Based on observation, interview, and record review, facility staff failed to ensure the residnet was free from a significant medication error when staff failed to administer of one resident's (Resident #1) Metolazone (a diuretic medication used to treat high blood pressure and edema) and Torsemide (a diuretic medication used to treat edema due to congestive heart failure (CHF), kidney disease, or liver disease) as directed by the physician and failed to notify the resident's physician the medication was not available to be administer which resulted in the resident being admitted to the hospital with acute chronic hypoxic respiratory failure (not enough oxygen in the blood), mild pulmonary edema with pleural effusion (fluid collected inside and outside of the lungs), and chronic kidney disease Stage IV. The facility census was 69. 1. Review showed the facility did not have a policy instructing staff what to do when a medication was not able to be started when ordered. 2. Review of Resident #1's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/20/23, showed staff assessed the resident as: -Cognitively intact; -Diagnosis of chronic kidney disease (CKD) (kidneys filter waste and excess fluid from the blood, as kidneys fail waste builds up), atrial fibrillation (irregular rapid heart rate that commonly causes poor blood flow), hypertension, (higher than normal blood pressure), and diabetes mellitus type II (the body is unable to produce enough insulin). Review of the resident's care plan, dated September 2023, showed staff documented the resident diagnoses of CHF. Interventions showed staff are directed to give cardiac medications as ordered and monitor/document/report any signs of congestive heart failure such as dependent edema (swelling to parts of the body influenced by gravity) of legs and feet, shortness of breath upon exertion, and crackles and wheezes upon auscultation (listening with stethoscope). Review of the resident's Physician Order Sheets (POS), dated November 2023, showed the physician ordered: -Lasix 40 mg give one tablet by mouth one time a day related to CKD in the morning, discontinue 11/2/23; -Lasix 40 mg give one tablet by mouth in the afternoon for edema, discontinue 11/2/23; -Metolazone 5 mg give one tablet by mouth one time only related to essential hypertension for one day, give 30 minutes prior to morning (A.M.) Torsemide, start 11/3/23; -Torsemide 40 mg give one table by mouth two times a day related to essential hypertension, start 11/3/23. Review of the resident's Medication Administration Record (MAR), dated November 2023, showed staff were directed to administer Metolazone 5 mg give one tablet by mouth one time only related to essential hypertension for one day, give 30 minutes prior to A.M. Torsemide, start 11/3/23 and Torsemide 40 mg give one table by mouth two times a day related to essential hypertension, start 11/3/23. Review showed the MAR did not contain documentation of the administration of Metolazone or Torsemide on 11/3/23 or 11/4/23. Review of the facility's order delivery report, dated 11/1/23 to 11/4/23, showed the residents Metolazone delivered on 11/3/23 and the Torsemide on delivered 11/4/23. Review of the nurses notes, dated 11/5/23 at 6:00 P.M., showed Licensed Practical Nurse (LPN) A documented the resident's family member asked if the resident had received his/her one time dose of Metolazone and started the Tosemide, because he/she had labored breathing. Upon assessment the resident had shortness of breath with oxygen on at 2 Liters/minute via nasal cannula (NC), inspiratory wheezing (a wheeze on inhale), a non productive cough, edema to both lower extremities, and a change in mental status. LPN A documented he/she reviewed the MAR and noted the resident's one time dose of Metolzaone and scheduled Torsemide had not been given as ordered. Review showed the resident's respirtory rate 24 and his/her blood pressure 154/66. Review of the nurses notes, dated 11/5/23 at 6:18 P.M., showed staff documented they notified the physician's office and received orders for an immediate x-ray, Guaifensin (medication for congestion), and breathing treatments every four hours for five days. Review showed staff documented the resident's family request he/she be sent to the hospital. Review of the nurses notes, dated 11/5/23 at 7:15 P.M., showed staff documented Emergency Medical Services (EMS) arried at the facility to transport the residnet to the hospital and staff notified the emergency room the resident was sent out. Review of the resident's hospital records, dated 11/5/23, showed the resident admitted with acute chronic hypoxic respiratory failure, COVID-19 pneumonia, mild pulmonary edema with pleural effusion, chronic kidney disease Stage IV, and urinary tract infection. During an interview on 11/9/23 at 11:10 A.M., Certified Medication Technician (CMT) D said nurses are responsible for entering orders in to the system. He/She said if he/she has any questions he/she asks the nurse. He/She said he/she saw the Metolazone and Torsemide on the MAR and had been ordered, but not delivered. He/She did not tell the nurse because the medications were ordered, but gave all other scheduled medications available to the resident for his/her shift. CMT D said he/she did not remember if he/she checked the back up medications, to see if the medication was available. He/She said he/she was not sure who was responsible for making sure medications are put in as delivered when they arrive from the pharmacy. During an interview on 11/9/23 at 11:28 A.M., LPN A said he/she was asked by the resident's family if he/she had received the new ordered medication from his/her cardiac appointment on 11/1/23. He/She said he/she checked the system to find the Metolazone had not been given and the resident had started the Torsemide on 11/4/23. The resident had been at his/her baseline on 11/5 and he/she was not told in report the resident was waiting on the medications. He/She said nurses are responsible for putting in the orders and the pharmacy receives them and fills