**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions to prevent pressure ulcer development for 1 of 1 resident (R1) reviewed for pressure ulcers. R1 admitted to the facility without pressure ulcers, subsequently developed an unstageable pressure ulcer related to necrotic (death of tissue). The facility failed to provide ongoing comprehensive skin assessments, monitor for signs of infection/deterioration, and notify R1's provider of changes, resulting in R1 being hospitalized . The immediate jeopardy began on 8/15/23, when a pressure ulcer was noted to R1's buttocks without proper assessment, physician notification, and documentation of interventions and was identified on 10/4/23. The administrator and director of nursing (DON) were notified of the on 10/4/23 at 4:55 p.m. The immediate jeopardy was removed on 10/6/23 but noncompliance remained at the lower scope and severity level 2, D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: The State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, revision 211, 2-3-23 indicated definitions for stage 3, stage 4, and unstageable pressure ulcers. Stage 3 Pressure Ulcer: Full-thickness skin loss: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. 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. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. Stage 4 Pressure Ulcer: Full-thickness skin and tissue loss: 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 parts 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 PU/PI. Unstageable Pressure Ulcer: Obscured full-thickness skin and tissue loss: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur. R1's admission note to the facility dated 3/24/23, indicated R1 had no skin issues except for bruising on her left arm due to lab draws and a biopsy procedure on her right arm. R1's care plan initiated on 3/27/23, noted she was at risk for skin breakdown and had interventions for turning and reposition program as needed every two hours, barrier cream to dry areas as needed, and wheelchair cushion. These interventions were discontinued on 4/26/23. The discontinue reason was Scheduled end date. R1's Physician Orders dated 3/27/23, noted skin assessment to be completed on weekly shower day, to be completed even if a shower is refused, all old and new skin abnormalities need to be documented. R1's care plan initiated 4/10/23, noted an intervention for risk for skin alteration; See eTAR (electronic Treatment Administration Record). A progress note dated 5/10/23, indicated staff reported a small sore on R1's coccyx, the nurse noted 1 centimeter (cm) x 1 cm, applied barrier cream, a foam dressing and left the provider a non-urgent voicemail. A progress note dated 5/16/23, noted R1 had a sore on her bottom and was added to wound rounds. A progress note date 5/22/23, noted R1 was seen on wound rounds and had a pea-sized pressure ulcer on her coccyx. No specific measurements, staging, description of wound bed, drainage or condition of peri-wound skin were documented. R1's Physician Orders dated 5/22/23, directed to care for the pressure ulcer as follows: cleanse with wound cleanser, skin prep to peri-wound and cover with foam daily. The order was discontinued on 6/23/23. R1's quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 was cognitively intact, required extensive assistance of one to two staff for bed mobility and transfers, and was not ambulatory. The MDS indicated R1 was at risk for pressure ulcers, had diagnoses of multiple sclerosis, weakness and abnormal posture and required the extensive assistance of one staff for bed mobility, dressing and toileting. A progress noted dated 6/29/23, indicated R1 was seen on wound rounds for a small blister on her coccyx area, which had healed. The progress note lacked further description. A progress note dated 7/5/23, indicated an open area on R1's coccyx was healed. A progress note dated 7/9/23, indicated open areas to R1's gluteal area, it was covered with a foam dressing. The noted lacked documentation of wound bed description, drainage, measurements, etiology, or peri wound skin. A progress note dated 7/17/23, indicated R1 received a shower, new open areas were found, and the wound nurse completed an assessment. The wound nurse documented a progress note that stated R1 had two open areas on her buttocks, the left buttock had visible adipose with full thickness skin loss and the right had partial thickness skin loss with exposed dermis. R1 was added to weekly wound rounds. The note lacked further