**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to perform timely comprehensive skin assessments, and implement interventions to promote healing and reduce the risk for further pressure ulcer development for 1 of 2 resident (R22) who was admitted to the facility without pressure ulcers. This resulted in harm for R22 when the facility failed to develop interventions to promote healing and prevention resulting in R22 developing three pressure ulcers. Findings include: A stage one pressure injury is intact skin with a localized area of redness that is non-blanchable (does not turn white when pressed). A stage two pressure ulcer is partial thickness loss of the skin with exposed dermis, presenting as a shallow open ulcer. A stage three pressure ulcer is full thickness loss of the skin in which subcutaneous fat may be visible. Additionally, slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be visible but does not obscure the depth of the tissue loss. R22's Face Sheet form indicated the following diagnoses: unspecified protein calorie malnutrition, pressure ulcer of unspecified buttock stage three, major depressive disorder, and type two diabetes. R22's admission Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not reject care, required partial to moderate assistance with toileting, showering, was occasionally incontinent of bladder, was five feet tall and 105 pounds, was at risk of developing pressure ulcers and did not have one or more unhealed pressure ulcers at a stage one or higher. Under the section Skin and Ulcer Treatments R22 had a check mark next to applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated R22 had moderate cognitive impairment, did not reject care, was occasionally incontinent of bladder, and frequently incontinent of bowel, was 104 pounds, was at risk for pressure ulcers and had one stage three pressure ulcer and under the section, Skin and Ulcer Treatments had a check mark next to pressure relieving device for R22's chair and bed, had nutrition or hydration intervention to manage skin problems, pressure ulcer care, and applications of ointments and medications other than to feet. R22's significant change in status (MDS) dated [DATE], indicated moderate cognitive impairment, did not exhibit behaviors, and did not reject care. Required substantial maximal assistance for toileting hygiene, partial moderate assist for moving from sitting to lying, and chair to bed to chair, and toileting transfers required supervision or touching assistance, was occasionally incontinent of urine and always continent of bowels. R22's weight was 101 pounds, was at risk of developing pressure ulcers and had two stage three pressure ulcers, and under the section, Skin and Ulcer Treatments had a check mark next to pressure reducing device for chair, bed, pressure ulcer care, applications of ointments and medications other than to feet. R22's care plan dated 7/7/23, indicated an activity in daily living (ADL) self care performance deficit and required staff assistance due to limited mobility, impaired balance and an intervention included to observe skin for redness, open areas, scratches, cuts, bruises and report changes. R22's care plan dated 7/7/23, indicated R22 had limited physical mobility and required staff assistance due to limited mobility and impaired balance. The care plan was later updated on 11/2/23, to include an intervention identifying R22 required assist of one to reposition in bed and assist of two to boost up in bed. This intervention further indicated R22 had an air pressure reduction mattress on the bed, and R22 preferred to sleep in the recliner and had an air pressure cushion. Prior to 11/2/23, the bed mobility intervention was last revised on 9/13/23, to include R22 required assist of 1 to reposition self in bed and encourage off loading in bed and chair. R22's care plan dated 10/9/23, indicated an altered nutritional status due to weight loss and impaired skin integrity. Interventions indicated providing a diet as ordered, monitor intake, obtain weights, monitor lab work, honor food preferences and requests. R22's care plan dated 10/13/23, indicated R22 was at risk for impaired skin integrity due to limited mobility, medication side effects, bladder incontinence, malnutrition and had two stage three pressure ulcers on the left buttock and coccyx. R22's goal indicated the current pressure ulcers would show signs of improvement by the next review date as evidenced by a decrease in size or a resolved status. Interventions indicated following facility protocols and policies for prevention of skin breakdown, a pressure reducing mattress, able to request assistance for toileting and repositioning, observe for signs and symptoms of breakdown and update the nurse promptly if noted. The most recent intervention on the care plan was dated 8/4/23, and indicated R22 required a pressure reducing wheelchair cushion. No new interventions were added following the development of new pressure ulcers. R22's care sheet dated 10/11/23, indicated R22 required assist of one with a transfer belt for transfers and ambulating