**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to identify and implement interventions to prevent new pressure ulcer (PU) development for 1 of 1 resident (R61) who was at risk for PU upon admission. This caused actual harm when the facility failed to identify interventions to prevent new PU's to R61's heels and hip. Findings include: R61's: 1) 7/6/23, admission Minimum Data Set (MDS) assessment identified R61's cognition was severely impaired. R61 was dependent on staff for bed mobility, transfers, and toileting. R61 was identified as at risk for pressure ulcer (PU) development with no pressure ulcers present at that time. R61 had no venous or arterial ulcers, however, did have a skin tear. R61's skin and ulcer treatment included application of a nonsurgical dressing other than on their feet and application of ointment/medication other than on their feet. R61's diagnosis included atrial fibrillation, arthritis, osteoporosis, heart failure, hypertension, dementia, malnutrition or at risk for malnutrition, anxiety, depression, and psychotic disorder. 2) 9/27/23, quarterly MDS identified R61 continued to be dependent on staff for bed mobility, transfers, and toileting. R61 was identified as having a stage I or greater PU. R61 was at risk for PU development. R61 had an unhealed PU, and 1 unstageable PU. R61's skin and PU treatment included a pressure reducing device in chair, PU care, and application of ointment/medication, other than on their feet. R61's diagnoses included peripheral vascular disease (lack of blood flow to extremeties), atrial fibrillation (abnormal heart rhythm that affects blood circulation), congestive heart failure, degenerative joint disease, heart valve inadequacies (regurgitation), history of facial cancer, and knee and hip replacements. Observation on 11/28/23 at 12:10 p.m., R61 was seated in Broda wheelchair reclined with her feet elevated and a heel boot on her left foot. At 2:59 p.m., R61 was noted to be laying down in her bed positioned on her back side. At 5:06 staff entered room and assisted R61 up out of bed and back into her recliner. R61's facility wound assessments identified: 1) On 8/9/23, the left foot 2nd toe appeared as dried dark black/brown scab that measured 0.6 centimeters (cm) length x 1 cm width x 0.6 cm area and was classified as a PU, unstageable with wound bed eschar (dead tissue) at 100%, surrounding tissue noted to be dry, with brown staining, and a small amount of drainage. Staff were to apply a wound dressing and notify the physician (MD). Staff noted details of left 2nd toe remained the same on 8/16/23, 8/23/23, 8/30/23, 9/6/23, and 9/12/23. There was no mention of interventions put into place to prevent further skin breakdown as R61 was identified at risk for skin breakdown and now had additional heightened risk for other PU related to identified skin breakdown on left 2nd toe. 2) On 9/27/23, staff noted R61's left 2nd toe appeared as brown, measured 0.2 cm x 0.1 cm x 0.02 cm. Staff noted it was a PU, unstageable, with the wound bed 100% eschar. The surrounding tissue was dry, and had a scant amount of drainage. Wound dressings were to be applied. 3) On 10/3/23, the left 2nd toe had 2 areas. The top portion of 2nd toe measured 0.7 cm x 0.5 cm and the bottom portion of the 2nd toe measured 0.6 cm x 0.9 cm x 0.54 cm. They appeared as intact brown, yellow, unstageable PU, with the wound bed 40% slough and 60% granulated (healthy tissue). The surrounding tissue was noted to be dry, red, was boggy but had no drainage. Wounds were cleansed with betadine and dressing applied and secured with medical tape. There was no documentation R61's physician had been updated with the change in status of the left second toe or interventions were reviewed for appropriateness or additional interventions were identified for the remainder of R61's feet. 4) On 10/10/23, the left 2nd toe had 1 area that measured 0.8 cm x 0.5 cm x 0.40 cm. Staff did not document the appearance or stage of the PU, however, the surrounding tissue was noted to be dry and intact. A wound cleanser was used and the dressing changed to a debriding type dressing (alginate). Details of the left 2nd toe remained the same on the 10/17/23, 10/22/23, and 10/24/23. 5) On 10/21/23, staff identified an additional area of concern as R61 had a rash to their right upper shoulder, starting along the backside of the right side of the neck and down the right upper arm. The rash was not causing R61 discomfort and was to be re-assessed the next day. On 10/22/23, the rash had gotten larger with blisters present. Staff contacted R61's MD and the resident was seen via video with a diagnosis of shingles and medication was ordered. (R61 was placed into isolation in their room). 