description of the pressure ulcers. R1's wound management form dated 7/17/23, noted R1 had an open area on her left buttock that measured 3 cm x 3.5 cm and an open area on her right buttock that measured 2 cm x 1.5 cm, and the healing status was stable. The wound management form lacked wound bed descriptors, drainage, peri wound skin or staging of the pressure ulcer. R1's Physician Orders dated 7/17/23 directed to cleanse with wound cleaner, apply skin prep to peri-wound skin, apply a small amount of Medi-honey to the wound bed, cover with foam and change daily. A progress note dated 7/27/23, indicated R1 was seen on wound rounds, treatment was performed to bilateral buttocks, wound nurse to see weekly. R1's wound management form dated 7/27/23, noted R1's wound measurements to the left buttock measured 1.5 cm x 2 cm, and the right buttock open area measured 2 cm x 3 cm. The wound management note lacked further description of the pressure ulcer. R1's care plan dated 7/27/23 identified R1 had skin breakdown on bilateral buttocks. The care plan indicated a Braden score (assessment for risk of skin breakdown) of 19 (indicates no risk for pressure ulcer development). R1's care plan lacked any interventions, indicating only to See eTAR. R1's July 2023, eTAR did not contain pressure ulcer prevention interventions but contained orders for wound care to R1's pressure ulcer. A progress note dated 8/6/23, noted R1 was pale and tired, dressing changed as ordered to stage 3 & 4 pressure ulcers. Vital signs were temperature 97.7 F, blood pressure 97/60, O2 95% on room air, heart rate 77, and respirations were 16. R1's wound management form dated 8/10/23, noted R1's left buttock measured 3 cm x 4 cm and her right buttock measured 5 cm x 4 cm and healing status was listed as stable. The note lacked any further descriptions. A progress note dated 8/13/23, noted R1's dressing change was completed, and a foul smell and drainage was noted, R1 would be turned every 2 hours to relieve pressure to buttocks. The note lacked documentation of provider notification. A progress noted dated 8/14/23, indicated R1 had a scheduled shower and that she has open areas to left and right gluteal cleft, eschar (devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) noted on right side, total affected area measured 10.5 cm x 5.5 cm, foul smell and significant drainage noted. Repositioning was offered every 2 hours, and the nurse manager would be notified. The note lacked documentation of provider notification. A progress note dated 8/14/23, indicated the nurse and the wound medical doctor (WMD) would assess the wound on 8/17/23 when onsite for wounds, staff to encourage R1 to reposition every 1-2 hours. R1's care plan initiated on 8/15/23, noted wound MD to eval [sik] and treat. A Nurse Practitioner (NP)-E note dated 8/15/23, noted R1 was seen that day for a worsening decubitus (pressure ulcer) ulcer per request for nursing staff. The NP-E noted R1 had worsening ulcer as noted by staff with necrotic (death of tissue) tissue, odor, and increased amount of drainage. The wound was approximately 10 cm x 5 cm, pink wound base with some necrotic tissue on the right, foul odor, yellow drainage and R1 had pain with dressing changes. The NP-E ordered staff to continue change foam dressing daily and as needed if saturated, to monitor for fever, chills, or increased chills, out of bed for meals only until seen by the WMD. R1's Physician Order dated 8/17/23, noted wound MD to eval [sik] and treat. An Initial Wound Evaluation & Management Summary dated 8/17/23, noted the WMD provided an assessment to R1's wound. R1 had an unstageable (due to necrosis) pressure ulcer to her sacrum, it measured 11.2 cm x 5.6 cm x 0.2 cm, had an odor, moderate serous drainage, had 80% necrotic tissue and 20% granulation (pink-red moist tissue that fills an open wound) tissue. The WMD ordered Santyl to be applied, covered with a foam dressing daily, off load pressure ulcer, reposition per facility protocol. The WMD performed bedside debridement and as a result the necrotic tissue was removed to a depth of 0.6 cm and decreased the nonviable wound bed from 80% to 40%. R1's wound management form dated 8/17/23, noted left and right buttocks wounds were merged into one wound that measured 11.2 cm x 5.6 cm x 0.2 cm. The wound had a moderate amount of drainage, it was seropurulent (yellow or tan, cloudy and thick), there was a foul and strong odor to the wound, and it was an unstageable (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) should