short distances. Additionally, R22 required assist of one when going to the bathroom, and with dressing, grooming, and bathing and required a body audit completed on Thursdays, further, R22 required frequent repositioning and offloading while in the bed and wheelchair. The care sheet had a yellow highlighted instruction dated 8/4/23, to remind R22 to reposition off bottom for a few minutes every two to three hours due to having a pressure ulcer. The care sheet lacked any information or instruction resident had a cushion for the reclining chair. R22's Amount Eaten Task form dated 10/3/23, to 10/31/23, indicated variable appetite, however mostly ate 76-100% of meals. R22's nursing progress notes dated 6/21/23 at 12:25 p.m., indicated R22's skin was clean, dry, and intact. R22's nutritional summary note dated 6/22/23 at 11:21 a.m., indicated R22 admitted to the facility with a wedge compression fracture, malnutrition, type two diabetes and consumed 76 to 100% at meals since admission. Additionally, the note indicated skin was clean dry and intact, and had a history of a pressure injury to R22's sacrum. An oral nutritional supplement (ONS) was discontinued due to refusals and a p.m. snack was added to promote intake. R22's nursing progress note dated 7/16/23 at 4:30 p.m., indicated R22 required an assist of one to transfer and usually self transferred and refused to be assisted and stayed in her recliner most of the time. R22 was checked changed and repositioned every two to three hours and as needed. R22's nutrition risk assessment dated [DATE], indicated R22 consumed 76 to 100% at most meals and received a p.m. snack every day with good acceptance and at times was sleeping and skipped the snack. Additionally, R22's weight on 7/19/23, was 110.2 pounds and was trending upwards which was desired due to malnutrition, but weight could fluctuate due to taking a diuretic medication. R22's nursing progress note dated 8/1/23 at 6:45 p.m., indicated a 1 inch stage two to three pressure ulcer on the right buttocks. The note indicated the coccyx, buttocks was macerated and erythematous and tender to touch and R22 was educated about frequent repositioning and sleeping in R22's bed versus the chair. The note indicated to continue to monitor and the next registered nurse was updated. R22's nursing progress note dated 8/4/23 at 8:21 a.m., indicated a late entry wound assessment and R22's daughter was notified of a stage two wound on buttocks and the practitioner, dietician, and therapy were notified. R22's nursing progress note dated 8/15/23 at 10:32 a.m., indicated R22 had a change in condition and was sent to the emergency room. At 5:58 p.m., nursing progress notes indicated R22 was admitted to the hospital and the hospital stated R22 had multiple sores on her bottom. R22's nursing progress note dated 8/16/23, indicated R22 came back to the facility, was fatigued and had a triad hydrophilic wound dressing. (A paste that maintains an optimal wound healing environment and facilitates a natural debridement.) Documentation lacked information a wound assessment was completed upon return from the hospital and a wound assessment was not completed until 8/25/23. R22's culinary progress note dated 8/22/23 at 8:16 p.m., indicated R22 had a weight gain and was 112.6 pounds. R22's weight continued to increase as a result of a good appetite and would be appropriate to discontinue from high risk monitoring however the dietician noted a wound assessment from 8/4/23, indicating a pressure area to R22's coccyx and body audits indicated the wound remained present, however a more recent wound assessment was not available. R22's nursing progress note dated 9/26/23 at 3:46 p.m., indicated R22 had two pressure ulcers; one on the coccyx (tailbone), and one on the left gluteal fold (the horizontal skin crease that forms below the buttocks). An additional progress note on 9/26/23, indicated R22 had a new pressure ulcer on her coccyx. R22's Order Summary Report form indicated the following orders: - 8/4/23 Boudreauxs butt paste external ointment 40% zinc oxide topical. Apply to buttock topically three times a day for pressure ulcer educate about not applying Vaseline to area; may use house supply of zinc oxide cream - 9/26/23 treatment for both open areas on buttocks (left gluteal fold, and below the coccyx area) to be done Monday, Wednesday, Friday, and as needed. Cleanse both buttocks open areas with normal saline, pat dry with gauze, use skin prep around both areas avoiding going into the wound, apply Manuka hd dressing directly in the wound and cover each area with a barrier film dressing every 1 hours as needed and replace dressing when soiled or if it falls off. During the month of 6/12/23 through 10/19/23, R22's completed body audit form indicated the following: - On 6/21/23, which indicated R22 had a trace of a healed pressure ulcer on her sacrum, with a small area of discoloration and required frequent reposition/offloading to avoid recurrence. - On 6/29/23, no skin concerns - On 7/2/23, skin was clean dry and intact clean, dry and intact (CDI) - On 7/6/23, skin was