Based on observation, interview, and record review, the facility failed to follow physician's orders for three residents (Residents #5, #34, and #40) out of 12 sampled residents. The facility census was 40. Review of the facility's policy titled, Physician's Orders, undated, showed: - Current lists of orders must be maintained in the clinical record of each resident to avoid conflict and errors; - Orders must be written and maintained in chronological order; - Physician orders must be reviewed and renewed. Review of the facility's policy titled, Skin Assessments, undated, showed residents at risk will have preventative measures implemented to include: weekly documented skin audits by a licensed nurse and treatments as ordered by the physician if skin breakdown occurs. 1. Review of Resident #5's medical record showed: - Diagnoses of schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), cellulitis (a bacterial infection of the skin), high blood pressure, hypokalemia (decreased blood level of potassium), venous insufficiency (a condition in which veins have problems moving blood back to the heart), atrial fibrillation (irregular heart beat), and bipolar disorder (a mental disorder that causes unusual shifts in mood); - An order for consulting wound care clinic to evaluate and treat for cellulitis, dated 11/07/23; - An order for weekly skin assessments completed and documented once a day on Thursdays, dated 12/28/23; - An order to monitor resident's shower/bath, chart, and fill out shower sheet if with any new skin issues once a day on Mondays, Thursdays, Saturdays, dated 02/22/24; - From 04/01/24 - 07/10/24, no documentation of weekly skin assessments completed for 04/04/24, 04/11/24, 04/18/24, 05/02/24, 05/09/24, 05/16/24, 06/06/24, 06/13/24, and 07/04/24, with nine out of 14 opportunities missed. Review of the resident's Treatment Administration Record (TAR), dated April 2024, showed: - An order to cleanse/lightly scrub bilateral (right and left) lower extremities (BLE) with warm water and ketoconazole (an antifungal) 2 percent (% ) shampoo, rinse, pat dry, apply generous amount of triamcinolone (a topical steroid) cream to the BLE twice daily for venous insufficiency, dated 11/14/23, and discontinued on 04/23/24, with 20 out of 60 opportunities missed; - An order to cleanse the BLE with Dakin's wound cleanser (DWC), measure, cut and apply tubigrips (tubular bandages for tissue support) daily for cellulitis, dated 01/30/24, and discontinued on 04/23/24, with 14 out of 22 opportunities missed. Review of the resident's Medication Administration Record (MAR), dated July 2024, showed: - An order for ammonium lactate (used to hydrate the skin) lotion 12%, administer topically at bedtime for cellulitis, dated 07/12/24, with three out of three opportunities missed; - An order to cleanse BLE with soap and water, pat dry, apply ammonium lactate lotion, wrap with an ace wrap daily, undated, with two out of three opportunities missed. Review of the resident's care plan, last reviewed on 06/24/24, showed: - Cellulitis with interventions not addressed; - Venous insufficiency with interventions not addressed. Observations of the resident showed: - On 07/09/24 at 10:07 A.M., 07/10/24 at 8:51 A.M., the resident sat in a recliner in the room with a tan compression sock on halfway up the left lower leg. At the top of the compression sock, the visible skin was red, dry, and swollen with scattered scabs. The right lower extremity (RLE) had a tan compression sock on up to the ankle area, the visible skin at top of the sock was red, dry and swollen with scattered scabs and open areas; - On 07/10/24 at 4:23 P.M., the resident sat in a recliner in the room with a tan compression sock on halfway up the left lower leg. At the top of the compression sock, the visible skin was red, dry, and swollen with scattered scabs. The right lower extremity (RLE) with a tan compression sock on up to the ankle area with the visible skin at top of the sock to the was red, dry and swollen with scattered scabs, open areas, and blisters; - On 07/10/24 at 4:45 P.M. Licensed Practical Nurse (LPN) P entered the resident's room and removed the resident's compression socks. The inside of the resident's RLE had blisters with drainage and multiple open areas noted. LPN P asked the resident where the compression socks came from because they were too small. The resident said he/she didn't know where they came from. LPN P informed the resident he/she would call the physician to see what to do and they should have been assessed by staff before now. The resident agreed with LPN P. LPN P notified the physician and received new orders to send the resident to the hospital; - On 07/15/24 at 8:35 A.M., the resident sat in a recliner in the room with no ace wraps on his/her lower extremities as ordered and yellow non-slip socks on his/her bilateral feet. BLE were red, dry, and swollen with dried skin flakes; - On 07/15/24 at 4:05 P.M., the resident sat in a chair in the