**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to safely use a full body mechanical lift per manufacturer's recommendations for 1 of 3 residents (R1) reviewed who used a mechanical lift. This resulted in harm when R1 fell from a full body mechanical lift causing ongoing pain in shoulders and neck region. In addition the facility failed to ensure comprehensive assessments were completed to determine proper sling size for 3 of 3 residents (R1, R2, and R3) who required transfers with a mechanical lift. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was alert and with diagnosis of quadriplegia, bilateral range of motion impairment to both upper and lower extremities. R1 was dependent with all activities of daily living (ADLs) except for eating, which required set up only and used a electric wheelchair independently. R1's Nursing Assessment for Total Mechanical lift dated 4/13/24 indicated R1 was deemed unsafe to use standing lift. The assessment directed staff to use the Hoyer lift (brand of full body mechanical lift) with two staff assist. The assessment did not address sling size and type. R1's care plan dated 7/10/24, directed staff to transfer R1 with a Hoyer lift with two staff, but did not identify size or type of sling to use during transfers. R1's progress notes dated 7/5/24 at 11:45 p.m., indicated at 11:10 p.m. R1 fell from Hoyer sling during transfer. R1 reported he had hit his head and his upper back. R1 rated his pain at 7/10 and was given Tylenol. Nurse discussed with R1 option of going into the emergency room (ER) to be further evaluated for any injuries, R1 declined further ER evaluation multiple times. No visible injuries noted. No swelling, redness or bruising noted anywhere at this time. Director of nursing (DON) notified by phone. Fall protocol worksheet initiated and continue to monitor. R1's Post Fall Evaluation dated 7/6/24 at 7:46 a.m., indicated R1 vocalized a pain rating of 7/10 and was a new issue. No further documentation noted. R1's situation background assessment, and recommendation (SBAR) progress note dated 7/9/24 at 10:44 a.m. identified R1 had a fall on 7/5/24, within the last week has had an increase in pain in the back and neck, recommendation to be seen at the clinic and have a CT scan completed to rule out fractures. R1's progress note dated 7/9/24 at 11:47 a.m., indicated R1 left the facility at 11:00 a.m. and returned at 2:45 p.m. R1's hospital After Visit Summary dated 7/9/24 indicated R1 was seen in the emergency room for back pain. R1 was administered an injection of Ketoralac 15 milligrams (mg) (non-steroidal anti-inflammatory medication to relieve pain). Imagining tests were completed with no new findings or fractures. New orders included: Tylenol 1000 milligrams (mg) every 6 hours for pain, could also take 600 mg of ibuprofen every 6 hours, and use topical over the counter patches such as lidocaine or Salonpas and over the counter ointments/creams Voltaren gel or Asper to assist with pain control. Apply ice and/or heat for 20 minutes at a time multiple times per day and can alternate ice and heat. R1's medication administration record (MAR) was reviewed for June and July 2024. The June MAR included a physician order for Acetaminophen (Tylenol) hydrocodone (narcotic pain medication) 325/5 milligrams (mg) three times a day; R1's average pain rating was marked 4 and 5 out of 10 scale (10 being the most severe). June's MAR also identified an order for as needed (PRN) Tylenol 1000 mg every two hours; MAR identified one administration on 6/22/24 for pain level of 8 out of 10. July's MAR identified the aforementioned orders. The pain rating for the scheduled Acetaminophen/hydrocodone identified increased pain ratings between 7/5/24 and 7/11/24 after the fall. R1 reported pain 6/10 on five occasions and 7/10 pain on 4 occasions. July's MAR also identified R1 was administered PRN Tylenol on 10 occasions between 7/5/25 through 7/11/24; R1 reported pain rated 6/10 prior to one administration, pain rated 7/10 prior to eight administrations, and pain rated 8/10 prior to one administration. R1's Nursing Assessment for Total Mechanical lift dated 7/25/24 indicated R1 was deemed unsafe to use standing lift; R1 could follow commands but not always cooperative. The summary included: Hoyer lift was appropriate and effective in transfers using two assist due to medical diagnoses. The assessment did not address the sling size or type. During an interview on 7/25/24 at 11:22, R1 recalled his fall from the lift on 7/5/24. R1 stated nursing assistant (NA)-B and NA-H were transferring him from his wheelchair to his bed with a mechanical lift when the right shoulder sling loop/strap came off the lift causing him to fall to the floor. R1's voice became rigid and abrasive as he explained his frustration that he had to go the hospital several days later on 7/9/24 to make sure nothing was broke even though he continued to have pain currently from this fall. During an interview on 7/25/24 at 4:00 p.m., NA-B indicated