6) On 10/24/23 at 4:23 p.m., staff identified the left 2nd toe was a dry scab, measuring 0.5 cm x 0.6 cm x 0.30 cm, and the wound bed was 100% eschar. This measurement indicated a decrease in size from the morning measurement. No other interventions were placed at that time to protect R61's feet from new PU. 7) On 10/29/23, new bilateral heel wounds (PU) were identified. A right heel wound was noted that appeared dark reddish purple and measured 2.7 cm length x 2.7 cm width x 7.29 cm area. No drainage was noted. Staff placed an adhesive bandage on the right heel for protection and placed booties on heel and were to float the heels. The left heel was identified to have a wound that measured 2.7 cm x 2.7 cm x 7.29 cm also with a adhesive bandage placed on that heel for protection. Staff contacted R61's MD for a referral to wound care. Staff now began new interventions of booties on heels and were to ensure R61's heels were floated while in bed or a chair. R61 was noted as having displayed discomfort with the dressing change. 8) On 10/30/23, the right heel was identified as healed, however staff noted the area remained fragile and heel protectors were to still be in place. The left heel showed redness with purple area in the middle that measured 2.5 cm x 1.4 cm x 3.50 cm. The left heel was identified as a pressure wound a stage 2, with an Optifoam dressing to be applied and ensure heel protectors were in place. Staff noted redness on R61's left heel and measured the PU at 5 cm x 4 cm with a purple area in center of red area that measured 2.5 cm x 1.4 cm. R61's MD was updated on the new stage 2 pressure ulcer noted to the left heel, with a question if hospice referral would be appropriate. On 10/31/23, the provider responded R61 was not quite at a hospice level yet. 9) On 11/1/23, R61's left heel measurements remained the same. The left 2nd toe was identified as having 2 areas a scab below the right side of the 2nd toenail and a scab on the knuckle of the 2nd toe. The measurement was 0.4 cm x 0.3 cm x 0.12 cm, unstageable, with the wound bed 100% eschar, and a scant amount of drainage. The dressing applied was a Polymem dressing. R61 was noted as having displayed discomfort with the dressing change. A scab below 2nd toenail measured 0.4 cm x 0.5 cm. Another new area on the left side of foot was noted to be pink measuring 1 cm x 0.7 cm x 0.7 cm, classified as a stage 1 PU, and a Polymem dressing was applied. The facility reached out to wound care for assessment and treatment of R61's left 2nd toe, with an appointment made for 11/2/23. Review of wound care progress notes from nurse practitioner (NP)-G identified on: 1) 11/2/23, NP-G assessed R61's left foot wounds and identified a stage IV PU on R61's left 2nd toe and pressure injury of deep tissue to the left heel. NP-G noted R61 had a Polymem dressing to the left 2nd toe wound and an Optifoam dressing to the left heel. R61 was noted to have had a heel protector on. Following debridement NP-G identified the underlying tissue was consistent with a stage IV PU (full thickeness with muscle and bone exposure) noted to the dorsal (top) aspect of the left second toe that measured 0.9 cm x 1.0 cm x 0.1 cm. probing into the bone. The wound bed was 50% slough and 50% necrotic tissue. NP-G noted a deep tissue PU of the left heel. R61's skin was intact with non-blanchable (lack of blood flow) purple discoloration, measuring at 1.0 cm x 1.5 cm. NP-G's plan revealed R61 did have a stage IV pressure injury to left second toe with some bone exposed and surrounding redness. NP-G would need to order an MRI to further assess for potential osteomyelitis (sever bone infection). Treatment for second left toe was to be a debriding dressing of calcium alginate as a primary dressing covered with a Polymem dressing. The left heel was not open. She would continue to cover this area with Optifoam dressing and change the dressing every 2-3 days. R61 was to continue to use heel protectors and staff were to ensure regular pressure offloading practices. 2) On 11/15/23, NP-G re-assessed R61's non-healing foot wounds. Family was present and significantly concerned with the non-healing nature of the wounds. R61 was scheduled to see the infectious disease team later that day. NP-G noted a full thickness ulcer on R61's left second toe that measured 2.3 cm x 1.4 cm x 0.1 cm with deep probing to the bone. The wound bed is 100% necrotic tissue. NP-G also noted a full thickness wound to left heel that measured 2.5 cm x 3.0 cm x 0.1 cm. Necrotic tissue was covering the wound bed. R61 had moderate sanguineous (yellowish)drainage. NP-G had a discussion with the family the possibility of vascular (blood flow) studies however, family was unsure they wanted to move forward with that given her advanced age and demented status. There was concern for underlying osteomyelitis or worsening infection and NP-G noted R61 may be better off treated by the infectious disease team with an antibiotic. R61's family was more willing to accept the potential risks of antibiotic therapy versus any surgical procedure. It was explained to the family by NP-G that without proper treatment, there was a possibility the wounds could become worse, and they could certainly could lead to a life threatening infection (sepsis). R61 was fitted for a heel suspension boot to be used at all times to offload the heel wound and written instructions were provide for the facility. 