**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R1: R1's quarterly Minimum Data Set (MDS) dated [DATE], indicated R1 was severely cognitively impaired. Section M-Skin Conditions identified R1 was at risk to develop pressure ulcers. M0300.-Current number of unhealed Pressure Ulcers at Each Stage: identified R1 had two unstageable pressure ulcers that were not present at the time of admit. R1's facesheet dated 2/7/24, indicated R1 was admitted the facility on 9/21/23. The following diagnoses were included: dementia, Alzheimer's disease, urinary retention, adult failure to thrive, non-pressure chronic ulcer of unspecified part of right lower leg with fat layer exposed, and chronic kidney disease. R1's care plan identified the focus area of alteration in skin integrity for venous ulcer right calf, pressure ulcer right heel, and pressure ulcer coccyx with the goal of skin breakdown resolved by 5/31/24. Interventions initiated on 9/21/23 included: -Monitor skin during cares and weekly skin inspection by nurse. -Treatment to open areas per order. -Pressure redistribution mattress on bed and wheelchair. -Encourage dietary supplements. -Weekly measurement and assessment of wound. -Monitor for skin break down for signs/symptoms of infection. Report signs/symptoms to provider. -Document on skin condition and keep MD or PA-C informed of changes. -Followed by wound care. Intervention initiated on 2/7/24: Heel protectors on at all times. R1's record included the following weekly skin checks: -9/28/23, No new changes to skin. Res has a wound dressing to right LE, and breakdown on coccyx buttocks area. Calmospetine ointment being applied with cares. -10/19/23, breakdown on buttocks, using calmoseptine. Wound to right shin, wound care done as ordered. -11/2/23, redness/breakdown on buttocks, using calmospetine cream. Wound on right shin and right heal, wound care done as ordered. -12/7/23, Skin is warm and dry. Lotion applied to dry legs, arms, and face. Bruise noted to right shin, small fading bruises on bilateral arms. Ongoing wound care completed to right heel and shin and buttocks. The admission MHM Skin Evaluation and Skin Risk Factors completed on 9/21/23, by RN-A identified R1 had a vascular stasis ulcer to the right lower extremity. The document indicated the coccyx/sacral area was not assessed during the admit skin assessment. The MHM Skin Evaluation and Skin Risk Factors assessment completed by RN-A on 11/30/23, indicated R1 had an unstageable ulcer on left buttock, and an unstageable right heel would, and a previously identified vascular ulcer on the right lower extremity. R1's IWC progress notes indicated they were consulted on 10/10/23, for evaluation and treatment for chronic venous ulcer and first encounter of pressure ulcer to right heel. The right heel was unstageable measuring 4x4 centimeters without exudate and 100% Eschar. R1's IWC progress note dated 11/14/23, indicated in addition to the venous ulcer and unstageable heel pressure ulcer, they were being consulted for first encounter for a pressure ulcer to the coccyx. The coccyx pressure ulcer measured 4 x 3 cm with no exudate and was 100% Eschar. Blue boots were recommended for heels. R1's regulatory provider encounter notes from a 9/29/23, indicated R1 had a chronic lower extremity non-pressure wound. Note did not address coccyx/buttock redness or breakdown. Provider encounter on 10/6/23, did not address R1's heel or coccyx/buttock redness or breakdown. Provider encounter on 10/27/23, indicated R1 was also being evaluated for an unspecified staged right heel blister. The provider advised to continue orders from wound care: wound cleaner, bordered foam, no shoes, and float heels. The note did not address coccyx/buttock redness or breakdown. Provider encounter on 11/1/23, did not address R1's heel or coccyx/buttock redness or breakdown. Provider encounter on 11/29/23, addressed R1's heel and sacral ulcer and included: The heel was covered with dry eschar. There was a soft boggy eschar overlying the right sacrum draining purulent drainage. The pressure ulcer measured 6 x 6 cm. The wound was debrided down to healthy granular tissue with no visible bone or tendon. Twice a day wound packing and low air mattress recommended. During an observation on 2/6/24 9:00 a.m., R1 was dressed with slipper socks on. During an observation on 2/7/24 at 7:40 a.m., R1 was seated in their wheelchair by the bird area. R1 was dressed with slipper socks on. During an observation on 2/7/24 9:43 a.m., R1 was seated in sitting area by nurse station in wheelchair. No heel protectors on. During an observation on 2/7/24 at 11:42 a.m., R1 entered the elevator with a staff, R1 did not have heel protectors on. During an observation on 2/7/24 at 1:04 p.m., R1 was in