on 7/5/24 at approximately 11:00 p.m. NA-H was helping him transfer R1 from his wheelchair to his bed. NA-B explained R1 was raised into the air and while the lift was pushed toward the bed, the right upper lift strap came off the lift hook causing R1 to fall approximately 3 feet to the floor. NA-B indicated they connected the sling to the lift the normal way, NA-B connected his side and NA-H connected her side. NA-B was not able to articulate why the strap came off of the lift and did not identify tension was checked prior to moving the lift away from the wheelchair. The NA's called for the nurse over the radio. RN-H arrived to the room and they used the same lift to get R1 off the floor and into bed after RN-H did an assessment. NA-B stated R1 was complaining of pain in his neck and back. NA-B indicated staff used whatever sling was in the room and was not able to articulate how sling sizes were determined. NA-B indicated the lift was not removed from operation per for a safety inspection immediately following the fall. During an interview on 7/25/24 at 4:07 p.m., NA-H indicated on 7/5/24 she was assisting NA-B with R1's bedtime cares. We (NA-H and NA-B) were transferring R1 from his chair to his bed. They moved the lift away from the chair and that is when the right upper sling strap, which was on NA-B's side of the lift, came off causing R1 to fall backwards to the floor. Initially NA-H thought the sling broke, but everything was fine. NA-H indicated the loop must not have been all the way around the hook and more resting on top of the hook, indicating they had not checked for the tension prior to moving. NA-H stated they called for the nurse immediately. RN-H responded, she checked R1 for injury and checked the lift to make sure it worked. After that was done, a different sling was used to get R1 off the floor into bed. R1 was complaining of pain in his upper back and shoulder area. NA-H indicated staff used whatever sling was in the room and was not able to articulate how sling sizes was determined. NA-H further stated the lift was not removed from the floor for inspection after the incident. The facility's fall investigation was reviewed; the investigation did not address and/or identify if the appropriate sling size and type that was used at the time of R1's transfer. The facility's Vulnerable Adult Investigation Form for NA-H dated 7/6/24 at 10:30 a.m. signed by DON indicated NA-H, reported We were putting resident to bed and hook up sling to the hoyer, we made sure the sling was attached. We lifted resident up and one of the straps snapped off, and resident rolled out the right side onto the floor The investigation form for NA-B dated 7/6/24 at 9:00 signed by DON indicated NA-B reported We were putting [resident room number] to bed like we always do. We made sure all the straps were hooked up. Resident [was] also checking to make sure he wasn't caught on anything and we started to lift him up and the strap on the right back snapped off and resident rolled out the right side onto his back .He was 2-3 feet up and it happened so fast there was nothing we could do. Both NA-H and NA-B's forms included Re-Education: discussed and educated CNA on the importance of checking and double checking the straps are properly hooked to hoyer. NOC [night] nurse on duty at the time of the fall educated staff on importance of checking straps during transfer. Nurse also observed res [resident] transfer in the a.m. with staff and hoyer. During an interview on 7/25/24 at 2:27 p.m., RN-H stated she was called to R1's room around 11:00 p.m. on 7/5/24, because R1 had fallen from a mechanical lift. RN-H entered the room, R1 was on the floor beside the bed on his back. R1 was alert and oriented, she did not observe any obvious injuries, however, R1 complained of pain in his upper back and neck area but refused to go the ED. RN-H inspected both the lift and the sling. She did not see anything wrong with either but used a different sling to get R1 off the floor. RN-H stated she thought a large size sling was used for both transfers however could not say for sure. RN-H indicated the facility did not have an assessment or system for determining sling sizes however she would make sure the sling covered the shoulders to upper thighs. RN-H indicated the lift was not removed from the floor because she had found it was in working order. RN-H had not asked maintenance to inspect the lift, nor was the transfer sling inspected. RN-H further indicated that R1 was continuing to have on going pain and had gone to the emergency room on 7/9/24 and was found to not have any injuries. Review of the facility's maintenance logs for the Hoyer mechanical lifts for the months of June and July indicated all lifts were checked on 6/5/24, one lift was checked on 7/8/24, three days after R1's fall. The records indicated the remaining lifts were inspected on 7/25/24. The facility was using EZ-Way brand lifts rather than Hoyer brand lifts. R3's quarterly MDS dated [DATE], indicated