wound clinic visit scheduled for this afternoon. Peri cares completed, pants pulled up and lowered into her wheelchair. During an interview on 9/19/25 at 2:15 p.m. licensed practical nurse (LPN)-A stated after the staples were removed on 8/26/25, from R1's left hip incision there were two spots at the top of the incision that had a scant to moderate amount of bleeding and small amount of redness. She had cleaned it with warm mild soap, water and applied Mepilex dressing over it to catch the blood daily. On 9/1/25, R1 was more tender with purulent drainage noted at the top of the left hip incision whereas she did not have pain prior. She may have talked to the director of nursing (DON) that day, but nothing was documented so unsure. Usually with an incision that looked like this one on 9/1/25, could have indicated infection, a registered nurse (RN) should have been informed, assess it, and notify provider. Pictures could have been taken, sent to provider, and antibiotics ordered. The nursing assistants informed her a couple of times two days in a row it looked red, unsure which days those were, and she did not document it. R1's incision should have been reported to the provider on 9/1/25 or at least by 9/2/25 and was not documented. During an interview on 9/19/25 at 2:51 p.m. NA-A stated R1 had a one-inch-wide dressing on her left hip incision and redness was seen around the incision /dressing two days before she was sent to the hospital. She had informed the nurse both days. During an interview on 9/24/25 at 11:30 a.m. LPN-B stated the skilled nursing charting/documentation was required to be completed daily and should have included the skin assessment as well. We want to make sure there is no infection going on in the surgical incision. When there are signs of infection such as change in drainage, abnormal vital signs, redness around the incision, or increase in pain the RN should have been notified, and she would contact the provider. When a resident has a daily dressing, the nurse would be expected to assess the incision for signs and symptoms of infection and document at least daily on what their assessment showed. R1's provider should have been contacted right away when a change was seen in her left hip incision to help identify infection and prevent sepsis and most likely could have made a difference. Anytime a provider was notified the nurse would be expected to document it so that it can be tracked and followed up on. During an interview on 9/24/25 at 1:23 p.m. medical doctor (MD) stated R1's dressing change was ordered to be completed daily, and he would expect the nurse to assess, change the dressing and document daily. Would be important to complete a daily assessment to prevent infection and change the plan of care if necessary to promote healing. The nurse would be expected to rely on their judgement as to when to notify the provider. When the nurse identified signs of drainage, increased redness, and fever, he would have expected to be contacted right away. He was always available to be contacted and would have wanted to know as soon as signs and symptoms of infection were identified. He would have expected the nurse to contact him on 9/1/25, he was traveling at that time and on vacation and the on-call provider would have been the one to contact. He did not recall being contacted on 9/2/25 but had a message on 9/3/25 regarding R1. He was unsure of what the message was about. During an interview on 9/24/25 at 1:50 p.m. RN-B stated a weekly thorough skin assessment would be expected to be completed by the nurse and then a daily skin assessment if a daily dressing change was ordered to catch any changes and determine if any signs/symptoms of infection are present. She was asked to assess R1's left hip incision on 9/4/25, it was noted to be red, swollen with pain and erythema. R1 informed her the incision throbbed and ached and her temperature was 100.0 degrees F. All those signs and symptoms were of infection, and she needed antibiotic therapy. She left a phone page to MD, and he usually responded even if he was on vacation, very good about that. The nurse would be expected to document on her left hip incision/dressing daily to monitor for infection, catch it faster, less need for antibiotics, and decrease the likelihood of sepsis. During an interview on 9/24/25 at 2:45 p.m. hospital MD-B stated if R1 would have been brought to ER even a day or two earlier she may not have become septic. The sooner the sooner you can recognize signs and symptoms of infection, contact the provider, get them treatment the better the outcome. The abscess was quite big in her hip and required surgery, I&D. Cultures were completed, and antibiotics were started. Her sepsis could have been life threatening. During an interview on 9/24/25 at 4:00 p.m. LPN-C stated right after (unsure of date) R1 had her staples removed from her left hip incision on 8/26/25, the incision started oozing clear but pale-yellow scant amount of drainage from the top part. She did not document the drainage or the skin assessments of the incision when she changed the dressing. Unsure why she did not change the dressing on 9/3/25, no documentation provided in the progress notes. A provider should have been contacted when signs and symptoms of infection were present such as bleeding, uncontrollable pain/fever/signs, and symptoms to help prevent the resident's condition from getting any worse. During an interview on 9/25/25 at 1:00 p.m. RN-C stated she had completed daily skilled nursing assessments but was unsure what to click on and what areas were required to be documented on. She clicked on areas she thought was appropriate for each resident documented on. R1's assessment should have included her skin/incision each time to monitor for infection and make sure