bed with covers on, could not determine if heel protectors were on. During an observation on 2/7/24 at 2:30 p.m., R1 was in the day room with slipper socks on wheeling self around. During an observation on 2/8/24 at 9:04 a.m., NA-C brought R1 into the shower room, transferred R1 to the shower chair and proceeded to bathe R1. R1's pressure ulcer dressing, and sacral dressing were on the resident after the shower. At 9:15 a.m. NA-C dressed R1 with new brief, pants, and a sweater and then transferred R1 back to their wheelchair. NA-C stated the nurse would check R1's wounds later. R1 was brought to their room. During an interaction on 2/8/24 at 12:10 p.m., licensed practical nurse (LPN-A) stated they would not be doing R1's dressing changes until after lunch. During an interview on 2/7/24 at 11:46 a.m., NA-A stated when they did a resident shower they did a skin sheet, they clipped fingernails as needed if the resident wasn't diabetic, and if they found something suspicious with the resident's skin they would usually try and get the nurse to look at the resident's skin in the shower. During an interview on 2/7/24 12:35 p.m., RN-A stated the nurses should be checking resident skin on bath days. RN-A confirmed the NA completed a skin sheet for each resident on their bath/shower day, however, it was still the nurse's responsibility to do an eyes on assessment of the skin. RN-A stated they looked at the treatment record to ensure skin assessments were being completed. Nurses are still required to complete a skin assessment, not just sign it off in the TAR. RN-A indicated moving forward, they would need to check the assessments, not the TAR to ensure an assessment was done and issues were communicated. For pressure ulcer care, even with a pressure reducing mattress, R1 should be repositioned in bed and off loaded when in their chair every 2 to 3 hours. R1 should also have heel protectors on at all times. These items should be part of the resident's plan of care. During an interview on 2/7/24 at 1:17 p.m., the director of nursing stated it was an expectation that the nurse always completed the skin assessment. The DON confirmed the NA did complete the skin assessment form, but not as an assessment. The NA form was used as information to pass onto the nurse, so the nurse could assess the skin. The DON stated they had the NAs complete the form because they were the most hands on with the residents. If something did get identified as skin break down by one of the nurses, the nurse manager should be notified so they can immediately follow-up on that. When there is skin breakdown identified, it should either be staged or called moisture associated. The nurse should follow-up on care and treatment. Usually, wound care is initiated through integrated wound care or Essentia wound care if we note any kind of skin break down. Even if it is something like break down form incontinence, we would consult wound care. During an interview on 2/8/24 at 12:20 p.m., RN-A pulled up R1's medical record and stated R1 was admitted with the non-pressure leg wound. R1 was also admitted with an order for barrier cream for their buttocks as a preventative measure for incontinence. RN-A confirmed R1's sacral/buttocks area was not assessed when R1 was admitted to the facility on [DATE]. RN-A indicated on 10/10/23, the heel ulcer was noticed, and wound care was asked to evaluate R1's heel pressure ulcer that day. RN-A stated they had not been notified R1 had any skin break down in the coccyx/buttocks area until right before they had the wound care nurses consulted on 11/14/23. RN-A confirmed weekly skin check documentation starting on 9/29/23, indicated R1 had redness and skin breakdown in the buttocks/sacral area. RN-A indicated they had not been notified of skin break down, but should have been notified immediately, when redness was identified in the buttock and coccyx area. RN-A did not find documented provider notification of R1's heel or coccyx pressure ulcers, but indicated they would have done that around the time they consulted wound care. The facility policy Skin Assessment & Wound Management dated 11/17/23, included a weekly skin inspection by licensed staff, notification of nurse manager for any changes, and routine daily skin inspection with care. In addition, the policy directed the following actions for new non-pressure wound/altered skin and for new pressure ulcers: notify the provider/obtain treatment orders, notify resident representative, complete education with resident, initiate wound skin and wound evaluation, notify nurse manager, review and update care plan, consult nutrition and appropriate therapies. Based on observation, interview and document review, the facility failed to notify the provider, monitor, determine