R3 did not have cognitive impairment. R3 had no impairment of upper or lower extremities. R3 was dependent with all transfers and did not walk. R3's Nursing Assessment for Total Mechanical lift dated 6/21/22, indicated R3 required a Hoyer lift with two staff assistance. The assessment did not address size and type of sling. R3's ADL care plan 6/21/24 directed staff to transfer R3 with Hoyer lift with two staff. The care plan did not include the sling size and type that R3 required. R3's Nursing Assessment for Total Mechanical dated 7/25/24, indicated R3 required a Hoyer lift with two staff assistance. The summary included: Hoyer lift is appropriate and effective for transfers and two assist due to resident's decline in mobility. This assessment also did not address sling size and type. During an observation on 7/25/24 at 12:56 p.m., R3 sat in her recliner with a green sling underneath her. This sling size was extra-large per manufactures sizing guide on mechanical lift outside of room. During an observation on 7/25/24 at 1:11 p.m., nurse manager (NM)-A entered R3's room and verified that the sling R3 was sitting on was extra large in size. NM-A was not aware of how to measure for the appropriate sling size and type and indicated there was no process in place for completing sling assessments. During an interview on 7/25/24 at 3:20 p.m., EZ-Way lift representative (LR)- A stated the sling R3 was sitting on, was not the correct sling size. LR-A stated R3 should be a large sling size and not extra large. R2's quarterly MDS dated [DATE], R2 had severe cognitive impairment. R2's diagnoses included hip fracture, Alzheimer's disease, and dementia. R2 was dependent for ADLs except required moderate assistance with eating. R2 had impairment on one side of her lower extremities and used a manual wheelchair. R2's Nursing Assessment for Total Mechanical lift dated 6/20/24, indicated R2 required a Hoyer lift with two staff assistance. The assessment did not address size and type of sling. R2's ADL care plan 6/20/24, for transfers directed staff to use a Hoyer lift with two staff. The care plan did not identify sling size and type that R2 required. R2's Nursing Assessment for Total Mechanical lift dated 7/25/24, indicated R2 required a Hoyer lift with two staff assistance. The assessment continued to lack mention of size and type of sling. During an interview on 7/25/24 at 10:25 a.m., NA-A stated an unawareness of how to properly determine sling size and would use the sling that was in the resident's rooms. NA-A thought nursing or therapy decided the sling size. During an interview on 7/25/24 at 10:51 a.m., NA-M indicated the sling size was dependent on the size and weight of the person. NA-M would check the sling size chart on the lift against the resident's weight. She would use whatever sling was in the room unless she questioned the fit. During an interview on 7/25/24 at 5:50 p.m., Administrator and DON both indicated if there was not anything wrong with the lift and the sling the cause of the fall would be operator error. DON and Administrator expected staff to follow the manufacturers recommendations for safety. Stated there had not previously been a process in place to determine proper sling size and staff were expected to follow the manufacturer's instructions. During an interview on 7/25/24 at 3:20 p.m., EZ-Way lift representative (LR)-A explained staff needed to check the tension of the sling loops/straps by touching each one to make sure they were secured onto the lift. This check is completed while the resident is being lifted and still on/over the surface that they are being raised off of. LR-A stated the correct sling sizes were important to prevent falls and injuries to both residents and staff. Additionally, with the correct sling size, the staff can obtain better resident placement in chair and bed without pushing or pulling on resident. EZ-Way Smart Lift Operator Manual included the following: WARNING: For safe operation of the EZ Way Lifts, the lift must be used by trained personnel in accordance with operators manual, video, and training checklist to avoid injury to patient. -do not modify the sling design in any way, make the accessories used with each lift are appropriate for both the patient and the transferring situation, -the sling size is calculated using the resident weight, height, and girth, a proper fir will involve judgement of the caregiver, - proper sling placement include top of sling at the shoulder level and the base of the sling two inches below the tail bone, -while lifting the patient upward, continue until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars before moving resident from over the surface transferring from, -all EZ Way equipment must be maintained regularly by competent staff according to the maintenance checklist provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R68's Diagnosis Report printed on 1/11/24, included hemiplegia (partial paralysis on one side of the body) following a