3) On 11/20/23, NP-G assessed R61's left foot wounds. R61 had been seen last week by podiatry and infectious disease. The family decided to move forward with symptomatic treatment at this time and forgo any aggressive management. R61's left second toe PU measured 2.3 cm x 1.4 cm x 0.1 cm deep and was probing to the bone. The wound bed was 100% necrotic (dead) tissue. R61's left heel full thickness PU wound measured 2.5 cm x 3.0 cm x 0.1 cm deep. Dry necrotic tissue covered the wound bed. There were two new areas of non-blanchable, deep red discoloration areas noted to her outer and inner ankle. NP-G's plan was to continue with betadine to the left second toe and the left heel as well with an Optifoam dressing to the left heel after the betadine wash dried. Staff were to continue with R61's heel suspension boot and offloading practices like floating the heels. Further review of R61's wound assessments identified on: 1) 11/7/23, R61's left side of the foot was noted as healed. The left heel identified the center of wound was purple, and was boggy. The left heel measured 1 cm x 1.5 cm x 1.5, and an Optifoam dressing was applied. The left 2nd toe was identified as moist, measuring 1 cm x 0.7 cm x 0.7 cm, stage 4, with 25% of the wound bed as slough and 75% of wound bed being eschar. The surrounding tissue was macerated (white from moisture) with a small amount of drainage. Calcium alginate was applied followed by a Polymem dressing. R61 was noted to have discomfort with the dressing change. R61 was followed by wound care. 2) On 11/16/23, identified no assessment of left toe or left heel. Staff did note a new potential PU area on right lateral hip and it measured 0.9 cm x 0.3 cm x 0.27 cm. Staff classified the wound as a stage 2 PU. Dressing applied was Optifoam 4 x 4. An air mattress was now to be applied to R61's bed. 3) On 11/22/23, R61's right lateral hip had a scab that measured 0.5 cm x 0.2 cm x 0.10 cm. Staff noted the wound to be a stage 2 PU which they felt was improving. The left heel center of the wound was purple, and its edges were noted to be separating. The appearance was pink, purple, and boggy. The heel measured 3.5 cm x 3 cm x 10.5 cm and was classified as a stage 2 PU with small amount of drainage. An Optifoam dressing was applied. The left 2nd toe appeared moist, and measured 1 cm x 0.7 cm x 0.7 cm. and was noted to be a stage 4 PU. A small amount of drainage was seen. R61 had discomfort with the dressing change and was to be followed by wound care. R61's routine Skin Inspections dated 9/23/23, 10/14/23, 10/21/23, 10/28/23, 11/4/23, 11/11/23 and 11/27/23 had no identification of R61's wounds. R61's progress notes identified on: 1) 9/28/23, R61 was at risk for skin breakdown and had a unstageable pressure ulcer to her left 2nd toe. A barrier was applied as a preventative and now a cushion was to be used in R61's wheelchair. 2) 10/29/23, progress note identified communication to the provider that nursing noted areas on both of R61's heels that resemble deep tissue injury. The areas measured approximately 2.7 cm x 2.7 cm and were dark red/purple in color. Nursing requested a referral to wound care. The noted identified Optifoam had been placed on bilateral heels for protection, and booties were to be placed on heels and feet heels were to be floated on pillows. 3) 11/15/23, progress note identified the director of nursing (DON) spoke with family members who requested therapy to evaluate R61 for a different wheelchair, and they also requested a foot board for the wheelchair to support R61's legs. A fentanyl (narcotic pain patch) was requested to help with foot pain, and an air mattress was now to be placed on R61's bed. There was no indication the DON had identified preventative measures should have been placed to prevent other new or worsening pressure ulcers before they occurred. 