root cause and revise interventions to address pressure ulcers for 1 of 2 residents (R21) reviewed who was at risk for pressure ulcer development/deterioration. The facility's failure resulted in harm when R21 developed 2 pressure ulcers, one that deteriated to a stage 3 and another to a stage 4. In addition, R1 had documented redness and skin breakdown to the buttocks area and a right heel wound that both deteriorated to unstageable pressure ulcers. Findings include: The National Pressure Ulcer Advisory Panel (NPUAP) definition of a stage 3 pressure ulcer included: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. The NPUAP definition of a Stage 4 pressure ulcer included: Full thickness, skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and or eschar may be visible on some part of the wound bed. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the wound bed, it is an unstageable pressure ulcer. Suspected deep tissue injury are identified as persistent non-blanchable deep red, maroon or purple discoloration intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. The NPUAP definition of Unstageable Pressure Injury included: obscured full-thickness skin and tissue loss: full-thickness skin and tissue loss in which the extent of tissue damage within is ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. R21's significant change Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact. R21's diagnoses included cancer, hypertension, cerebrovascular accident, hemiplegia(weakness/lack of use to one side of the body) and seizure disorder. The MDS did not identify R21 had a pressure ulcer. The Care Area assessment dated [DATE], indicated pressure ulcers was a specialized area of concern that needed to be addressed in the care plan. R21's care plan dated 10/3/22, indicated alteration in with a goal of skin breakdown would be resolved by next review. Interventions of monitor skin integrity daily during cares, weekly skin inspections, pressure redistribution mattress to bed, pressure redistribution cushion to wheelchair, and monitor for skin breakdown/notify provider were added on 10/3/22. On 10/20/22, turn and reposition or reminders to offload every 2-3 hours was added as an intervention. No other interventions had been added until 2/2/24, staff had to document on skin conditions and keep health care provider informed. On 2/4/24 at 5: 36 p.m., a large dressing was observed on R21's left posterior buttocks and medial coccyx. R21 stated at that time he had two large sores underneath the bandages. He rated the pain at that time a 6 out of 10 but stated staff were giving him pain medication. R21 refused to allow the surveyor to look at the wounds at that time. The undated facility standing orders identified the wound care nurse would be notified to conduct a root cause analysis (RCA) to determine wound type and recommended dressings and well as MD/NP notification. The following Weekly Skin Inspection forms were reviewed from 10/30/23 to 12/11/23, as followed: -On 10/30/23 at 1:56 p.m., R21 had self-inflicted scratches to legs. All other skin ok. -On 11/6/23 at 1:32 p.m., R21 had redness and breakdown on buttocks. -On 11/20/23 at 1:46 p.m., R 21 had redness and breakdown to buttocks. -On 12/11/23 at 10:23 a.m., R21's wound on coccyx is getting worse. All of the weekly skin inspection forms above lacked documentation of notification of the health care provider or new interventions to prevent worsening of the pressure ulcers. The forms also lacked any documentation of an RCA related to the wounds. Skin & Wound Evaluation form dated 10/30/23 at 3:01 p.m., identified R21 had an abrasion on the front right lateral lower leg. No other skin concerns noted. Skin & Wound Evaluation form dated 11/21/23 at 2:50 p.m., identified R21 had a new in house acquired Moisture Associated Skin Damage (MASD) to the Sacrum (Bone at the top of the Buttocks region) which measured 3.5 centimeters (cm) long (L) by 2.3 cm Wide(W). The wound had 20% Epithelial, 20% granulation and 60% slough. There was a light amount of serosanguinous (pinkish clear colored) drainage. There was a photo attached to the file that showed a stage 3 pressure ulcer with 60% slough noted. A copy of the picture was requested but not provided. Skin and Wound Evaluation form dated 12/1/23 at 3:04 p.m., identified R21 had a deteriorating MASD to the sacrum that measured 4.3 cm L by 2.3 cm W. The form lacked any other documentation of the wound and lacked documentation the provider was notified. On 12/12/23, Integrated Wound Care (IWC) saw R21 for the first time and documented R21 had a stage 4 pressure ulcer to the medial coccyx with exposed bone and tunneling. A stage 3 pressure ulcer to the left posterior buttocks was also documented. The