CDI. - On 7/13/23, R22 had blanchable redness to buttocks and skin was intact. - On 7/20/23, R22 had blanchable redness on gluteal folds, some parts were minimally excoriated and butt paste was applied and the rest of R22's skin was CDI. - On 7/27/23, R22 had blanchable redness to buttocks and butt paste was applied. - On 8/3/23, R22 had blanchable redness on gluteal folds and noted excoriation on the left gluteal fold and Boudreauxs Butt Paste was applied and the rest of the skin was CDI. - On 8/10/23, R22 had blanchable redness to buttocks and excoriation on left gluteal fold and butt paste was applied. - On 8/16/23, under comments indicated pressure on left gluteal fold and surrounding areas were excoriated and wound treatment was in place. - On 8/24/23, body audit indicated R22 had a stage two pressure injury to the left gluteal buttock and treatment and monitoring was in place. - On 8/31/23, body audit indicated R22 had pressure on the left gluteal fold and blanchable redness on surrounding areas and wound treatment was in place. - On 9/7/23, the body audit form indicated a stage two pressure ulcer to the left gluteal fold and a hydrocolloid was applied after R22's shower. - On 9/14/23, R22 continued with the left gluteal fold pressure ulcer with blanchable redness on the surrounding areas. - On 9/21/23, The body audit form indicated the pressure injury to the left gluteal fold and no increase in size. - On 9/28/23, the body audit form indicated R22 had pressure ulcers on the coccyx and the left gluteal fold. - On 10/5/23, the body audit indicated two pressure ulcers to left buttock coccyx region. - On 10/12/23, the body audit indicated a pressure injury on both the coccyx and left gluteal fold were still present. - On10/19/23,the body audit indicated a pressure injury on the coccyx and left gluteal fold. - On 10/26/23, the body audit indicated no new skin issues were observed and had a pressure injury on both the coccyx and left gluteal fold. The body audits lacked any kind of assessment of the wounds. R22's Bowel Bladder and Skin Risk assessment dated [DATE], indicated R22 stayed in her recliner most of the time. Additionally, R22's Bowel Bladder and Skin Risk assessment dated [DATE], indicated R22 self transferred to the bathroom and spent most of each shift in her recliner. The assessment indicated R22 self transferred and was occasionally incontinent of bowels and was checked, changed, and repositioned every 2-3 hours and as needed. R22's Skin and Wound Evaluation Assessment form indicated a skin and wound evaluation was completed on the following dates in the electronic medical record (EMR): - 8/4/23, a new stage two in-house acquired pressure ulcer to the coccyx measuring 0.6 centimeters (cm) long by 0.4 cm wide and was documented as not applicable for the depth, no tunneling (a passageway of tissue destruction under the skin) or undermining (destruction of skin tissue extending under the skin edges. The goal of care for the wound was documented as healable - 8/25/23, the coccyx pressure ulcer measured 0.7 cm long by 0.8 cm wide and had a depth of 0.5 cm and 10% of the wound contained slough. - 9/1/23, the coccyx pressure ulcer measured 0.7 cm long by 0.6 cm wide and the depth was not applicable and 10% of the wound contained slough. - 9/18/23, the coccyx pressure ulcer now identified as a stage three ulcer measuring 0.8 cm long by 0.8 cm wide with a depth of 0.5 cm and 10% of the wound contained slough. Under the section labeled, Additional Care which included check boxes of various interventions such as cushion, air flow pad, or mattress with a pump, none was indicated. - 9/26/23, contained two wound assessments: At 8:29 a.m., a stage three coccyx pressure ulcer that measured 0.8 cm long by 0.8 cm wide by 0.5 cm deep. At 8:33 a.m., a stage three pressure area to the coccyx documented as New as of 9/26/23 and measured 1.1 cm long by 0.7 cm wide with a depth of 0.5 cm and 50% of the wound contained slough with 4 cm of redness to the surrounding tissue. A cushion, turning and repositioning program was indicated in the check boxes under the section, Additional Care. - 10/2/23, at 1:47 p.m., indicated a stage three pressure ulcer to the coccyx that measured 1 cm long by 0.9 cm wide by 0.5 cm deep and contained 10% slough. - 10/10/23, at 1:24 p.m., indicated a stage three pressure ulcer to the coccyx that measured 0.8 cm long by 1.1 cm wide by 0.5 cm deep. At 1:23 p.m., a stage three pressure ulcer to the coccyx that measured 1.1 cm long by 0.9 cm wide and 0.5 cm deep and 10% of the wound contained slough. - 10/26/23, at 9:25 a.m., indicated a stage three pressure ulcer to the coccyx that measured 1.1 cm long by 11.1 cm wide by 0.3 cm deep. - 10/31/23, indicated a stage three pressure ulcer that measured 1.2 cm long by 1.0 cm wide and no depth. An additional form indicated 0.8 cm long by 0.8 cm wide by 0.5 cm deep. The Skin and Wound Evaluation Assessment form identified each wound was located on the coccyx. A record request form was provided to the facility requesting all assessments related to skin and wounds since admission