only be removed after careful clinical consideration and consultation with the resident's physician, or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws. If the slough or eschar is removed, a Stage 3 or Stage 4 pressure ulcer will be revealed. If the anatomical depth of the tissue damage involved can be determined, then the reclassified stage should be assigned. The pressure ulcer does not have to be completely debrided or free of all slough or eschar for reclassification of stage to occur) due to 80% of the wound bed being slough and/or eschar, and 20% granulation tissue, the pressure ulcer had macerated/soft, irregular edges, the peri wound skin had blanchable erythema (redness), and the healing status was stable. A progress note dated 8/17/23, noted R1 had her dressing changed three times that day due to increased drainage and bleeding after debridement. The note lacked documentation of physician notification, or orders to increase dressing change due to drainage. A progress note dated 8/18/23, indicated R1's dressing was changed due to dressing condition and R1 had pain during the dressing change that was not controlled with as needed Tylenol. R1 was having pain when seated in her chair and with dressing changes. The note indicated an order to increase R1's pain medication was obtained, she had poor appetite eating 5% of her meal and returned to bed after mealtime was over. A progress note dated 8/19/23, noted R1's dressing was changed and the skin on the right side of the pressure ulcer was now a dark gray in color, R1 was repositioned every two hours that shift and was compliant with repositioning. The note lacked documentation that the provider was notified of the change in coloration of the pressure ulcer. A progress note dated 8/20/23, indicated R1 had increased pain related to her pressure ulcer receiving two as needed doses of narcotic pain medication - 2.5 milligrams (mg) of Oxycodone once in the morning and once at bedtime. R1's dressing was changed twice, and she was repositioned frequently due to pressure ulcer discomfort. The note lacked documentation that the provider was notified of increased pain and discomfort related to the pressure ulcer. A progress note dated 8/21/23, noted R1's dressing was changed, she was wincing and clenching which indicated pain but verbally denied pain, no odor was noted. The note lacked documentation that the provider was notified of increased pain. A progress note dated 8/22/23, indicated the dressing was changed as ordered, it had a foul odor, and the wound base was dark gray in color. The note stated the nurse had the NP-E assess the wound that day. An NP-E note dated 8/22/23, indicated that R1 had a worsening decubitus ulcer with tissue necrosis that underwent bedside debridement by the WMD last week. The NP-E stated that staff was reporting increased odor and drainage, R1 is having increased pain and current dose of Oxycodone was not effective in pain management, R1 was not having fevers. The note described the pressure ulcer as being large ulcer on her coccyx, approximately 10 cm x 5 cm, deeper than previous, with gray colored tissue at wound base with some darker black area, drainage is yellow and there was a foul odor. The note indicated the NP-E discussed the pressure ulcer with the primary physician, the note stated they decided to forego infection markers (blood labs to assess for inflammation) as it may not be reliable due to chemotherapy drugs. The NP-E and primary physician noted they would order a CT (computerized x-ray) of her pelvis and lumbosacral spine to rule out osteomyelitis and WBC with diff (blood lab to look at the percentage of white blood cells to help diagnose infection). The NP-E note indicated she spoke with R1's mother and she agreed with treatment plan, that a palliative care consult was recently canceled to continue with active treatment. The note stated the NP-E discussed R1's poor appetite, low protein stores, anemia, breast cancer, and immobility which increased R1's risk for pressure ulcers, infection, and poor healing. The note stated staff should monitor R1 daily for a fever. A Wound Evaluation & Management Summary note dated 8/24/23, indicated the WMD saw R1 for her pressure ulcer. R1's unstageable (due to necrosis) sacrum pressure ulcer measured 12 cm x 6.8 cm x 2.5 cm, it had moderate serous drainage, the peri wound skin had an odor, maceration (occurs when skin is in contact with moisture too long), and erythema, it was 80% necrotic, 10% granulation. The