**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to comprehensively assess pressure ulcers and monitor for skin breakdown to prevent and/or mitigate the risk of deterioration resulting in actual harm for 2 of 3 residents when (R1) admitted with a stage 1 pressure ulcer that developed into an unstageable pressure ulcer and R2 admitted with a stage 2 pressure ulcer that developed into an unstageable pressure ulcer resulting in ongoing pain. Findings include: Definitions of pressure ulcers: Pressure Ulcer/Injury (PU/PI) is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. The appearance will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin. Intact skin with a localized area of non-blanchable erythema (redness). In darker skin tones, the PI may appear with persistent red, blue, or purple hues. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Stage 2 Pressure Ulcer: partial thickness skin loss with exposed dermis. Partial thickness skin loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: 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. Unstageable pressure ulcer: 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. If the slough or eschar is removed, a stage 3 or 4 pressure ulcer will be revealed. Eschar: dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. Slough: non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy, and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. Serosanguinous drainage: a thin, watery fluid that's often slightly yellow and has a light pink tinge that can ooze from a wound as a part of the wound healing process. R1's admission assessment dated [DATE] identified R1 had non-blanchable redness at mid-spine and buttock with blanchable redness. The assessment did not include measurements and did not identify the staging of the pressure injury identified. R1's admission Minimum Data Set (MDS) dated [DATE], identified R1 had moderate cognitive impairment, had diagnoses of diabetes, fracture of sternum, left humerus (upper arm bone) and left patella (knee), required two person assist with toileting, transfers, and bed mobility. Further identified R1 was at risk for pressure ulcers and had one stage 1 pressure ulcer and one surgical wound. Skin ulcer/injury treatments did not identify pressure reducing devices, turning/repositioning, pressure ulcer/injury or surgical wound care. R1's pressure ulcer Care Area Assessment (CAA) dated 8/22/24, identified R1 needed assist with bed mobility, had a pressure ulcer, and was at high risk for pressure ulcers. R1 to see therapy for strengthening to increase independence with activities of daily living (ADL)'s. Will continue to update the physician and care plan as needed. R1's care plan revised 8/22/24 identified a focus that R1 was at risk for impaired skin integrity related to a surgical wound; no related interventions were included. An additional focus dated 8/22/24, included R1 had an ADL deficit related to subdural hematoma and multiple fractures with intervention of requiring 2 staff assist with bed mobility. R1's care plan did not identify any pressure ulcer prevention interventions. R1's physician orders included the following: -R1 to lie down on side while in bed due to pressure ulcer on upper back (dated 8/20/24). -Back wound-cleanse and apply Mepilex (absorbant dressing) every 3 days and as needed (dated 8/21/24). -Reposition every two hours and encourage to sit in chair during the day and apply Mepilex to sacrum every 72 hours for sacral wound (dated 8/22/24). -Apply non-adherent dressing mid-spine on pressure ulcer one time per day (dated 8/23/24). R1's Treatment Administration Record (TAR) dated August 2024 identified the aforemented physician orders and were marked as completed: -8/20/24 to 8/28/24 R1 to lie down on side while in bed due to pressure ulcer on upper back. -8/21/24 to 8/27/24 back wound cleanse and apply Mepilex every 3 days and as needed. -8/22/24 to 8/28/24 reposition every two hours and encourage to sit in chair during the day and apply Mepilex to sacrum every 72 hours for sacral wound. -8/23/24 to 8/28/24 identified to apply nonadherent dressing mid-spine on pressure ulcer one time per day. R1's Medicare Skilled Documentation note dated 8/26/24 identified R1 had a stage 2 pressure ulcer to midback. The documentation did not include pressure ulcer characteristics to include, measurements, wound bed, drainage, peri wound, signs and symptoms of infection, pain, or a description of the treatment. R1's certified nurse practioner (CNP) visit dated 8/27/24 identified R1 had a stage 2 pressure sore to back .unable to turn to see it due to R1's pain, will attempt to view this in the facility electronic medical record (EMR) which should have documentation. No new treatment ordered. R1's Medicare Skilled Documentation note dated 8/28/24 identified R1 was sent to the hospital from dialysis due to low blood pressure .dressing on spine changed before leaving for dialysis. Review of R1's medical record did not identify a comprehensive pressure ulcer assessment to include staging, wound bed description, peri-wound, amount and type of drainage, signs and symptoms of infection or if pain