stroke, protein-calorie malnutrition, anemia, and end-stage renal disease requiring dialysis. A PU was not included in the admission diagnoses from 8/11/23. A PU of sacral region, stage II, was added on 12/20/23. R68's comprehensive skin assessment dated [DATE], was completed upon admission. The assessment indicated R68 had a Braden risk score of 15, indicating mild risk for PU development. The skin assessment indicated R68 had a red coccyx; no open lesions and no current PU. The form indicated weekly, and PRN skin assessments were to be completed, to notify the provider of concerns, and to remind and assist R68 to off-load buttocks. Weekly skin assessments and off-loading had not been added to R68's care plan or orders. R68's admission Minimum Data Set (MDS) assessment dated [DATE], indicated R68 was cognitively intact; could understand and be understood. R68 was at risk for PU development, but had no unhealed PU's. R68 was dependent upon staff for most activities of daily living (ADL's). R68's care plan dated 8/22/23, indicated R68 was at risk for alterations in skin integrity due to impaired mobility, incontinence, and multiple medical issues. Interventions included monitoring [skin] for breakdown with cares/bath. Lower head of bed to decrease friction/shearing, wrinkle free bedding. In addition, R68's care plan indicated R68 had impaired physical mobility related to weakness. Staff were to reposition R68 every two hours when in bed or chair. Further, staff were to assist R68 per her request for transferring, wiping, and pericare after incontinence. Progress note dated 9/24/23, indicated R68 had an open area to coccyx measuring 2.3 x 1.5 cm (centimeters). Abd (abdominal) pad applied for protection; resident off-loading with pillows while in bed. During document review, the next time a skin assessment was documented was on 9/24/23, six weeks after admission and when R68 returned from a seven-day hospitalization. The skin assessment indicated R68 had an open area to the coccyx measuring 2.3 x 1.5 cm, and the open area had been acquired before admission. This conflicted with the admission skin assessment conducted on 8/11/23, which indicated a red coccyx -- no open skin. The skin assessment form indicated staff would continue weekly and PRN skin assessments, weekly wound assessments, and would update the provider with any changes. The weekly skin assessments had not been added to the care plan or orders. R68's physician orders dated 10/3/23, indicated wound care: Mepilex foam dressing, every shift change, every three days or PRN (as needed) for open area to coccyx. Documentation of skin assessments varied regarding whether R68 had a PU to the coccyx at the time of admission or if it was acquired after admission: --An admission comprehensive skin assessment dated [DATE], indicated a red coccyx. No open lesions, no current PU. --The admission MDS dated [DATE], indicated no unhealed PU's. --A comprehensive skin assessment dated [DATE], indicated the open area on coccyx was acquired before admission. --Wound assessment flowsheets dated 9/26/23, 10/23/23, 11/2/23 and 1/10/24, indicated the wound was present upon admission. --Wound assessment flowsheets dated 11/15/23 and 1/8/24, indicated the wound was not present upon admission. A total of eight skin assessments had been documented from admission on [DATE] to 1/10/24, and conducted by five different nurses. During an observation and interview on 1/8/24 at 3:57 p.m., R68 was lying in bed with the head of the bed elevated approximately 30-45 degrees. R68 had a naso-gastric (NG) tube in place, not attached to a supplemental feeding. An alternating air pressure mattress was observed on the bed. R68 stated she had a PU on her bottom which was acquired after she moved into the facility on 8/11/23. R68 admitted she usually rested in bed in her current position - supine with head of the bed elevated. During an observation on 1/10/24 at 8:41 a.m., with registered nurse (RN)-B, observed R68's PU to coccyx. The PU was a pink circular wound, approximately the size of a quarter on the coccyx. The skin appeared in intact, no exudate, no odor. RN-B measured the PU to be 2 x 2 cm and stated it was healing well. During an interview on 11/10/24 at 8:57 a.m., RN-B stated R68 had been admitted to the facility on [DATE], and arrived with a red coccyx but did not have open areas on her coccyx. RN-B, while looking in the electronic medical record (EMR) stated the first time an open area to R68's coccyx was documented was on 9/24/23. The first note by a provider regarding the open area was on 10/3/23, nine days after it was observed by nursing staff. During an interview on 1/10/24 at 10:57 a.m., medical doctor (MD)-B, who was familiar with R68, stated R68 would be at risk for PU development due to co-morbidities and that she would expect regular skin monitoring and repositioning for any resident who had mobility issues. MD-B was not able to say if R68's PU had been preventable. During an interview on 1/10/24 at 11:05 a.m., the