common area near the entrance with no ace wraps to his/her BLE as ordered. During an interview on 07/09/24 at 10:07 A.M., Resident #5 said he/she had an infection to his/her right leg that was slow to heal and had been on antibiotics, but not any longer. He/She said the staff used to come in and treat his/her legs but not in a while. During an interview on 07/11/24 at 11:35 A.M., the Assistant Director of Nursing (ADON) said if a resident refused skin assessments and care the staff should give the resident a little bit of time, go back in and try again. She expected nursing staff to document on the resident's skin assessment sheets/shower sheet and in the nurse's notes, what was done, what was tried, what another person tried. If there was a skin concern, the resident should get a shower sheet completed too. If a resident refused a shower or skin assessment, the staff should sign it, a witness should sign it, and the resident should sign it if able, and then it should be turned into her. She was not aware the last skin assessment for Resident #5 was completed in May 2024, and she was not aware it was not getting done. Registered Nurse (RN) E moved to the day shift in June 2024, to make sure the skin assessments were getting done. The charge nurse was responsible for doing the skin assessments, and RN E audited them and made sure they were done. Resident #5 didn't like someone in the shower with him/her so the staff stood outside of the shower curtain and he/she would take a shower. The resident would refuse medications and skin assessments, but she would expect staff to go in and try again later, try another staff member, or a different time for medications, and even another day for assessments and showers. She said they had to get social services involved a lot. The resident's legs should had been found before 07/10/24. There should have been two sets of eyes on the skin assessments, and it should have been caught. During an interview on 07/11/24 at 2:25 P.M., RN E said Resident #5 would complain about pain to his/her legs and would take Tylenol. The resident complained the Tylenol wouldn't do anything, but he/she didn't complain of any pain after it was taken. During an interview on 07/11/24 at 3:19 P.M., Certified Nursing Assistant (CNA) N said every once in awhile the Resident #5's legs were red. The resident was mostly independent with his/her activities of daily living (ADLs) so didn't see his/her legs a lot. He/She can't remember the last time he/she saw the resident's legs. During an interview on 07/11/24 at 3:25 P.M., RN E said the night shift charge nurse was in charge of completing skin assessments. He/She didn't know who was in charge of auditing the skin assessments to ensure they were completed. He/She had not done any skin assessments since moving to the day shift last month. Resident #5 had been aggressive toward him/her when trying to do the skin assessments. He/She hadn't seen Resident #5's legs in over a month and a half. During an interview on 07/11/24 at 3:30 P.M., the Social Services Designee (SSD) said Resident #5 used to listen to him/her but stopped about four - five months ago. He/she was verbally aggressive but not generally physical. He/She had not seen the resident's legs in a very long time and the resident hadn't mentioned them. During an interview on 07/11/24 at 3:35 P.M., the ADON said she had not seen Resident #5's legs since she discontinued the treatment back in April 2024. She discontinued that treatment because the resident only had a penny sized scabbed area. The resident did end up needing oral antibiotics within six days for cellulitis after that. The resident had not complained about pain in the last couple of months. The resident's legs should have been seen prior to them getting to the point of having to go to the hospital. During an interview on 07/11/24 at 4:15 P.M., the Corporate QA RN said the resident could refuse care up until it's started causing harm and then the facility staff would need to step in and figure out some way to provide the care the resident required. The resident couldn't go two months without a shower. The resident shouldn't go more than two weeks since he/she was non-compliant, and no staff saw his/her legs. Physician orders should be followed to include the skin assessments and showers. The resident's legs should have been caught before the point they were at. During an interview on 07/11/24 at 4:15 P.M., the Administrator said they couldn't do skin assessments or showers on Resident #5 because he/she refused everything. The resident even refused care and medications. She had not seen his/her legs. During an interview on 07/11/24 at 10:44 A.M., the Physician said if an order was given, he/she expected it be followed. Resident #5 had a lot of medical conditions. He/She refused to take baths and medications. He/She was not aware of the condition of the resident's skin on his/her legs until last night when the nurse called. That was the first he/she had heard of it. The resident's legs had some chronic conditions, and could have some fungus growing in the wounds. The resident received intravenous (IV) antibiotics while at the hospital. The facility staff should document when the resident refused care. During an interview on 07/11/24 at 4:19 P.M., the Physician said it could have just taken days for Resident #5's legs to get to this point they were before he/she went to the hospital because of him/her living in such a high microbial environment, the resident picked at his/her skin, and refused care. Review of the facility's policy titled, Lab Reporting Guidelines, undated, showed it did not address what to do when lab orders were not completed. 