WMD noted the wound was exacerbated, due to nutritional compromise, infection, and a generalized decline. R1 was sent to the hospital due to the appearance of the pressure ulcer, increased size, depth and tunneling. The WMD recommended transfer to the emergency department (ER) for further evaluation, surgical debridement, and treatment with intravenous antibiotics. R1's wound management form dated 8/24/23, noted R1's unstageable pressure ulcer measured 12 cm x 6.8 cm x 2.5 cm, had moderate seropurulent drainage, a sour odor, and was 80% eschar, 10% granulation tissue, the wound edges were not attached to the base, the peri wound skin was white or gray in color, the wound healing status was declining and R1 was sent to the ER for surgical debridement. A progress note dated 8/24/23, noted R1 was seen on wound rounds by the WMD and was sent to the ER for increased necrotic tissue, inability to tolerate bedside debridement to her unstageable pressure ulcer. R1's family was present and brought her to the ER. R1's Minnesota Cause of Death Worksheet undated, indicated R1's date of death was 9/15/23. R1's immediate cause of death was due to septic shock as a consequence of parapneumonic pleural effusion (accumulation of fluid with a lung infection, mainly pneumonia typically associated with bacterial infections). Other significant conditions contributing to R1's death included multiple sclerosis, stage 4 sacral ulcer, urinary tract infection, and metastatic breast cancer. During an interview on 9/29/23, at 12:19 p. m. family member (FM)-A stated the first she knew about the pressure ulcer is when she saw it on 8/17/23, when the WMD was there, she took pictures with her phone of the pressure ulcer on that date as well as a week later when the WMD was there again. FM-A stated she was aghast when she saw the pressure ulcer and since R1 required full care and questioned why the facility did not prevent the pressure ulcer. FM-A stated just prior to R1's hospitalization the facility had started to reposition R1 but by that time, the pressure ulcer was too bad. FM-A stated an intensive care unit (ICU) nurse at the hospital told her that R1 had septic shock and she did not want this to happen to anyone else. During an interview on 10/2/23, at 11:34 a.m. licensed practical nurse (LPN)-A was also a clinical manager and wound nurse for long term care. LPN-A stated she performed weekly wound rounds and confirmed that many of R1's wound management forms were incomplete and lacked detailed descriptions of the pressure ulcer such as wound bed appearance, drainage, per wound status. LPN-A confirmed there was no notification of the provider when R1 had necrotic tissue, odor, increased drainage, pain or when it increased in size. LPN-A stated she would expect a nurse to call the provider with any change in the pressure ulcer. LPN-A stated the interventions to prevent pressure ulcers for R1 included an air loss mattress repositioning every 2 hours, protein supplement and a tilt in space wheelchair, however, confirmed R1's care plan did not reflect those interventions. During an interview on 10/2/23, at 1:30 p.m. the WMD stated she did not know when she was first contacted to see R1, but that it was the same day she saw her. The following week the wound had deteriorated, and she thought R1 needed surgical debridement. During an interview on 10/2/23, at 1:56 p.m. FM-B stated she did not know about the pressure ulcer until just prior to R1 going to the hospital and questioned why the facility did not get the WMD involved before it got so bad. FM-B stated staff at the facility told her that they were going to start repositioning her every 2 hours but noted R1 was frequently not repositioned when she visited, she questioned staff about R1 being up in her wheelchair so long and was told that it was because it was nearly mealtime. FM-B stated another time, R1 was left up in her wheelchair all night long by an agency staff and only knew because R1's roommate told her. FM-B stated a staff member at the hospital told her that R1 was in septic crisis because of the pressure ulcer on her coccyx. During an interview on 10/3/23, at 11:20 a.m. the director of nursing (DON) stated she expected nurses to complete weekly skin assessments in a progress note. The DON confirmed that R1 did not have full descriptions of her pressure ulcers in the wound management form. The DON stated R1 had pressure ulcer prevention interventions that were on a nursing assistant (NA) group sheet but since R1 was