4) 11/17/23, progress note identified R61 was on contact precautions related to MRSA culture from wound to the bone and being treated for osteomyelitis. R61's current care plan identified on: 1) 6/30/23, staff were to reposition R61 every 2 hours. The care plan lacked identification of the 8/9/23, of R61's unstageable pressure ulcer identified on R61's left second toe that was documented in the wound assessment section of the medical record, along with interventions to prevent worsening of that wound or prevention of additional PU. 2) 10/30/23, the care plan was updated and identified heel protectors were implemented to both heels while in bed and staff were to offload and float heels when able. There was no indication of interventions to prevent heel PU prior R61 acquiring their heel PU. 3) 11/13/23, the care plan was updated to include staff implemented contact precautions related to methicillin resistant staphylococcus aureus (antibiotic resistant organism) (MRSA) in R61's left 2nd toe. 4) 11/16/23, a care plan updated identified an air mattress was implemented due to R61's high risk for skin breakdown. There was no indication the facility proactively attempted to identify and implement interventions to prevent R61's heel and hip PU, nor how routine repositioning every 2 hrs was adequate to ensure R61 had properly offloaded their weight to ensure pressure reduction. R61's Tissue Tolerance assessments revealed on: 1) 6/30/23, the assessment identified after 2 hours of lying supine redness was noted on the coccyx with the intervention of repositioning put into place. The care plan identified repositioning every 2 hours however, the assessment had no mention how the facility determined a routine 2 hour repositioning was appropriated for a resident already at risk, nor if staff had identified the need for increased monitoring or repositioning. 2) 7/1/23, the assessment identified after 2 hours of lying supine areas of pressure had been observed on the coccyx with the same intervention of repositioning identified. The care plan remained the same with repositioning every 2 hours. There was no indication staff had identified increased repositioning was required as R61's 2 hour repositioning had not been adequate to prevent the area of pressure identified on the coccyx from occurring. 3) On 7/2/23, the assessment identified after 3 hours lying supine an area of pressure had been observed with redness noted on the coccyx with an intervention put in place to elevate with pillow and reposition. There was no mention of what staff were to elevate with a pillow. Interview on 11/27/23 at 4:28 p.m., with family member (FM)-E and FM-F reported R61 was admitted to the facility at end of June 2023, with no skin issues. By the end of August, R61 had developed a PU on her left second toe. FM-F stated they did not understand how R61 could come into the facility with no skin issues then develop a pressure ulcer. FM-E reported the facility did not do or have any treatments in place until November 2023. R61 had not seen podiatry or wound care until the wound turned almost black. At that time, the infectious disease (ID) physician extended R61's current antibiotic order until 12/15/23 and then planned to reassess. The ID physician advised the family the next step was amputation. FM-E and FM-F did not feel it was in R61's best interest to have the amputation. FM-F had met with the director of nursing (DON) at beginning of November 2023 and requested a foot cradle for the bed, a different wheelchair as R61's did not even have foot pedals and an air mattress for the bed. FM-F felt all of those interventions should have been done a couple months ago. FM-F and FM-E were concerned if R61 was actually being repositioned when family was not present. FM-E reported they had asked the facility about R61's left toe PU was getting worse and they were told when R61 had shingles she was not eating and her immune system was compromised, and that was the reason for the decline in her PU status. FM-F added if they had not spoken to the DON and had made suggestions for prevention of PU, R61 would not have the air mattress, foot cradle, or a new wheelchair. Interview on 11/28/23 at 3:38 p.m., with nursing assistant (NA)-D identified R61 came back from the local hospital yesterday with padded boots and white pads on her ankles. R61 was not to have the blankets touch her feet. NA-D was unsure how R61 developed her PU's but reported they had gotten worse. She had heard staff speak about her getting an amputation but was unsure if that was going to happen. NA-D reported if R61 was laying down staff were to only reposition her every 2 hours. She confirmed staff were to reposition R61 even if family was visiting. Observation and interview on 11/29/23 at 11:00 a.m., with registered nurse (RN)-C completing wound care treatments identified R61 was combative with the 2 nursing assistants, yelling and attempting to hit out. RN-C first removed a dressing from R61's buttocks and observed was a PU on R61's left buttocks cheek. RN-C cleaned the PU with normal saline, and measured it as 0.3 centimeters (cm) x 0.4 cm. RN-C then applied a new Optifoam dressing. RN-C reported R61's dressing changes typically occur in the evening, so she was unable to state if she felt the wound had improved or not. The right buttocks cheek was observed to have no reddened areas. The left second toe was cleaned with normal saline, measured as 2.3 cm x 1.3 cm. RN-C then applied betadine to the area and reported that the left second toe was to be left open to air. The right hip was observed to have a small scab that measured 0.3 cm x 0.6 cm. RN-C had cleaned the area and stated it would be left open to air. The left heel dressing was removed with a small amount of yellowish drainage noted on dressing. RN-C cleaned the area and measured the area as a whole measuring 4.3 cm x 3.4 cm. The inner opened area measured 0.6 cm x 2.4 cm. There was also an unstageable part covered in eschar measuring 3.9 cm x 2.9 cm. RN-C applied betadine and let that dry and applied another Optifoam dressing. RN-C identified on the left great toe a small scab that measured 0.3 cm x 0.4 cm. The right back side of R61's ankle had what appeared to be reddened skin resembling a rug burn or shearing that measured 0.2 cm x 0.6 cm. The left top portion of R61's ankle had a dressing RN-C removed. RN-C reported that this must be new. The area appeared to be reddened skin that measured 1.8 cm x 1.4 cm. Interview on 11/29/23 at 1:53 p.m., with director of nursing identified she was unable to find documentation that R61's MD had been update after the left 2nd toe status changed on 10/3/23 or that the care plan had been reviewed for appropriate interventions or needed revisions to prevent worsening of the current pressure ulcer or to prevent additional skin breakdown. She confirmed that the air mattress to R61's bed had not been implemented until 11/16/23 and that she had ordered a support device for R61's wheelchair however, that had not come in yet. She reported that she felt it was important to note that R61 had shingles diagnosed on [DATE], that potentially contributed to her decline. She confirmed that the facility should be communicating with R61's MD when a decline in wound status was identified and the resident's care plan should have been reviewed and revised as necessary. She revealed R61's tissue tolerance assessment identified concerns after 2 hours and that the facility implemented an every 2 hour repositioning when R61 first arrived. She further revealed if the tissue tolerance assessment identified after 1 hour a resident was red then staff should have reposition R61 hourly. She revealed the heel protectors were implemented on 10/30/23, the heel suspension boots on 11/15/23, a foot cradle for the bed was implemented and stated I don't know what else we could do. Interview on 11/30/23 at 8:45 a.m., with trained medication aid (TMA)-E identified R61 had never walked since admission. R61 was unable to move herself in her wheelchair and needed extensive assistance of staff since admission. TMA-E identified preventative measures in place for skin breakdown were reposition and toileting. TMA-E reported they thought R61 developed the heel ulcer after she had shingles in October 2023. Observation on 11/30/23 at 8:45 a.m., R61 was in bed sleeping, foot cradle in place, and was positioned with pillows on her left side facing the doorway. It was unknown if R61's heel boots were on or heels were floated in bed as she was covered up. Interview and observation on 11/30/23 at 8:54 a.m., with licensed practical nurse (LPN)-B in R61's room where R61 was lying in bed on her back slightly leaning more towards her left side. LPN-B identified wound rounds were completed weekly with measurements. R61 was known to be combative with cares. R61 used to use a standing lift but had further declined and now uses a total body lift. R61 then instructed LPN-B to leave her room. R61 was observed moving her feet up and down rubbing them while in her bed. Upon leaving the room, LPN-B reported that was how she believed R61 got her heel wound. Interview on 11/30/23 at 9:11 a.m., with nurse practitioner (NP)-G identified R61 was first seen on 11/2/23 for a stage 4 pressure ulcer on left second toe and a deep tissue injury on her left heel. NP-G reported the development of deep tissue PU's depended on each resident and their co-morbidities. R61 did not have good vascular status (blood flow to her limbs) and that increased her risk of acquiring a PU. NP-G reported R61 had even developed a new wound between weekly visit confirming she was prone to skin breakdown. When residents are at risk for skin breakdown, she typically recommended heel suspension boots. She reported there were concerns for osteomyelitis (bone infection) however, R61's family did not want to pursue aggressive measures related to her not being a good surgical candidate. Family also felt R61 would not tolerate