2. Review of Resident #34's medical record showed: - Diagnoses of congestive heart failure (CHF - an inability of the heart to pump sufficient blood flow to meet the body's needs), high blood pressure, hip fracture, and pressure ulcer (damage to the skin and/or underlying tissue as a result of pressure) Stage 4 (full thickness tissue loss with exposed bone, tendon or muscle); - Care plan, last revised on 04/24/24, the resident with a wound to the coccyx (the small triangular bone below the spine). The wound will be followed by the consulting wound clinic and treatment orders followed; - An order to lightly wet plain packing strip with Vashe (wound cleanser), apply collagen (helps promote tissue growth) to strip and pack wound with collagen strip once a day, dated 06/19/24; - An order to soak the wound to the coccyx with Vashe before the treatment, dated 06/19/24; - An order to cut Polymem (a dressing that will constantly cleanse the wound bed, while also managing drainage) to size and place over the wound tissue and cover with bordered gauze daily, dated 06/27/24; - An order for weekly skin assessments completed and documented on Mondays, dated 02/26/24. -Review of the the resident's TAR, dated June 2024, showed an order for weekly skin assessments to be completed and documented on Mondays, with a start date of 02/26/24. Three out of the four Mondays in June 2024 had no skin assessments documented. Review the resident's TAR, dated 07/01/24 through 07/10/24, showed: - An order for weekly skin assessments to be completed and documented on Mondays, with a start date of 02/26/24. No documentation the for the assessment on 07/01/24 (Monday). - An order, dated 06/19/24, to lightly wet plain packing strip with Vashe, apply collagen to strip and pack wound with collagen strip once a day, with two out of 10 opportunities missed; - An order dated 06/19/24, to soak the wound to the coccyx with Vashe before the treatment, with two out of 10 opportunities missed; - An order dated 06/27/24, to cut Polymem to size and place over the wound tissue and cover with bordered gauze daily, with two out of 10 opportunities missed. Observation on 07/10/24 at 1:00 P.M., of the resident's wound care showed: - LPN P soaked the packing strip with Vashe wound cleanser and applied Santyl (a wound debridement) to the packing strip; - LPN P used Santyl instead of collagen as ordered. During an interview on 07/10/24 at 1:30 P.M., LPN P said Santyl and collagen were the same medication. During an interview on 07/11/24 at 10:30 A.M., the ADON said in a resident's medical record, if the TAR has an order for a treatment, and there is no corresponding initial to indicate the treatment was completed, then there is no proof the treatment was completed. Santyl and collagen were not the same treatments and the physician's order for collagen should have been followed. During an interview on 07/11/24 at 1:00 P.M., the consulting wound care clinic nurse said there was a difference between Santyl and collagen powder. Collagen powder was what was ordered for Resident #34's wound. Santyl broke down bad tissue and collagen built up new tissue. The collagen was ordered on 06/18/24. The use of Santyl could cause negative effects like maceration (when a wound experiences excessive moisture, leading to the softening and breaking down of the surrounding skin) of the tissue which would stall the improvement of the wound and create a more wet environment. It wouldn't destroy the healthy tissue but the tissue would be too wet of an environment for tissue growth. During an interview on 07/11/24 at 3:00 P.M., RN E said he/she used collagen powder for Resident #34's wound care. Santyl was an old order and not the same thing as the collagen powder. Santyl shouldn't be used for the resident's wound. During an interview on 07/11/24 at 3:10 P.M., the ADON said physician orders should be followed. During an interview on 07/11/24 at 4:15 P.M., the Corporate QA RN said collagen powder and Santyl were not the same thing. Physician orders should be followed. During an interview on 07/11/24 at 4:17 P.M., the Administrator said physician orders should be followed. 