was noted. R1's hospital notes dated 8/29/24 identified R1 had an unstageable pressure injury to spine was present on admit that measured 11.0 centimeters (cm) x 3.0 cm. Wound bed had 50% eschar and 50% slough with a scant amount of serosanguinous drainage and liquifying slough. Bedside nurse reported R1 stated he was not turned all night at the nursing home. Treatment goal infection control/prevention, protection, and to remove and soften necrotic tissue. R1's coccyx had a stage 3 pressure ulcer measured 4.5 cm x 1.2 cm x 0.3 cm. Wound bed had 50% slough and 50% epidermis with a scant amount of serosanguinous drainage. During an interview on 9/16/24 at 8:16 a.m., nursing assistant (NA)-B stated she was there the day that R1 was sent to the hospital from dialysis, stated she got him up in his chair that morning. NA-B stated R1 had a pressure ulcer on his spine with dark spots half way up his spine. During an interview on 9/17/24 at 8:25 a.m., NA-A stated she was taking care of R1 the day they found the pressure ulcer on his coccyx and mid-spine area however, never saw what they looked like. During an interview on 9/16/24 at 3:34 p.m., registered nurse (RN)-E stated a comprehensive skin assessment should be completed on admission; any pressure area or wounds should be measured, wound bed described, and peri wound, along with the amount and type of drainage. RN-E stated our policy was to do a comprehensive skin assessments for the first three days of admission and then weekly. If a new wound was found or had a change the family and physician should be notified. RN-E verified R1 had admitted with a stage 1 pressure injury to his back and had redness on his buttocks. RN-E stated the stage 1 pressure injury should have been measured and the care plan should have had interventions in place for prevention of worsening and to promote healing. RN-E verified he did see the unstageable pressure ulcer to R1's back on 8/28/24 and stated it should have been measured and the provider should have been notified. During an interview on 9/16/24 at 4:12 p.m., director of nursing (DON) indicated R1's skin was not comprehensively assessed or monitored to mitigate the risks of pressure ulcer development or deterioration. DON stated all residents admitted should have comprehensive skin assessments performed, and weekly thereafter. Further stated when a wound/pressure ulcer is found, the family and physician should be notified and a comprehensive pressure ulcer assessment should include documentation of stage of pressure ulcer, wound bed characteristics, measurements, peri-wound, amount and type of drainage, signs, and symptoms of infection and if there is pain. R2 R2's hospital After Visit Summary (AVS) dated 8/30/24, indicated R2 had a pressure ulcer to left heel with care instructions that included paint with betadine daily, leave open to air if no drainage, if drainage was noted cover with dry gauze, float heels at all times while in bed or recliner. Return to wound provider on 9/4/24. R2's admission Assessment note, dated 8/30/24, identified R2 had a wound next to heel on left foot, looked greenish purple, open to air. R2's care plan dated 9/3/24, identified a focus that R2 was at risk for impaired skin integrity related to venous stasis ulcer, wound left heel and right foot with interventions to do wound cares as ordered, and ensure that a pressure reducing/relieving mattress is in place on the bed, observe for wound complications and call medical doctor (MD) with any changes. R2's wound care provider visit dated 9/4/24 identified a stage 2 pressure ulcer to left heel, treatment to apply iodine daily. Return to wound provider on 9/18/24. R2's order summary dated 9/4/24 identified dressing change instructions to left heel, apply iodine daily. R2's pressure ulcer Care Area Assessment (CAA) dated 9/5/24, identified R2 needed assist with bed mobility, frequently incontinent of bowel and bladder, making R2 at higher risk for development of pressure ulcers. R2 will see therapy for strengthening to increase independence with ADL's. Staff will continue to update the physician and care plan as needed. R2's admission MDS dated [DATE], identified R2 was cognitively intact, had a diagnosis of osteomyelitis and sepsis, required substantial to maximal assist with toileting and required intravenous (IV) medications. Further identified R2 was at risk for pressure ulcers and had no existing pressure ulcers. R2's Skin assessment dated [DATE], did not identify a pressure ulcer on left heel. R2's Skin assessment dated [DATE], identified a wound next to heel on left foot, looked greenish purple and left open to air. Review of R2's medical record did not include comprehensive wound assessments and evidence of monitoring were performed to ensure ordered treatments were effective to promote healing and prevent deterioration of pressure ulcer to left heel. During an interview on 9/16/24 at 4:05 p.m., R2 was seated in his wheelchair and was noted to have Pressure Relief Ankle Foot Orthosis (PRAFO) boots on both lower extremities. R2 stated he had a pressure sore on his left heel, and no one has looked at that pressure sore for 8 days. R2 stated