discharged , they do not have saved copies of the group sheet. The DON stated R1 had her own wheelchair cushion, she received an air mattress at the end of June and the facility obtained a tilt in space wheelchair on 8/10/23 to reduce the pressure to her sacrum. During an interview on 10/3/23, at 12:59 p.m. the NP-E stated she had not been working at this facility long and her first visit with R1 was on 8/1/23 following a urinary tract infection (UTI). The NP-E stated she did not look at the pressure ulcer then and was not sure that she knew about it at that time. The NP-E looked at the primary provider notes and stated the physician did not mention a pressure ulcer in her notes either. The NP-E stated she thought the WMD was involved and did not know about the pressure ulcer worsening until 8/15/23, when she was at the facility and a nurse stated, you need to see this wound. The NP-E stated there was necrotic tissue and yellow drainage, she ordered staff to change the dressing daily and as needed for saturation. The NP-E stated she saw the pressure ulcer again on 8/22/23, following debridement from the WMD and had increased her Oxycodone for pain. The NP-E stated at that visit the pressure ulcer had increased depth and necrotic tissue, she spoke with the primary physician, and they decided to forego any infection markers but ordered a CT to rule out osteomyelitis. The NP-E stated she also spoke with R1's emergency contact who agreed with the plan, while also trying to explain the decreased likelihood of healing. During an interview on 10/3/23, at 1:34 p.m. NA-A stated she never saw R1's pressure ulcer but remembered that she could smell it, she stated she thought R1 had a bowel movement, but another staff member told her the odor was R1's pressure ulcer. During an interview on 10/3/23, at 1:41 p.m. NA-B stated she was aware of R1's pressure ulcer and had reported it to the nurse during a shower when it was getting bad, it was getting bigger, draining more. During a follow up interview on 10/4/23, at 12:57 p.m. The DON confirmed R1 did not have consistent weekly skin assessments and that those weekly skin checks were supposed to be completed on R1's bath day. The DON expected nurses to describe skin alterations, new and old, she also expected nurses to fully describe skin alterations with location, wound bed descriptions, drainage, peri wound skin and etiology of skin alteration. The DON stated all nurses are responsible for updating care plans and that the nurse that initially discovered R1's pressure ulcer should have updated the care plan with interventions, should have been continually changed with the worsening condition of the pressure ulcer, and that turning and repositioning every 2-3 hours should be in any resident at risk for pressure ulcers care plan. The DON stated she expected all nurses to know signs and symptoms of infection and to report those signs to a provider immediately, they should not wait, should not just update the DON or wound nurse. A facility policy titled Prevention and Treatment of Skin Breakdown effective 9/1/18, noted documentation of the skin impairment should be completed, staging of pressure injury is completed by trained licensed associates, standing orders are initiated and then notification to the provider. Staff should also notify the provider if the pressure injury has not shown progress in 2 weeks and/or deteriorating unexpectedly and to re-evaluate the care plan. The policy also noted evaluation of the current pressure reduction interventions and revision of the care plan. The immediate jeopardy that began on 8/15/23, was removed on 10/6/23, when the facility assured all residents had a current Braden Scale completed, residents that were at high risk for pressure ulcers were identified and skin/body audits were completed, residents with pressure ulcers had comprehensive skin assessments completed with care plan interventions reviewed and updated, providers were notified of current status, treatment and interventions. The facility reviewed their policy and education on the policy, comprehensive skin assessments, interventions for pressure ulcers, provider notification and pressure ulcer prevention modalities in accordance with plan of care was provided to nursing staff prior to their next scheduled shift, but the noncompliance remained at the lower scope and severity level 2, D - isolated scope and severity level, which indicated no actual harm with potential for more than minimal harm that is not immediate jeopardy.