including picture assessments that identified each wound and their measurements, however the requested information was not entirely received. During interview and observation on 10/30/23 between 5:48 p.m., and 5:50 p.m., R22 stated she had irritation on her bottom that was hard to heal and stated they provided a pillow to use, and had not spoken with her about staying off her bottom. R22 had a circular cushion in another chair but did not have a cushion in the recliner R22 was in. R22 had a cushion in the wheel chair and additionally had an air mattress on her bed. R22's care sheet updated on 10/11/23, lacked interventions for a cushion in the recliner. During observation on 11/1/23 at 6:56 a.m., R22 was in her room in her reclining chair and her head was bent forward. During interview at 11/1/23 at 7:19 a.m., registered nurse (RN)-B stated R22 slept in her recliner 90% of the time and refused to sleep in the bed despite encouragement and added it was R22's choice. RN-B stated R22 was supposed to have a cushion in the chair she slept in. During interview and observation on 11/1/23 at 7:25 a.m., R22 was in the bathroom with staff and had a circular type cushion in her arm chair, but was not in R22's recliner chair where she slept. nursing assistant (NA)-B stated she had worked at the facility for two years and stated R22 slept in her chair. NA-B verified the circular cushion was not in R22's recliner chair she slept in this morning when R22 got up and verified R22 did not have any type of cushion in her recliner when she assisted her to get up. NA-B stated they toileted and repositioned R22 and stated R22 was continent. NA-B offered to apply the circular cushion to R22's recliner chair and R22 accepted. NA-B stated as the day goes on, R22 got weaker and needed assist and stated R22 could shift positions in her chair and added they tried to push for R22 to sleep in the bed as much as possible. During interview on 11/1/23 at 10:19 a.m., NA-C stated R22 could not get out of the recliner by herself and when R22 stood, she pushes off, but cannot get up on her own and just rocks in her chair and needed assist. During interview on 11/1/23 at 12:54 p.m., licensed practical nurse (LPN)-B stated wounds were measured once a week and stated R22 had two pressure ulcers and one was near the coccyx and the other on the left gluteal fold. LPN-B clarified R22's left buttocks was deteriorating and stated it looked like it was deeper and like the wounds were not improving. LPN further stated the pressure ulcers were hard to heal because R22 did not get off her bottom and wasn't eating well. LPN-B stated R22 could get up to go to the bathroom by herself and added R22 slept in her recliner chair. During interview on 11/1/23 at 1:07 p.m., nurse manager (NM)-G stated she asked hospice about an offloading cushion for R22 at the care conference on 10/13/23, and added R22 received an air mattress for her bed, and a gel cushion for R22's wheel chair. NM-G verified the care conference note lacked information regarding a cushion for the recliner chair. NM-G further stated R22 wished to only sleep in her chair and when asked about a circular cushion observed in R22's room, NM-G stated the cushion could have come from hospice and hoped the family brought in the cushion because hospice should notify the facility if they bring items in. NM-G further stated she had not followed up to see if interventions were effective and did not follow up to verify if a cushion was in place. During interview on 11/1/23 at 1:14 p.m., LPN-B verified no wound assessments were completed after 8/4/23, until 8/25/23. LPN-B stated from 10/10/23, to 10/26/23, they were missing a week of assessments. LPN-B further stated the problem with putting the cushion in the chair when they had therapy look at it, was the manufacturer wouldn't approve a cushion in the recliner because they couldn't guarantee it wouldn't slide out and that was why they asked hospice to look into it. During interview on 11/1/23 at 2:20 p.m., the health unit coordinator (HUC)-H verified the hospice notes in the paper chart and in the electronic medical record (EMR) lacked any information regarding a cushion or follow up on a cushion for the reclining chair. During interview and observation on 11/1/23 at 3:38 p.m., R22 was in her reclining chair with a pillow behind her back, but there was no cushion on the seat of the recliner chair. RN-F measured the wound on R22's left buttocks and was 1.6 cm long by 0.9 cm wide and 0.3 cm deep. RN-F measured the wound to R22's coccyx and was 1 cm long by 1 cm wide that included tunneling in the corner right inside corner that measured 0.4 cm at 1 O'clock. RN-F also stated R22 had a new stage one pressure injury to R22's right inner buttocks that measured 0.7 cm long by 0.9 cm wide. RN-F stated R22 did not want the cushion her daughter gave her and stated R22 didn't always use it and stated R22 was on a repositioning schedule and occupational therapy got R22 a special cushion she thought was the circular cushion. RN-F stated since R22 had a new wound they may have to do something different and