the pressure sore on his left heel was the size of a prune, it was yellowish and then it broke open. R2 further stated the staff here put iodine on it once in a while and that he will see the wound provider the day after tomorrow. R2 stated he had ongoing pain in the left heel. During an observation and interview on 9/17/24 at 10:34 a.m., RN-A, RN-B and RN-E assisted with a dressing change to R2's left heel. R2's left leg had tubigrip on it, the tubigrip had a small amount of dried brownish drainage in the heel area. Tubigrip was removed and R2's left heel had a hard blackened area. RN-E stated the left heel was an unstageable pressure ulcer that had 90% eschar and 10% slough. Further stated there was a small amount of serosanguinous drainage noted on tubigrip and inside of PRAFO boot. RN-A stated the measurements were 5.3 cm x 4.3 cm. and the peri-wound was slightly macerated on one side. R2 stated he had level 2 to 3 pain in the left heel most of the time. R2 stated staff here looked at his left heel maybe once a week and that he has had the iodine put on his heel maybe two or three times in the last two weeks. R2 stated a girl came in his room yesterday and saw that there was drainage all over his sheets from the left heel draining and she changed his bedding for him. RN-A stated she would call the doctor to update the change in the status of the pressure ulcer. During an interview on 9/17/24 at 11:24 a.m., DON indicated R2's left heel pressure ulcer was not comprehensively assessed or monitored to mitigate the risks of pressure ulcer development or deterioration and should have been. Facility policy, Wound Treatment Management, dated January 2023, identified a Policy to promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise or is wet. 4. Dressings will be applied in accordance with manufacturer recommendations. 5.Treatment decisions will be based on a. Etiology of the wound: i. Pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical. iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma, calciphylaxis). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth, and presence of tunneling and/or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of the resident/representative. 6. Guidelines for dressing selection may be utilized in obtaining physician orders (See Wound Treatment Guidelines). a. The guidelines are to be used to assist in treatment decision making. b. Due to unique needs and situations of individuals, the guidelines may not be appropriate for use in all circumstances. c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record or in the electronic health record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above). c. Changes in the resident's goals and preferences, such as at end-of-life or in accordance with his/her rights. Facility policy, Skin Assessment, dated January 2023, identified it is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, daily for three days, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury. 2. Procedure: a. Wash hands. b. Explain the procedure to the resident. c. Provide privacy and adequate lighting. d. Put on gloves. e. Begin head to toe, thoroughly examining the resident's skin for conditions. Pay close attention to pressure points, bony prominences, and underneath medical devices. f. Remove any special garments or devices, if not contraindicated or ordered to remain in place. g. Remove any dressings, using clean technique, unless contraindicated or ordered to remain in place, and note findings. h. Note any skin conditions such as redness, bruising, rashes, blisters, skin tears, open areas, ulcers, and lesions. i. Dispose of contaminated items safely. j. Remove gloves and perform hand hygiene prior to leaving room. 3. Consider the general status of the resident's skin. a. Color. b. Temperature. c. Moisture status. d. Sensory perception. e. Skin texture/turgor. f. Perfusion. 4. Considerations for a resident with darkly pigmented skin: a. It is not always possible to identify redness on darkly pigmented skin. b. Indicators of early pressure damage: i. Localized heat ii. Edema iii. Bogginess iv. Induration v. Temperature differences of surrounding skin vi. Skin discoloration 5. Considerations for a bariatric resident: a. Perform assessment with at least one other staff member to assist with mobility and positioning of body parts. b. Approach resident in a manner that promotes dignity and respect. c. Thoroughly inspect each surface of a skin fold. d. Consider moisture and weight exerted by opposing skin and/or body parts (i.e. abdominal pannus) when determining pressure versus moisture related etiology. Pressure injuries may result from tissue pressure of high concentration of adipose tissue and may be in areas other than bony prominences. 6. Differentiating the extent of redness a. Blanchable erythema (redness) loses its redness when a finger is pressed on the erythema for 3 seconds and released. Blanching is assessed following the removal of the finger. b. Non-blanchable erythema (redness) persists when touched. 7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. f. Document other information as indicated or appropriate.