3. Review of Resident #40's medical record showed: - A diagnosis of Alzheimer's disease; - An order for weekly weights for four weeks, dated 06/11/24; - On 06/11/24, the resident weighed 106.9 pounds (lbs); - No documented weight for the week of 06/18/24; - No documented weight for the week of 06/25/24; - On 07/02/24, the resident weighed 101.8 lbs, with a 4.77% weight loss in three weeks; - The facility failed to weigh the resident weekly for four weeks as ordered with two out of four opportunities missed. During an interview on 07/10/24 at 10:42 A.M., the Administrator said the ADON was responsible for making the weekly weight list and monitoring. During an interview on 07/10/24 at 02:53 P.M., the Physician said if weekly weights were ordered, he/she would expect them to be completed as ordered. During an interview on 07/12/24 at 8:09 A.M., CNA L said the resident did not have weekly weights. The resident was not on the weekly weight list. During an interview on 07/12/24 at 8:16 A.M., the ADON said the resident was not on the weekly weight list. She didn't know why the resident wasn't added and didn't get weekly weights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a safe transfer for one resident (Resident #23) in a manner to prevent accidents, when staff did not utilize two staff for transfers as directed on the resident's care plan and the resident sustained a hip fracture. Also, the facility failed to safely transfer one additional resident (Resident #8) outside of the sample. The facility census was 40. Review of the facility's policy titled, Gait Belt (a device used for assistance with transfers and walking) Transfers, undated, showed: - Assist resident to a sitting position; - Apply belt to the resident's waist and tighten to fit snugly with the buckle at the side; - Face the resident; - Bend your knees and place your hands around the gait belt on each side of the resident's waist; - Bring the resident to a standing position while straightening your knees; - After the resident is standing, the belt provides assistance stabilizing the turning of the resident. 1. Review of Resident #23's medical record showed diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following a stroke, pneumonia, muscle weakness, COPD, difficulty in walking, fracture of the neck of the left femur (thigh bone), pain to the left hip, bipolar disorder (a mental disorder that causes unusual shifts in mood), and anxiety disorder. Review of the resident's quarterly MDS, dated [DATE], showed: - Cognitively intact; - Substantial/maximal assistance of staff for dressing, personal hygiene, transfers, toilet use, and bathing. Review of the resident's care plan, last revised 05/23/24, showed: - The resident required assist of staff with ADL's, incontinent care and transfers; - Required a minimum of two staff to transfer. Review of the nurse's notes showed: - On 06/19/24 at 3:47 P.M., the resident requested to be transferred from the wheelchair to the recliner. The resident was assisted to stand with a gait belt by Registered Nurse (RN) E. While pivoting, the resident began leaning to the left. RN E attempted to correct the resident's position and the resident leaned further due to his/her left sided weakness. The resident was lowered to the floor by RN E and he/she complained of left hip pain. RN E and a second nurse assisted the resident to a sitting position and transferred the resident into the recliner. The resident had a small skin tear to his/her left hand. The physician was notified and received an order for an x-ray of the left hip; - On 06/19/24 at 7:30 P.M., the left hip x-ray was obtained; - On 06/19/24 at 9:46 P.M., the resident continued to complain of increased pain to the left hip. The resident requested to be sent to emergency department (ED). The physician was notified and received an order to send the resident to the ED. - On 06/20/24, the ED staff notified the facility of the resident being admitted to the hospital for a fractured left hip with possible surgery; - On 06/24/24, the resident returned to the facility from the hospital and the resident's left hip with a small incision with seven sutures in place. Review of RN E's Employee Counseling Notice, dated 06/20/24, showed: - Employee failed to follow the resident's care plan; - Employee transferred a two person assist resident by his/herself resulting in an injury to the resident. During an interview on 07/10/24 at 2:53 P.M., the Physician said staff should transfer residents as indicated. During an interview on 07/11/24 at 11:00 A.M., RN E said the resident started yelling he/she wanted to be transferred. There was no one readily available to assist and he/she thought the resident would be able to assist. The resident was usually a two person assist. The resident did help stand but while pivoting, the resident started leaning over to one side. RN E tried to correct the resident's leaning, but they both started to fall. The resident lifted his/her right leg, which was the strong one, to try to help but when that happened, RN E and the resident fell. He/She tried to control the resident's fall, but it was hard due to falling him/herself. The resident did complain of hip pain immediately. Another nurse came to help assess the resident and they got him/her up out of the floor because of difficulty breathing. They gave the resident pain medication and ordered an x-ray. Later that night, the resident complained of increased pain while the facility still was waiting for results from the x-ray. They sent the resident out to the hospital and he/she did have a fractured femur. During an interview on 07/11/24 at 10:10 A.M., the Administrator was aware of the incident and interviewed RN E. RN E said she transferred the resident as a one person assist but used a gait belt. The staff were in-serviced. She did not complete an official investigation which showed documentation of the incident. She didn't have any monitoring of staff transfers since the incident occurred. 2. Review of Resident #8's medical record showed diagnoses of dementia (a disorder marked by memory loss, personality changes, and impaired reasoning that interferes with daily functioning), pneumonia (an infection that inflames the air sacs in one or both lungs), chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a disease that results in too much sugar in the blood), fracture of left clavicle (bone that connects arm to body), anxiety disorder (persistent worry and fear about everyday situations), and chronic heart failure (CHF - a serious condition that occurs when the heart is unable to pump blood efficiently). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument required to be completed by the facility staff), dated 06/05/24, showed: - Cognition severely impaired; - Dependent on staff for activities of daily living (ADL's); - Mechanical lift not indicated; - Impairment to one side of upper and lower extremity; - Sit to standing and all transfers to be substantial/maximal assist where helper does more than half the work. Review of the resident's CNA Care Card, undated, showed the resident required assist of two for mechanical lift transfers. Observation on 07/11/24 at 10:10 A.M., of the resident showed: - CNA D and Nursing Assistant (NA) B transferred the resident from the bed to the wheelchair by a Hoyer Lift (a mechanical lift to move residents); - CNA D and NA B pushed the resident across the hall to the shower room in the wheelchair where Hospice Aide (HA) Q waited to assist the resident with a shower; - CNA D and NA B transferred the resident from the wheelchair to the shower chair by a Hoyer lift; - NA B left the shower room; - While the resident sat in the shower chair, HA Q placed his/her right arm under the resident's left axillary (arm pit area), CNA D placed his/her left arm under the resident's right axillary area, HA Q and CNA D lifted the resident and removed the brief. The resident's feet did not touch the floor to bear weight and no gait belt was used by HA Q and CNA D; - NA B returned to the shower room and the resident sat in the shower room outside of the shower. During an interview on 07/11/24 at 2:45 P.M., CNA D said the resident should be transferred with a Hoyer lift. When the resident was lifted from the shower chair to remove his/her brief a gait belt should've been used, but he/she was just following the lead of HA Q because he/she acted more experienced. CNA D said he/she just started a few weeks ago, was still learning, and hadn't received any training or education on transfers at this facility. During an interview on 07/11/24 at 2:47 P.M., CNA L, said the facility staff verbally tell hospice staff how the residents needed to be transferred. During an interview on 07/11/24 at 2:50 P.M., NA B said lifting the shower chair with the resident in it was the only way to get the resident into the shower when the resident required a Hoyer lift. There was no other way. The facility had a policy that a resident couldn't be taken down the hall in a shower chair, so he/she couldn't be taken to a different hall in the shower chair. He/She hadn't received any recent in-services/education on transfers. Hospice usually did the resident showers for the residents on hospice. During an interview on 07/11/24 at 3:35 P.M., the Assistant Director of Nursing (ADON) said it was not safe transferring a resident without a gait belt or with a gait belt if the resident can't bear weight, a Hoyer lift should be used for a resident that bears no weight. Hospice staff was communicated with verbally and there were CNA care cards for each resident that were available for review. During an interview on 07/11/24 at 4:15 P.M., the Corporate Quality Assurance (QA) Registered Nurse (RN) said staff should not lift residents by placing their arm/hands under the resident's arms at all. If a resident does not bear weight during a transfer, she would expect a Hoyer lift be used for safety. During an interview on 07/11/24 at 4:15 P.M., the Administrator said would expect the resident to be lifted by a gait belt, not under their arms. Complaint #MO237896