visit documentation from 12/12/23, to 1/10/24, was requested but not provided. On 1/16/24, IWC documentation indicated an ulcer to the medial coccyx that measured 5cm L by 6cm W by 1cm deep (D) that had bone exposed and undermining that was 1-4 cm deep. The documentation also indicated an ulcer to the left posterior buttocks that measured 3 cm L by 1.5 cm W x 0.1 cm D. There was moderate serosanguinous drainage and 100% slough. Healthcare provider visit notes from 11/10/23 to 11/29/23 were reviewed and lacked documentation of provider awareness of the pressure ulcers and/or treatment plans for the pressure ulcers. The documentation indicated the skin was warm and dry at each visit. Review of nursing documentation from 11/1/23 to 12/12/23, indicated the following: -On 11/7/23 at 6:04 p.m., the nurse practitioner (NP) reviewed the labs and ordered new labs. -On 11/7/23 at 9:11 p.m., purplish area on coccyx. Reminded resident to shift frequently in bed. There was no documentation of provider notification. -On 11/22/23 at 3:46 p.m., the NP again saw R21 but the documentation only addressed vital signs and med changes related to the vital signs. It lacked any documentation the NP was aware of the wound and treatment plan orders for the wound. -On 11/29/23 at 12:07 p.m., medical provider on rounds. No new orders at this time. -On 12/1/23 at 3:35 p.m., .wound needs orders. Orders requested from hospice. Review of all health care provider orders from 11/1/23 to 12/12/23, lacked any orders related to wound care treatment for the pressure ulcers on the buttocks or coccyx. On 12/12/23, the first orders from IWC were written. On 2/7/24 at 9:28 a.m., a message was left with IWC, but no return call was received. During an interview on 2/6/24 at 10:14 a.m., licensed practical nurse (LPN)-A stated if a resident acquired a new wound of any kind they would notify the nurse manager of the wound right away and also notify the provider of the wound. After notifying each person a note would be made in the progress notes to indicate they were notified. LPN-A stated R21 had a stage 4 pressure ulcer to the coccyx and a stage 3 pressure ulcer to the buttocks that had been treated for at least two months. The notes from 11/6/23 to current date were reviewed and LPN-A acknowledged all documentation was about the same wound. She became aware of the wound the first time on 11/7/23 and did not report anything to the NP because she assumed it was already reported since that was protocol. During an interview on 2/7/24 at 9:08 a.m., registered nurse (RN)-B stated the picture attached to the 11/21/23, Skin and Wound Evaluation form had been taken during the skin and wound evaluation on 11/21/23. She confirmed the picture was a stage 3 pressure ulcer and did not know why the form called it moisture associated skin damage. RN-B stated when a new wound was reported to the nurse managers, the wound would be evaluated right away and then the provider would be notified for orders to treat. A skin analysis was also done to see what caused the new wound to form. After everything was completed, documentation would be placed in the chart as a progress note by the nurse. RN-A reviewed R21's medical records and acknowledged there was no notification to provider or skin analysis documented, and based on the lack of findings confirmed it more than likely was not performed. During an interview on 2/7/24 at 11:03 a.m., the Director of Nursing (DON) stated any new wounds should be reported to the nurse manager right away, but no later than the next morning so they could be evaluated. Part of the evaluation process was to analyze what caused the wound and what additional interventions where required to prevent worsening of the wounds. The provider would be notified right away to get order to treat the wounds and assist in monitoring of the wounds. During an interview on 2/8/24 at 11:23 a.m., the primary care provider (PCP) stated she had been on medical leave in November 2023 and the NP was covering during the leave. She was made aware of the pressure ulcers after returning on 12/1/23 by hospice. On 2/8/24 at 11: 42 a.m., a message was left for the NP to return a call. No return call was received. Facility policy Skin Assessment & Wound Management last revised 11/17/23, stated when a new pressure ulcer was identified the provider would be notified for treatment orders, an initial Skin and Wound Evaluation form would be completed, the nurse manager/wound nurse would be notified. Lastly the care plan would be reviewed and updated with interventions and risks for skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to promptly obtain opioid medication and failed to notify the physican to prevent opioid withdrawal for 1 or 1 residents (R13) reviewed for pain management. This practice resulted in a significant medication error and actual harm when R13 did not receive opioid medication for 7 consecutive days resulting in R13 being sent to the emergency room to receive care for acute opioid withdrawal. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 was cognitively intact and reported almost constant pain, which limited ability to sleep and complete day to day activities. MDS diagnoses included neurofibromatosis type 2 (growth of noncancerous tumors in the nervous system), long term (current) use of opiate analgesic, and paraplegia. R13's elder care visit summary dated 1/2/2024, identified R13 was prescribed 4 milligrams (MG) of oral hydromorphone (opioid medication) every 4 hours as needed for pain. R13 was not being tapered from this medication. Review of R13's medication administration record (MAR) from 12/1/23 to 1/1/24, identified hydromorphone was administered 3 to 6 times daily with a minimum of 3 administrations per day. On 1/2/24, hydromorphone was administered once. From 1/3/24 to 1/9/24 hydromorphone was not administered. R13's progress notes from 1/3/24 to 1/7/24 gave no indication R13 was out of hydromorphone or R13's provider was contacted. Progress notes failed to identify any attempt to get R13 hydromorphone or any other type of opioid pain medication. R13's progress note dated 1/8/24 at 9:05 p.m., stated, resident says I need my pain meds. R13's progress note dated 1/9/24 at 4:45 p.m., stated received order to substitute 2 MG hydromorphone tablets for 4 MG tablet. R13's progress note dated 1/9/24 at 9:02 p.m., stated resident was sent to the emergency department due to having severe high blood pressure (172/102 and 197/100) and vomiting. Has not been feeling well all day. Had diarrhea and vomiting in the morning. By the afternoon estimated has vomited 10 times throughout the day. R13's emergency department after visit summary dated 1/9/24, identified a visit diagnosis of acute opioid withdrawal. Instructions state if hydromorphone is unavailable give oxycodone every 4 hours. Included information identified opioid withdrawal occurs when a person has used opioids daily for at least 3 weeks. R13 was discharged at 11:45 p.m., 3 doses of hydromorphone had been administered and blood pressure was 136/75. During interview on 2/5/24 at 3:51 p.m., R13 stated the facility has failed to consistently provide opioid medications on at least 3 occasions. R13 has gone at least 3 days without opioid medications, and this most recently occurred a few weeks ago. R13 was unsure when the other 2 occasions occurred. During interview on 2/7/24 at 12:57 p.m., licensed practical nurse (LPN)-A states all floor nurses can request a refill on a controlled mediations if the medication has a refill. If a medication needs a refill, was not delivered, or if a resident was out of a medication, a registered nurse would be notified. LPN-A acknowledged difficulty obtaining R13's hydromorphone and stated the facility received a slip from the pharmacy notifying of hydromorphone national shortage. LPN-A was unsure of when the facility received this notification. On 2/8/2224 at 9:15 a.m., registered nurse (RN)-B stated they were not notified R13 was out of hydromorphone because RN-B was out of the facility from 1/3/24 to 1/10/24. Upon return, RN-B was having difficulty obtaining refill of hydromorphone due to the national shortage and needed to contact the provider to obtain a prescription for a new opioid medication. RN-B stated was unaware if provider was contacted during absence but explained phone contacts made to the provider are documented in excellent professionals individualized care (EPIC) (an electronic health record). RN-B reviewed EPIC and confirmed no phone contacts were made to the provider from 1/3/24 to 1/8/24. RN-B's stated during absence, first-floor clinical manager and director of nursing (DON) were managing nursing duties. During interview on 2/8/2024 at 1:31 p.m., director of nursing (DON) confirmed was in part managing RN-B's nursing duties during absence. DON stated having the expectation of being notified if a resident was out of a medication and a progress note was made. DON stated was not notified R13 was out of hydromorphone. DON expects opioid medications are obtained the same day the medication was needed and if it cannot be obtained the resident should be sent to the emergency department to obtain the medication. The Food and Drug Administration (FDA) Drug Safety Communication dated 4/9/19, identified serious harm has been reported when patients who are physically dependent on opioid medications suddenly have these medicines discontinued. Requested copy of EPIC provider contact documentation. Documentation was not provided.