verified that wound assessments were supposed to be done weekly and used to be completed on Wednesdays, but stated there had been some changes and verified wound assessments were documented in the chart and were missed. RN-F further stated if wounds are not monitored they are going to get worse because you cannot evaluate a wound if you are not assessing them and expected there to be interventions in place regarding R22's recliner chair. During interview on 11/2/23 at 8:11 a.m., the director of nursing (DON) stated she found a wound assessment in a file and provided four of five pages of a hand written note on a Body Audit form dated 10/16/23. The form indicated R22's left gluteal fold measured 0.8 cm long by 0.76 cm wide by 0.5 cm deep and the coccyx measured 0.57 cm long by 0.66 cm wide by 0.5 cm deep. During interview on 11/2/23 at 8:25 a.m., LPN-B stated she had the mobile application for documenting the wound assessment on her phone and it was deleted so the assessment dated [DATE], did not pull over and stated the assessment was completed on 10/16/23, and stated they were 100% paperless and verified prior to 10/16/23, R22 was missing several wound assessments. During interview on 11/2/23 at 10:52 a.m., the hospice RN stated, she just met R22 on 10/27/23, and was hopeful R22's wounds would heal and was dependent on her nutrition status. Hospice RN stated she just forwarded an email from the house hold coordinator (HHC)-C to check on the status of a wound cushion. During interview on 11/2/23 at 11:02 a.m., hospice RN stated she was not notified of a new wound and was not aware R22 was not sleeping in her bed and stated it would be important if R22 was in her chair to have an intervention for her recliner chair and further stated wound assessments were important to complete to make sure new interventions were put in place if the wound was not healing according to the plan. During interview on 11/2/23 at 12:34 p.m., hospice RN stated HHC-C sent her an email on 11/1/23, regarding a cushion and stated it was the first time she had heard about a cushion and further stated she ordered a standard cushion and the nursing facilities wound care team was taking care of the wounds and updating her on the wound measurements. During interview on 11/2/23 at 12:46 p.m., nurse practitioner (NP)-J stated R22's albumen level (an indicator of nutritional status) was completed on 8/15/23, and was 3.7 which was within normal limits. NP added R22 sitting in general like she preferred to do, put her at increased risk, but not having a cushion in addition to the reclining chair could have contributed to worsening pressure ulcers and additional ones as well and further stated she would have expected weekly skin assessments because even if there were no pressure ulcers, you want to see if there was one developing and once one was present, you want to make sure it doesn't worsen and if you have one pressure ulcer, you are at additional risk of getting another one. During interview on 11/2/23 at 1:27 p.m., DON stated wound assessments should be completed according to their policy of every seven days at a minimum and would have expected staff to document wound assessments and additional interventions in place knowing R22 did not want to lie in bed. During interview on 11/3/23 at 11:40 a.m., DON stated assessments were not getting completed and they were looking to adjust staff loads to include trained medication aides. A policy, Skin Integrity Management Policy dated October 2022, indicated it was the facility policy to properly identify, assess, and monitor residents whose clinical conditions increase the risk for impaired skin integrity, and pressure ulcers/injuries; to implement preventative measures; and to provide appropriate treatment modalities for pressure ulcers/injuries according to industry standards of care. A Braden scale was completed on admission and weekly to determine level of risk and regardless of the resident's total risk score, each risk factor and potential causes should be reviewed individually, addressed in the analysis and interventions implemented. Based upon findings of the clinical assessment in partnership with the resident and or family input, a care plan will be developed or modified to reflect alterations in interventions and implementation of new interventions specific to the resident. When a non surgical wound is discovered a new Wound Assessment is documented in point click care that includes the onset of the skin condition, type of wound, location, date, stage, length, width and depth; wound base description, surrounding skin description and if present drainage, odor, undermining, tunneling, and or pain. Documentation on the wound using the wound assessment with a structured progress note generating from the assessment should be done at least weekly, or more frequently depending on the wound characteristics or type dressing used. Implement appropriate interventions and update care plan and nursing assistant assignment sheets. An avoidable pressure ulcer/injury means the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate.