**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to consistently monitor and document the progression of pressure ulcers for one (Resident (R) 25) out of two residents reviewed for the development of pressure ulcers in the total sample of 21 residents. The facility staff failed to monitor a pressure ulcer identified on a care plan on 05/10/22 through 07/12/22 when the pressure ulcers progressed to the depth of exposed tendon and bone resulting in harm to R25. Findings include: Review of a document provided by the facility titled Skin Management Policy, dated 02/03/09, indicated . To identify residents at risk for impaired skin integrity, and to provide direction for proper prevention, treatment, and documentation of skin impairments. Full Body Skin Assessment . Wound/Ulcer Assessment . Documentation should include, but not limited to, the size, location, and characteristics (color, drainage, etc) of the injury in the form of a skin/wound progress note . A pressure ulcer is localized to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear . Under a category titled Measuring the document revealed . Length/Width . Depth . Undermining . Tunneling . Periwound [surrounding condition of the wound margins] . Under a category titled Exudate Types indicated Serous drainage . Sanguineous drainage . Serosanguinous exudate . Seropurulent exudate . Purulent exudate . Review of a document provided by the facility titled Hospital Discharge Note, dated 04/27/22, indicated R25 had a closed nondisplaced bimalleolar (both ankle bones) fracture of the right lower leg with routine healing. The discharge note indicated the resident had a diagnosis of peripheral vascular disease (poor circulation). Review of a document provided by the facility titled admission Record, indicated R25 was admitted to the facility on [DATE] with a nondisplaced ankle fracture, cerebrovascular disease, and peripheral vascular disease. Review of a document provided by the facility titled Order Summary Report, dated 04/27/22, indicated R25 was to have a CAM boot on at all times. In addition, there was an order for R25 to have a full body skin assessment. There was no indication the facility questioned the medical provider to permit the clinical staff to remove the CAM boot as part of the full body skin assessment. Review of a document provided by the facility titled Comprehensive Assessment, dated 04/27/22 (date of admission to facility), indicated R25 had no skin issues. Review of a document provided by the facility titled Braden Scale for Predicting Pressure Sore Risk, dated 04/27/22, indicated R25 was at mild risk for developing a pressure ulcer with a score of 17. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/04/22 indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which revealed R25 was cognitively intact. This MDS assessment indicated R25 required extensive assistance of one staff member for bed mobility and extensive assistance of two staff for transfers. This MDS assessment revealed R25 was at risk for the development of pressure ulcers and had no pressure ulcers upon admission to the facility. Review of a document provided by the facility titled Progress Note, dated 05/06/22, indicated the resident had her toenails debrided and there was no mention of pressure ulcers on her right foot. Review of documents provided by the facility titled Resident Weekly Summary, dated 05/07/22, documented no skin issues for R25. Review of a document provided by the facility titled Care Plan, dated 05/10/22, indicated R25 had a non-surgical right ankle fracture and pressure ulcers under her CAM boot. There were no associated interventions identified in the care plan that addressed the care and treatment of the resident's pressure ulcers or the risk factors of wearing the CAM boot and the development of pressure ulcer injury. There was no description or measurements of the pressure ulcers on the care plan. Review of the EMR Progress Notes, Orders, Medication Administration Record (MARs), and Treatment Administration Records (TARs), dated 05/07/22 through 05/20/22 revealed no documentation of or treatment for pressure ulcers on R25's right foot. Review of documents provided by the facility titled Resident Weekly Summary, dated 05/14/22, documented no skin issues for R25 despite the care plan, dated 05/10/22, stating there was a pressure ulcer under the CAM boot. Review of a document titled Message, which was written by Podiatrist F and dated 05/20/22, which revealed he saw R25 on this same date, indicated the resident was safe wearing the CAM boot while transferring and wanted to see R25 in one week to check on the status of a new . pressure injury . Podiatrist F ordered R25 to put some pressure to her right foot if this added her in safe transfers. Podiatrist F directed staff to keep the boot on at all times Further review of this document and the EMR Orders tab revealed no description of the pressure injury and no orders for treatment. Review of a document provided by the facility titled Podiatry Note Clinic, dated 05/27/22, written by Podiatrist F, indicated R25 was seen as a follow-up for her ankle fracture. Podiatrist F indicated in the report, in addition to being seen for the ankle fracture, the resident's skin was intact and had small superficial abrasions, pressure ulcers at the lateral foot. The report indicated the resident had well managed edema in this region. Further review of this note and the EMR Orders tab revealed no description of the pressure ulcer at the lateral foot and no orders for treatment. Review of a document provided by the facility titled ER (emergency room) Urgent Care-Provider, dated 05/28/22, indicated R25 was transferred to the ER for evaluation of neuropathic pain. Further review of this document revealed R25 had a pressure ulcer of the dorsum (top) of right foot. This document included no description of the pressure ulcer. Review of a document provided by the facility titled Admission/Discharge/Transfer . Physician Plan of Care . , dated 05/28/22, indicated R25 had pressure ulcers on her foot and to change padding in boot every three days. The orders for care indicated to remove the CAM boot to right foot as needed based on resident's symptoms and to change padded foam every three days. Review of this document revealed no description of the pressure ulcer. Review of documents provided by the facility titled Resident Weekly Summary, dated 05/30/22, documented no skin issues for R25. Review of a document provided by the facility titled Treatment Administration Record (TAR), dated 05/31/22, R25 had an order to remove the CAM boot to the right foot and to change padded foam every three days. Review of the TARs revealed this order was carried out as ordered and continued until 06/15/22. Review of EMR Progress Notes and TARs revealed no description of the pressure ulcer even though the nursing staff was removing the CAM boot and changing the padded foam every three days. Review of a document provided by the facility titled Wound/Ulcer Assessment, dated 06/01/22, indicated the top right foot had a 1 x (by) 2 centimeters (cm) pressure ulcer. On the right outside of the foot on the pinky toe was a 0.5 x 0.5 cm pressure ulcer. The assessment indicated four scabbed areas on front of the right shin. The assessment reiterated the physician order, dated 05/28/22, to replace foam padding in boot and rewrap with gauze and replace boot every three days. This is the first description of the pressure ulcers since first mentioned in the Care Plan, dated 05/10/22, that indicated R25 had pressure ulcers under her CAM boot. This nursing Wound/Ulcer Assessment did not describe the characteristics (color, drainage, peri wound, odor, tissue of wound base) of the injury. Review of a document provided by the facility titled Nursing Home Comprehensive Note, dated 06/01/22, indicated R25 had multiple pressure sores on her foot of which the Medical Director was aware. The progress note revealed the clinical staff applied cast padding to her foot and it was to be changed every three days. There were no measurements or description of the pressure sores included in the progress note. Review of a document provided by the facility titled Nursing Home Notes, dated 06/01/22 and written by the Nurse Practitioner revealed the NP did not remove R25's CAM boot to look at her pressure ulcers. Review of a document provided by the facility titled Resident Weekly Summary, dated 06/06/22, indicated R25 had right foot sores which revealed a wound on the top of her foot which measured 1 cm x .75 cm, 1 cm x .5 cm, sore back of heel is .1 cm x .1 cm. Medial ankle sore 2 cm x 1 cm. Further review of this document revealed no description of the pressure ulcers other than measurements. The measurement of the pressure ulcer on the top of the foot now included a depth of 0.5cm which indicated a worsening of the area and a new pressure ulcer on the back of the right heel. Review of a document titled Laboratory Results, dated 06/11/22 indicated a culture was obtained from R25's right foot pressure ulcer and results revealed the resident had microbes found and there was a potential for infection. The results stated the bacterial organisms may not require therapy. The provider must use clinical assessment of the resident's symptoms to make a final judgement on antibiotic use or not. Review of a document provided by the facility titled RN note, Progress Note, dated 06/13/22, revealed a culture taken of R25's wound did not indicate the initiation of antibiotics. Review of a document provided by the facility titled Wound Care, dated 06/13/22, revealed R25 was seen by a wound Registered Nurse (RN). The wound RN identified the wound on R25's right foot as mixed arteriovenous ulceration and described the wound on the top of the foot of an UTD (unable to determine) depth and required debridement (the removal of nonviable, dead tissue). The wound on the right ankle posterior area was measured at 2cm x 1cm x .2 cm and required debridement. Both areas were assessed as full thickness (damage extends below all layers of skin into the subcutaneous tissue or beyond to muscle, bone, tendons). The RN wrote to apply Santyl for debridement and place an oil emulsion to provide a non-stick covering. The orders continued by placing a super absorbent dressing to wick away excess exudate away from the wound and peri-wound. This order was to be done daily and directed the clinical staff to monitor for decline in wound healing or the development of necrotic tissue. Further review of the note written by the wound nurse revealed it was written the same day as the following facility nursing note titled Resident Weekly Summary, dated 06/13/22: R25's top right foot pressure ulcer measured 1.0 cm x 1.0 cm x 0.5. The resident's medial ankle pressure ulcer measured 0.1 cm x 0.1 cm. The back of the resident's heel measured 2.0 cm x 1.0 cm. There was no description of the wounds other than the measurements. Review of a document provided by the facility titled provider's order note Progress Note, dated 06/15/22, indicated for wounds to the right fifth toe lateral, right dorsal mid-foot, right proximal foot, and right posterior ankle to cleanse area, pat dry, and to apply Santyl about nickel thick. To cover with oil emulsion, secure with roll gauze and tape, to apply low stretch (setopress) wraps as ordered and to change daily. Review of a document provided by the facility titled medication administration Progress Note, dated 06/18/22 indicated R25's treatment to her wounds was to cleanse, pat dry and to apply nickel thick Santyl. Then to cover the area with oil emulsion and secure with rolled gauze and tape. To apply low stretch (setopress) wraps as ordered and to change daily. Review of a document provided by the facility titled TAR, for the month of June 2022, indicated the treatments were administered as ordered and continued until 07/11/22. Review of a document provided by the facility titled Provider's Order, dated 06/20/22 ordered clinical staff to change the bandages of R25 to foot wounds every other day and to monitor for signs of infection. Review of a document provided by the facility titled Resident Weekly Summary, dated 06/27/22 stated details of R25's wounds were on the Medication Administration Record (MAR). Review of the June 2022 and July 2022, MARs revealed no descriptions of the wounds. Review of a document provided by the facility titled skin note Progress Note, dated 06/30/22, indicated there were wounds to the right lower extremity (no measurements). The progress note revealed the resident had slough covering the wound beds and wound was not showing any improvement. The progress note indicated the nurse attempted to use calcium alginate and covered with bordered foam and wrap to help remove slough from wound bed. There was no indication the facility notified the physician of the lack of improvement for the resident's right ankle. Review of a document provided by the facility titled skin note Progress Note, dated 07/01/22 indicated R25 had a pressure ulcer on the top of her right foot which measured 1.5 cm and was 3 cm redness around. The wound bed was noted to have slough, had bloody drainage, redness around the area. There was no documentation that the physician was notified of these findings. Review of a document provided by the facility titled Order Summary Report, dated 07/04/22, indicated the physician ordered R25 to have an ulcer/wound assessment completed for each ulcer on her right foot. Review of a document provided by the facility titled skin note Progress Note, dated 07/11/22, indicated R25 had a posterior wound caused by an ankle fracture and use of a CAM boot. The measurements were 1.0 cm x 1.0 cm and scabbed over the healing wound. The wound bed and peri-wound were intact. Another wound located on the top of the right foot measured 1.5 cm by 1.0 with unstageable slough present. The wound bed and peri-wound had some drainage. Review of a document provided by the facility titled Order Summary Report, dated 07/11/22 indicated the medical provider ordered treatment to R25's right foot/ankle on 07/11/22. The treatment was to cleanse the area, pat dry and apply nickel thick Santyl on the right proximal foot and right posterior ankle. To apply low stretch (setopress) wraps and change daily. Review of a document provided by the facility titled Wound Care Skin Integrity Evaluation, dated 07/12/22, indicated R25 was seen by a wound RN. The evaluation revealed the resident had a right dorsal mid-foot mixed arteriovenous ulceration, non-pressure, which measured 0.90 cm x 1.00 cm x 0.3 cm. The evaluation noted the wound bed was yellow 20 percent and had soft and slimy slough. The resident had exposed tendon/muscle/bone at 80 percent. The treatment for the first wound was to cleanse, pat dry, and apply Santyl to wound bed and to cover with hydrogel gauze, cover with super absorbent dressing and secure with roll gauze and tape. Change daily. A second wound was on the resident's right posterior ankle and measured 1.50 cm x 0.80 cm x 0.3 and was full thickness and was a mixed arteriovenous ulceration non-pressure. The treatment for the second wound was to cleanse area, pat dry and apply hydrogel gauze to wound bed. Then cover with super absorbent dressing. Secure with roll gauze and tape then apply setopress wraps and to change daily. Review of a document provided by the facility titled RN note Progress Note, dated 07/12/22, indicated R25 was seen by the wound RN on this date and new recommendations were made from the visit. The progress note revealed the resident had an exposed tendon on the anterior surface of her right foot with increased drainage today. There is no indication that the physician was notified of the exposed tendon since last week after the slough came loose from the wound bed. Review of a document provided by the facility titled ED/Urgent Care Note, dated 07/14/22, indicated R25 was seen in the ER for neuropathy pain and had skin ulcerations. The note revealed the resident had skin ulcerations on the dorsum of her right foot and over the Achilles tendon. During this visit the physician stated the wounds did not appear infected. There was no treatment ordered. Review of a document written by the hospital staff and provided by the titled Urgent Care Note, dated 07/14/22, indicated R25 had two open ulcerations on her right lower extremity. Specifically, .One is on her lower leg posteriorly proximal to the ankle that is about 1.5 cm in diameter is moist. There is a smaller ulceration on the dorsum of her right foot that is also about 1.5 cm in diameter and is quite moist. The note continued by stating there was a pulse to the foot and there was no evidence of infection or edema. Review of a document provided by the facility titled Progress Notes, dated 07/18/22, written by Podiatrist F, indicated the dorsal foot wound was deep and frankly exposed tendon and positive probe to the bone. The note indicated some redness and drainage and indicated the need for antibiotic use. The progress notes specifically revealed . Dressings to right foot are to be left in place. They will be changed at next office visit as scheduled . Review of a document provided by the facility titled infection control note Progress Note, dated 07/18/22 revealed R25 was to begin the antibiotic doxycycline 100 mg po BID times 10 days. A RN Progress Note, indicated the resident went to the ER on [DATE] and revealed the resident had skin ulcerations on the dorsum right foot and over the Achilles tendon. The wounds did not appear to be infected. Review of a document provided by the facility titled Provider's Order, dated 07/21/22 and written by Podiatrist F, revealed to remove the CAM boot from R25's right foot for comfort. To continue with antibiotics and to leave dressings clean, dry, and intact. Review of a document provided by the facility titled Progress Notes, dated 07/25/22, indicated R25 had a pressure wound which measured 0.5 cm by 0.3 cm and was partial thickness destruction through the epidermis extending into but not through the dermis. There was no exudate or odor present. The wound edges were defined, and the peri-wound was pink with no tunneling. The progress notes indicated a wound culture was taken of the resident's pressure ulcers while at the Podiatrist's office. Review of a document provided by the facility titled Provider's Order dated 07/25/22, written by Podiatrist F, revealed R25 was placed in a CAM boot based on resident symptoms. During this visit, Podiatrist F wrote to change dressings to foot wounds daily both the anterior and posterior ankle wounds covered with allyven dressings. The dorsal foot wound was dressed with Promogran and a small piece of gauze. The orders continued by indicating a small piece of foam was around a wound for off-loading pressure and could be left there unless it was significantly soiled. The foot was then to be lightly wrapped with Kling (rolled gauze) and a light layer of compression. Review of the MAR, dated July 2022, revealed the treatments were administered as ordered by the physician. Review of a document provided by the facility titled Provider's Order dated 07/27/22 indicated R25 was to receive Rocephin 2 grams intravenously every 24 hours for suspected osteomyelitis times 28 days. Review of a document provided by the facility titled Progress Notes, dated 07/28/22, written by Podiatrist F, revealed R25 had surgery on her right foot. Review of a document provided by the facility titled RN Progress Note, dated 08/10/22 indicated R25 had an above the knee amputation of her right leg. During an interview on 09/28/22 at 12:42 PM, Staff L, Licensed Practical Nurse (LPN), stated if a resident was at risk for the development of pressure ulcers, skin should be checked daily by the Certified Nursing Assistants (CNA). Staff L stated as a nurse we need to look at the resident physically to see if there are any pink area and the nurse would then complete a tissue tolerance test. CNAs would reposition a resident. Staff L stated the skin assessment was to be completed on a weekly basis and stated there was no wound nurse since all the facility nurses complete wound care. Staff L stated as part of wound care, measurements would be taken. Staff L stated R25 would not allow the staff to remove her CAM boot. Staff L was asked to show any information on R25's refusals and Staff L stated she could not locate this information. During an interview on 09/28/22 at 2:13 PM, with Staff C, MDS Coordinator, and she stated she would have expected the staff to remove R25's CAM boot for a full skin assessment which would be head to toe. Staff C confirmed the only interventions for the CAM boot were done after 06/01/22 when the facility received orders to loosen the straps on the resident's boot and this was done after the development of the pressure ulcers. Staff C stated the resident had no pressure ulcers when she was first admitted and the pressure ulcers on her foot developed while at the facility. Staff C stated part of the nursing assessment when looking at a wound was to gather the measurements, appearance, the edges, wound bed, signs and symptoms pf infection, and drainage. During an interview on 09/28/22 at 2:51 PM, Staff M, LPN stated R25 would refuse to have her CAM boot removed. Staff M stated the only thing the resident would permit them to do was to loosen her bootstraps. Staff M was asked to locate information in the clinical record which would indicate the resident's refusal to have the boot removed. Staff M was unable to identify this in the clinical record during this interview. During an interview on 09/28/22 at 2:58 PM, R25 denied that she refused to have her CAM boot removed. During an interview on 09/28/22 at 3:28 PM, Staff F confirmed he saw R25 on 05/20/22 for a follow-up to her right ankle fracture. Staff F stated the next time he saw the resident was on 05/27/22 and there were superficial abrasions to her right lateral foot. Staff F stated he saw the resident on 06/20/22 and there were wounds that had healed and some wounds on the dorsal foot in varying stages of healing. Staff F stated wound care treatment was changed and was aware the resident had extremely poor circulation and was not a good candidate for surgery. Staff F stated he did classify her wounds as pressure ulcers on 07/18/22. Staff F stated he wanted the boot to remain on since the CAM boot was like a cast and not to be removed. Staff F stated it was a balancing act to keep the boot on to heal the fracture or to take it off with the resident to be at risk for the development of pressure ulcers. During an interview on 09/28/22 at 3:59 PM, the Staff H, Infection Control Preventionist (ICP), confirmed there were no other skin descriptions other than the measurements of R25's wound on 06/06/22 and on 06/13/22. Staff H stated there were no stages identified. During an interview on 09/28/22 at 4:23 PM, the Staff E, Medical Director stated the staff were very concerned about R25's skin. The Staff E stated the resident initially had superficial areas on her foot. Staff E stated the resident was initially non-weight bearing and could not comply and so the Podiatrist then made her partial weight bearing. Staff E stated R25 had very poor circulation and had a great deal of edema which contributed to her vascular issues. Staff E stated she had placed R25 on diuretics and encouraged the resident to elevate her legs, but the foot was enormously swollen. Staff E stated it was the swelling that caused the pressure ulcers to the right foot. During an interview on 09/29/22 at 9:23 AM, the Staff H had the electronic medical records accessible. Staff H was asked about the nursing note dated 06/30/22 and indicated the wounds on R25 had not improved and if the physician was notified. Staff H stated the resident was seen the prior day by a physician and the issue of a possible urinary tract infection for R25. During an interview on 09/29/22 at 10:20 AM, Staff I, Registered Nurse (RN)confirmed she worked with R25 frequently. Staff I stated the resident was seen by the Podiatrist on 05/20/22 and the skin was grossly intact. Staff I said padding was changed every three days and there was no other wound care ordered at this time. Staff I stated the resident complained of pain on 05/31/22 and this was when the Podiatrist was reached out to, and he gave permission to open the CAM boot. Staff I stated the facility was watching the resident during this time. Staff I stated cultures were gathered, an x-ray was performed and again no concerns. Staff I stated the resident was even seen by a wound clinic. Staff I stated nutritional needs were evaluated during this time as well. A subsequent interview was conducted on 09/29/22 at 1:12 PM, Staff I stated there were no skin checks done from 06/14/22 through 06/27/22. Staff I stated Podiatrist F saw R25 on 06/20/22. Staff I confirmed there were no notes to reflect the physician was notified of worsening pressure ulcers from a note written on 06/30/22 or from a progress note entry dated 07/01/22.