director of nursing (DON) stated since R68 had a red coccyx upon admission, she would have been at risk for skin breakdown. The DON stated once staff identified the red coccyx, staff should have put an order in the EMR for weekly skin monitoring, and a provider should have been informed of any skin concerns. The DON admitted these actions had not been taken. The DON admitted no skin monitoring or assessments had been documented between R68's admission on [DATE] and 9/24/23, when the PU was discovered. The DON stated the care plan should have included something about monitoring bony prominence's, education on importance of repositioning. The first progress note identifying a provider was aware of skin concerns was on 10/3/23, and treatment orders were received. It was possible the PU was acquired during hospitalization from 9/16/23 to 9/24/23, however, not able to determine this since the only documentation of R68's skin on 8/11/23, indicated a red coccyx, no open skin. An After Visit Summary from the hospital dated 9/24/23, did not mention skin concerns or PU's. The facility Skin Assessment protocol dated 2/17/20, included: -Weekly full head to toe skin assessment must be completed on the resdient's bath day indicted on the bath schedule. Skin assessment should be charted under bath/skin note in the progress notes. - Skin assessment needs to include: - Color of the skin and any redness. Redness over a bony prominence is present indicate whether it is blanchable or not -Skin integrity/any breakdown -All bony prominence's scapula, sacrum, heels, elbows, occiput, ankles, knees, hips and ears -Wounds and bruising new and existing. Include location, measurements, color, how the resident thinks the got it, any intervention and if there is any pain or swelling. Follow-up on wounds and bruising noted in previous skin assessment. A Pressure Injury policy and procedure last revised 9/19, included: - Upon noticing a pressure injury, complete a Wound Assessment and Braden scale. - Add an order to complete a Wound Assessment in the EMAR weekly -Start interventions as ordered/needed -Notify MD or in house NP of new pressure injury -Noisy family of new PU -Notify dietary of new pressure injury -Consult MD or in house NP, nurse manager, visiting wound nurse or wound clinic as needed for treatment -Complete a new Wound Assessment weekly -Document weekly and as needed in the nursing notes on size, drainage, odor, pain, surrounding tissue and current treatment -Review at interdisciplinary team meetings Based on observation, interview and document review, the facility failed to assess, monitor and implement pressure relieving interventions for 2 of 2 resident (R71, R68) who developed pressure ulcers. The facility failure resulted in R71 sustaining harm when the resident developed an unstageable pressure ulcer to left gluteus (butt cheek) along with three additional stage II pressure ulcers on gluteus. Findings include: Pressure Ulcer stages defined by the Minimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ ruptured blister.) Unstageable pressure ulcer: (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.) R71's Record of Admission, printed 1/10/24, indicated admission to the facility on [DATE], with diagnoses per the Diagnosis Report Sheet including: end stage renal disease with dependence on renal dialysis, orthopedic aftercare after acquired absence of right great toe and other right toe (1st and 2nd toes), reduced mobility, diabetes mellitus, heart failure, anemia (deficiency of health red blood cells in blood), morbid obesity (excessive body fat), and urgency of urination. R71's admission Nursing Comprehensive Skin assessment dated [DATE], indicated Braden Risk score (a scale that measures the risk of developing pressure ulcers) of 13 which indicated a mild risk. Other risk factors included assistance with activities of daily living, non-compliance with diet, fluids, mobility, head of bed elevated majority of the day and psychotropic drug use. Skin conditions and treatments included bruises, and surgical wound. Assessment of potential problem areas was blank. Areas found on assessment included abrasion on left gluteal fold 4 centimeter (cm) x 1.2 cm, bruises and incision from amputation on right foot. No additional comprehensive skin assessments were completed per electronic medical record. R71's Wound Assessment completed by licensed practical nurse (LPN)-D on 11/17/23 at 12:21 p.m., included a left gluteal fold wound present on admission and identified as other non-pressure wound. Contributing factors included resident is incontinent. Wound is 4 cm x 1.2 cm with no tunneling or infection present. Nursing interventions included other and under treatment identified R71 was placed on the nurse practitioner board for orders. There was no indication the provider was notified of the new wound and change in skin condition R71's admission Minimum Data Set (MDS) dated [DATE], indicated R71 had intact cognition, understood and understands, requires partial to moderate assistance with rolling left and right and lying to sitting on the side of bed and dependent with ability move from sitting on side of bed to lying flat on the bed. R71 was depend on all transfers. R71 was occasionally incontinent of stool and was continent of urine. R71 is at risk of developing PU and currently has no PU's but does have a surgical wound. Skin and ulcer treatments included a pressure reducing device for the bed and surgical wound care. A progress note 11/21/23 at 2:54 p.m., by dietary manager (DM) included appetite was not good at times and has chewing, swallowing, taste changes and mouth pain. R71 is not on a supplement at this time. R71's Braden Scale (standardized assessment tool used to assess and document risk for developing pressure injuries) was completed on 11/23/23, with a score of 15 indicating mild risk for skin breakdown. Although the Braden Scale assessment indicated mild risk, the skin assessment indicated risk factors of impaired mobility, cardiovascular disease, end stage renal disease, obesity, diabetes and requires assistance with ADLS. R71 also had a gluteal abrasion on admission. In addition, there were other discrepancies between the assessments. The MDS indicated resident was continent of urine, progress notes indicated R71 required assist of one changing incontinent pads and was incontinent of loose stools. R71's plan of care dated 12/4/23, included R71 was at risk for alteration in skin integrity bruising, skin tears related to impaired mobility, multiple medication problems, diabetes, dialysis, obesity, occasional incontinence, anticoagulant therapy and requires assistance with ADL's. The care plan also included alteration in skin integrity related to surgical wound from right 1st and 2nd toe amputations on 11/2/23, and dialysis access site of right upper arm. Interventions included: Monitor for breakdown with cares and bath. Mobility per care plan. Use pressure reducing measures as needed. Lower head of bed, and keep bedding wrinkle free. Toilet per care plan, lotion to dry skin with cares. Dietician to evaluate nutrition status as needed and encourage adequate fluid and food. Treatment to surgical wound per medical doctor (MD) orders. Update provider if concerns noted. Monitor for bruising and bleeding. On 1/3/24 an alternating air mattress and pressure reducing wheelchair cushion was added. The care plan failed to direct staff on the frequency for R71's repositioning, transferring or toileting plan to reduce the risk of pressure ulcers. On 12/6/23, Butt paste (topical medication for diaper rash and skin irritations) was ordered four times a day as needed to irritated peri rectal area and inner thighs from nurse practitioner (NP)-D. On 12/10/23 at 11:16 p.m., a progress note by LPN-C indicated wound open area of right inner thigh, and on left medial buttock measure 2.5 x 2 cm and wound on right medical buttock measuring 1.5 cm by 1 cm and 0.8 cm depth. Also has an unstageable ulcer on lateral left buttock measuring 2.5 cm x 3 cm. Hydrocolloid dressing was applied to areas on buttocks and zinc oxide (butt paste) applied to area on inner thigh. Review of the medical record lacked notification to the provider regarding the development of PU and no new interventions were initiated . A Wound assessment dated [DATE] at 11:24 p.m. by LPN-C included: an unstageable PU on left lateral buttock, not present on admission. Eschar (dry, hard, leathery tissue that is not part of wound healing process and must be removed to support healing) present over 90% of wound bed and full thickness. Contributing factors included non-compliance, personal habits, non weight bearing, in bed most of the day with limited offloading (technique used to protect wounds from getting worse due to added weight on the area). Wound is 2.5 x 3 cm with no tunneling and 90% eschar present with pink wound edges. Nurse interventions included chair cushion. Current wound treatment indicated R71 was placed on nurse practitioner board to be addressed at next visit. On 12/14/23 at 1:47 p.m., a progress note by NA-B, also identified as health unit coordinator, included a wound unstagable pressure ulcer to left lateral buttock 2.5 x 3 cm with 90% eschar. Also has open areas bilateral medial buttock with left 2.5 cm x 2 cm and right 1.5 cm x 1 cm and 1.5 and 0.8 cm. and hydrocolloid dressing applied. Recommendations included dressing order please. Physician orders were okay for Mepilex to areas and to change every 3 days and as needed and to be discontinued to when healed. On 12/23/23 at 1:05 a.m., a Wound Assessment by registered nurse (RN)-F indicated right gluteal fold, pressure ulcer stage 2. Appearance of wound indicated area difficult to measure, reddened friable tissue with some open macerated areas on right gluteal fold. A second wound on left gluteal fold identified as PU, stage 2 with measurements of 1 cm x 0.5 cm with 100% slough present and some maceration and friable tissue noted surrounding the wound. A 3rd wound on left lateral buttock identified as PU, not staged and documented as not applicable (NA). Wound is 0.5 cm x 0.75 cm with no tunneling present. A fourth wound identified on left center buttock indicated PU and unstageable related to eschar, slough. Wound is 4 cm x 4 cm x 0.3 depth. Unable to determine if tunneling is present without debridement. Slough was 85% with eschar present for 15% of wound around edge. Nursing comments included frequent incontinent loose stools. Resident placed on nurse practitioner list for review of possibly adding pressure reducing mattress for resident. Although an additional wound was identified, no additional interventions were added at this time. The director of nursing (DON) reviewed and signed wound assessment on 12/28/23. On 12/29/23 a Braden scale was completed with a score of 14 which indicated moderate risk for skin breakdown. No additional interventions were added. A Wound assessment dated [DATE] at 12:40 p.m. by LPN-D included right buttock PU stage 3 not present on admission. Wound was 1 cm x 1 cm with depth 0.3 cm. Drainage was present and surrounding tissue was red. A second wound included left buttock which was not present on admission and was PU stage 3. Medical provider was checked as being notified, but there was no indication the medical provider had made any changes or comments about R71's PU. A progress note dated 1/4/24 at 3:01 p.m., by NA-B indicated right wound was 4 cm x 4 cm, granulation with slough covering wound bed with moderate drainage. Bloody and odorous. Severe pain present and current treatment not effective. Wound clinic appointment not until January 24th this month. Nurse Practitioner (NP)-D ordered collagen, Zeroform and Mepilex to be completed every other day and as needed. A progress note 1/5/24 at 3:35 p.m., indicated registered dietician (RD) was consulted due to R71's skin breakdown on buttock region. R71 continued on therapeutic diet, a new weight was requested due to fair to poor appetitive at times. Nutritional supplement provided at dialysis when available. RD recommend a high protein healing supplement to support wound healing and protein levels. Although a progress note on 11/21/23 at 2:54 p.m., by dietary manager (DM) identified poor appetite and concerns of chewing, swallowing, taste changes and mouth pain. There was no indication any nutritional changes were completed even though she was admitted to the facility with a pressure ulcer on 11/23. R71's significant change MDS dated [DATE], indicated R71 has 1 unhealed PU, and 2 stage 3 PU's not present on admission. A pressure reducing device for chair and bed is present and turning and repositioning program. R71's Care Area Assessment (CAA) dated 1/5/23, indicated R71 is at risk for PU's and requires staff assistance to move sufficiently to relieve pressure over any one site. R71 is confined to bed or chair all or most of the time. R71 needs special mattress or seat cushion to reduce of relieve pressure and requires regular schedule of turning. Observation and interview 1/8/24 at 1:42 p.m., R71 stated she has a PU from laying on the bars of the bed. R71 added she could feel the bars on her buttock, in the area of sores. She could feel the bars through the mattress. R71 stated she didn't have a wound when she came here and at the hospital they were putting a protective heart shaped dressing on her bottom but they didn't do that here. She has a dressing on it now that she has an open area and has an appointment on 1/24/24 to see wound care. R71 stated I don't think it is very deep but deep enough. R71 was laying on her back in the bed with head of bed (HOB) at 30 degrees. R71 indicated she turns herself in the bed without assistance from staff but sometimes has to call for help to get a pillow tucked behind her to keep her on her side. R71 has an alternating air mattress present on her bed. Observation and interview 1/8/24 at 5:38 p.m., LPN-B indicated R71 had a loose bowel movement (BM) and her dressings came off her buttocks. At 5:51 p.m., R71 rolled to her left side with partial assistance from LPN-B and used the grab bar to keep herself in position. One dressing on mid left gluteal area remained intact. Wounds without dressings were measured and described by LPN-B and included: -Right gluteal area measured 0.5 centimeter (cm) by 0.5 cm. Slough (non-viable tissue) was present on wound bed. -Left lateral gluteal area 0.75 cm by 1 cm with slough present. -Left gluteal fold measured 1 cm by 0.75 cm with slough present. -Left mid gluteal area dressing was removed by LPN-B who described a moderate amount of white with brown tinged drainage present, which had a slight odor. LPN-B cleansed the wound with saline and 4x4 gauze pad and indicated the skin was red around the wound bed area. Measurements were completed and were 6 cm by 5 cm with a 1 cm hole in upper left portion of the wound. LPN-B indicated there is tunneling present but did not attempt to measure the tunneling. LPN-B indicated this was an unstageable PU