the incision was healing well without adhesions. The NAs are informed to let the nurse know if there are changes in skin and are good about doing that. She was unsure why she documented on 8/21/25, left hip dressing change was not completed d/t condition. The surrounding skin should have been assessed at that time and any changes documented to catch signs/symptoms of infection and prevent complications. The nurse would be expected to notify a provider right away when signs/symptoms of infection are noted such as fever, redness around incision, change in drainage, pain, change in mental status. Purulent drainage meant there was puss and infection present on 9/1/25 and a provider should have been called and documented. During an interview on 9/25/25 at 1:39 p.m. RN-D stated on the electronic medication administration record (EMAR) skilled nursing assessment were scheduled for every shift, however nursing staff were only required to have completed it once a day according to the guidelines. The order was placed in there that way so that it would not get missed. R1's left hip incision should have been assessed and documented every shift especially with a daily dressing change so that signs and symptoms of infection could have been recognized early on and prevent sepsis from occurring. There was a noted change in R1's left hip skin/incision on 9/1/25, charge nurse and the provider should have been notified. There was an event created on 9/3/25, provider contacted but only for her foot. RN-D verified there was no skin/incision assessments completed from 8/27/25 through 8/31/25 (4 days) and should have been. On 9/1/25, documentation identified a changed in her incision, a decline, signs of infection which would have been considered a significant change. The nurse would have been expected to contact the provider and documented so that we could have followed up on it. Recognizing signs and symptoms of infection early was important. During an interview on 9/25/25 at 3:43 p.m. DON stated the skill nursing assessment charting should have been completed daily and included the skin/incisions. She verified from 8/27/25 through 8/31/25, there was no documentation of a skin assessment on R1's left hip incision and should have been completed at least once a shift to monitor for signs and symptoms of infection. The nurse would be expected to assess the incision, surrounding skin when the daily dressing was completed and document their findings. The nurse would be expected to contact the provider right away when signs and symptoms of infection are seen such as increase in pain, drainage, purulent drainage, fever, and redness. The nurse can contact the provider by texting or calling depends on the provider and document. If it had been over two hours the nurse would be expected to follow up with the provider again so that continuity in care can be provided. The provider should have been contacted on 9/1/25 when purulent drainage, redness, and tenderness were noted on R1's left hip incision area. Identification of an infection early and starting an antibiotic would be important to avoid sepsis. Facility document Infection Prevention and Control (dressing changes and wound care) undated identified read the care plan of seeing resident to know if/how the wound is be cleaned and what type of dressing if needed should be applied. After wound care and/or dressing change has been completed documentation was required. Facility policy Preventing Skin Infections dated 9/2023, identified the purpose was to promote wound healing while preventing infection. Skin injuries will be observed daily or as ordered. If dressing change is not indicated daily, there will still be a visualization of the surrounding skin condition. A comprehensive wound assessment will be completed on a weekly basis and include location of skin injury, length, width, and depth measurements recorded in centimeters. Direction of length of tunneling and undermining if present. Appearance of wound base. Type and percentage of tissue in wound such as eschar, slough, granulation, epithelial. Drainage amount and characteristics including color, consistency, and odor. Drainage identified as sanguinous: blood drainage; blood drainage in a chronic wound may represent a sign of increased microbial load in the wound, which indicates an assessment for signs of infection was needed. Localized signs of infection would be erythema, induration (hardening of tissue around the wound site can indicate inflammation/infection), increased drainage, change in character of tissue, foul odor, increased pain at wound site, delayed wound healing, general malaise, mental confusion, loss of appetite, leukocytosis, fever (often not present in elderly), hypothermia, blood sugar changes in diabetic. Document progress toward healing following facility protocol on when to request change of treatment. Facility policy Change in Condition dated 10/2/23, identified the provided care and services are based upon the current needs of the resident under the direction of the attending provider. When a significant change in the resident's physical, mental, or psychosocial status is identified by the licensed nurse, or when there is need to alter treatment significantly, the licensed nursing associate consults with the attending provider and notify the resident/resident representative. Assess significant change in the resident's condition noted through direct observation, interview, or report for [sic] other staff. Notify the attending provider of the change in condition and implement orders for treatment and appropriate monitoring as directed. If unable to contact the physician, contact the medical director as appropriate. Document symptoms, assessment, observations, resident/resident representative, and medical provider notification.