a PICC line (IV line used to get antibiotics directly into the blood stream near the heart). NP-G reported there were definitely things [interventions] that should have been put in place prior to R61 acquiring new PU. The family was made aware that R61 could become septic (life threatening infection if not treated) related to not wanting to do any interventions other than oral antibiotics. NP-G revealed that every 1 to 1.5 hour repositioning would be ideal as every 2 hour repositioning for a resident who was a known PU risk was not appropriate. She agreed the facility should have anticipated R61's needs and identified and implemented interventions to try and lower her risk of new PU development. Observation and interview on 11/30/23 at 10:46 a.m., of R61 who was seated in recliner, reclined with feet elevated and heel boot on. FM-E reported there have been multiple times when FM-E had to request staff to reposition R61. FM-E further reported that R61 did not receive a boot to suspend her heel until she was seen by podiatry and reported R61 did not have any foot pedals for her wheelchair for the first 5 months until occupational therapy finally assessed her for wheelchair positioning. R61's 11/22/23, occupational therapy evaluation identified a referral was made for an evaluation for optimal positioning while in recliner and wheelchair for skin integrity and comfort. The therapy note identified R61 was found to have a ROHO cushion that was flat noted in wheelchair. A replacement cushion, low profile was provided. Therapy also provided a dycem cushion for recliner. There was no indication that therapy had been consulted for positioning upon admission or when PU had been discovered. R61's 11/15/23, Infectious Disease (ID) visit note identified left second toe with osteomyelitis with associated cellulitis (skin infection). Family was present and discussed the chances of a cure might be hampered by multiple variables including poor vascular supply and age. A discussion on side effects of antibiotic and after a full explanation of the clinical scenario a decision was made to proceed with antibiotic therapy. The left foot medial heel ulcer was assessed also. R61's case was extensively discussed with family members. A MRI, vascular study was offered but declined by family and decision to only treat with antibiotic was made given her advanced age and dementia. A follow up appointment on 11/27/23, identified a concern for osteomyelitis with a recommendation for MRI or bone scan to evaluate. It was noted that family declined the desire to have R61 go through a MRI, vascular studies or source control (e.g amputation). the ID planned to treat R61 with Docycycline (antibiotic) 100 mg twice a day until 12/13/23 then follow up in 2 weeks as an outpatient. Review of June 2023, Skin Condition Identification and Prevention Program policy identified residents would be assessed for risk of pressure ulcer development or presence of pressure ulcers upon admission. The facility will implement interventions to prevent pressure ulcer development and/or treat current pressure ulcers. For residents who have been identified as having a pressure ulcer upon admission interventions will be implemented to promote healing. Residents who develop a pressure ulcer after admission, the facility will reevaluate prevention intervention for appropriateness of preventative measures. The facility was to document pressure ulcers weekly by the type of injury, the stage, measurements, describe the wound bed, describe the wound edges, any drainage, any pain and progress towards healing. There was no indication PU should be assessed more frequently as needed to ensure worsening did not occur. If a resident has a pressure ulcer not showing evidence of progress within 2-4 weeks the resident and interventions should be reassessed. The facility was to implement a baseline care plan within 48 hours that included preventative measures based or the residents risks and needs that were identified such as repositioning, pressure relieving devices, moisture barriers, and nutritional needs with measurable goals identified. The policy further provided references for prevention, assessing, staging, and types of interventions the facility could use. The pressure ulcer development reference identified the provider and the wound care team should be notified of a new pressure ulcer development for an assessment. The facility was to notify the MD if no evidence of healing occurred in 2-4 weeks. The policy references included performing a tissue tolerance test and how to conduct the test. For example if a resident that had remained in the same position for 2 hours developed any areas of redness the test should be stopped as the resident would require repositioning at an interval of every hour.