due to wound bed being covered with slough. Collagen powder (healing gel that keeps out bacteria) was applied to all 4 wounds, Zeroform (non adhering dressing) placed then Mepelix (highly absorbent form dressing) covering. LPN-B was unsure if the wounds were improved or worsened as this is her first time changing the dressings. R71 indicated there was some discomfort with changing of the dressings but otherwise she tries to position herself so she is comfortable. Observation and interview 1/9/24 at 3:28 p.m., with R71 indicated she had just returned from dialysis and was sitting in her wheelchair with her head in her hands. R71 indicated she is always tired after dialysis and her blood pressure was low again during dialysis. R71 indicated she had diarrhea this morning so took Immodium (medication used to treat sudden diarrhea), and only passed gas during her dialysis today. R71 indicated when she is at dialysis if she has a loose stool, she will just wait until she gets back to the facility to be changed because she can see how busy the staff are and doesn't want to bother them. R71 indicated at dialysis she can lay down in the chair or can sit up and controls that herself. R71 indicated no one has educated her to try to stay off her buttock or not to sit for long periods of time and generally will try to find a position that is the most comfortable. At 3:50 p.m., NA-A and NA-E entered the room and using a lift assisted R71 to her bed. R71 was then lying on her back with HOB at 20 degrees. Interview 1/9/24 at 4:00 p.m., nursing assistant (NA)-A indicated R71 is capable of turning herself so is not on a turning program but sometimes will call for assistance if incontinent. NA-A indicated they use a lift to transfer her to her wheelchair for dialysis and upon return but she rarely gets into a chair per her request. During interview on 1/9/24 at 3:55 p.m., LPN-A indicated she was not aware R71 had PU's but it should all be documented in her medical record. LPN-A was not aware of any offloading program or of the wound care treatment but indicated she could look that up in the medical record if needed. During observation on 1/10/24 at 7:11 a.m., R71 was lying in bed and appears to be lying on her back with HOB flat. During interview on 1/10/24 at 9:20 a.m., NA-I indicated R71 is able to turn and reposition herself independently and will call for assistance if needed. NA-I indicated staff use a lift when she needs to get out of bed, otherwise she uses a bed pan. During interview on 1/10/24 at 10:44 a.m., medical doctor (MD)-B indicated she wasn't aware that R71 was so immobile and believed she was able to bear weight on her good leg and should have been more active. MD-B indicated R71's immobility put her at a higher risk for developing pressure ulcers along with incontinent liquid stool. MD-B stated the skin breakdown isn't unexpected, but the severity was preventable. MD-B added interventions should have been put into place once a PU was identified to prevent further breakdown not just wound treatment. MD-B indicated she had not seen R71's PU's. During interview on 1/10/24 at 11:05 a.m., R71 again indicated she repositions herself and staff do not come in to assist unless she calls for help. R71 indicated initially on admission she layed on her back a lot because her surgical wound on her foot had to be elevated. R71 indicated the first time she actually stood up was 2 days ago when therapy assisted her. R71 stated she rarely sits in the chair due to being incontinent of diarrhea and finds it easier to, with assist from staff, to use the bed pan if she is in the bed. R71 denied every refusing to reposition in the bed. R71 added she hasn't had a shower or bath since she was admitted due to her surgical wound needing to be closed with scab off prior to any bathing. R71 did indicated she has had all bed baths. During interview on 1/10/24 at 11:25 a.m., NP-D indicated skin breakdown wasn't completely unexpected but the severity should have been prevented by off loading pressure. NP-D indicated once one wound was identified the facility should have done more to prevent the other three from developing. NP-D indicated the facility has to make sure R71 is truly offloading if they aren't doing that currently and not just rely on R71 to turn herself. NP-D added he was aware of the wounds, but not the severity or of any tunneling and added he has not seen the wounds. During interview on 1/10/24 at 10:00 a.m., the DON confirmed R71 should have been put on an off loading schedule and the staff are responsible to ensure offloading is being completed. The DON confirmed education with R71 should have occurred with importance of offloading and repositioning. The DON confirmed R71 was on a regular facility mattress, which are supposed to prevent skin breakdown, until the air mattress arrived on 1/4/24. The DON added the plan of care did not include a repositioning program and no new interventions were put in place prior to or after initial PU's were identified.