them. He/She said staff are expected to check the Omnicell (backup medication location) to see if they have an initial dose before the pharmacy delivered the resident's medication. If they do not have the medication, staff are expected to notify the charge nurse. The nurse calls the pharmacy to see when the medication is expected to be delivered and to notify the physician to see if something different needs to be given until the medication arrives. He/She was not made aware by the CMT the medications were not available. He/She said the nurse would be responsible for changing the start and stop date on the one time dose medication. He/She said the Director of Nurses (DON) had been responsible for making sure this was completed, but was not sure who was responsible at this time. During an interview on 11/9/23 at 3:00 P.M., the Clinical Director said the charge nurse is responsible for putting in orders from the doctor. He/She said the pharmacy automatically fills the prescription when entered, because their system is synced with the pharmacy. He/She said pharmacy deliveries are normally delivered at the front nurse's station. The nurses or CMT's are expected to reconcile the medications delivered, marked as delivered in the system, and put the medications away in the medication carts. The Clinical Director said he/she put the new order in on 11/2/23 for the metolazone and torsemide and discontinued the resident's Lasix as ordered, and the new medications were ordered to start on 11/3/23. He/She said staff are expected to check the Omnicell to see if the medication is available if it is not on the medication cart. If the medication is not available, the CMT is expected to notify the charge nurse and the charge nurse is expected to contact the pharmacy and the physician. The nurse should also change the start date when the medication is delivered so the order is updated in their system. He/She said the nurses are responsible for checking the start and stop dates. He/She said the CMT should have reported to the charge nurse when the medication was unavailable so the pharmacy and doctor could be notified and see what, if anything should be done. The Clinical Director said he/she has been responsible for making sure orders have been put in correctly and followed, but it is typically the DON or Assistant Director of Nurses (ADON). During an interview on 11/22/23 at 10:13 A.M., CMT E said he/she does not remember what medications he/she checked in but knows he/she put all medications delivered on 11/3/23 in the appropriate medication carts. He/She did not tell the nurse the resident's medication had been delivered, because he/she did not know the resident was waiting on it. He/She said he/she did not know there was an area to mark the medications as received in point click care. If a medication is not available to give, staff are to check the omnicell and report to the charge nurse so they can call the doctor. He/She said the nurse would be responsible for changing the start and stop date of medications. He/She does not know who is responsible for checking to make sure orders are put in and filled. During an interview on 11/22/23 at 1:49 P.M., CMT F said the nurses are responsible for putting in orders. He/She said if a medication is not available staff are to check to the Omnicell and notify the charge nurse. He/She said he/she was not made aware by the night nurse the medication had been delivered. He/She said he/she did not see the resident's Metolazone on the cart or on the MAR but could have overlooked it if it was a single dose medication, because the resident's medication come in a rollpack with contains all the medications the resident takes during a specific time period. He/She said if there were any medications on the MAR not available he/she would have checked the Omnicell and notified the nurse. He/She said the ADON would be responsible for checking to make sure orders are put in and followed. During an interview on 11/22/23 at 3:03 P.M., CMT H said nurses are responsible for entering orders. He/She said he/she believes the DON and ADON would be responsible for making sure the orders are put in and followed. He/She said if a medication is unavailable, staff are expected to check the omnicell and report to the charge nurse if it is not available. He/She said he/she told the nurse the medications were not available, but does not remember the nurse he/she told. He/She said there is an option to mark if the medication has been received but he/she does not know if staff are supposed to mark it or not. He/She was not made aware the resident was waiting on medications at shift change. During an interview on 11/22/23 at 3:20 P.M., LPN C said nurses are responsible for putting in orders and he/she is not sure who is responsible for making sure they are put in and followed. He/She said staff are the check the omnicell and tell the charge nurse if the medication is not available. He/She was not made aware the resident's medication was not available and was not made aware the resident was waiting on medications when he/she received report. He/She said the pharmacy and doctor should have been notified and the start and stop date adjusted at the doctors discretion. LPN C said he/she has reconciled medications before, but the CMT's are responsible for putting them away in the medication cart. During an interview on 11/30/23 at 1:35 P.M., the physician said he/she would expect staff to notify his/her office or the on call staff if a medication was not available to start as ordered. He/She said the resident needed to be on a diuretic (medication used for edema and fluid retension) due to his/her diagnoses. He/She said it is a possible cause of the resident's change in condition. MO00227070

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility staff failed to provide care consistent with professional standards of practice to promote the prevention of pressure ulcer (PU) development for one resident (Resident #52) after staff identified the resident was at risk for PUs. Additionally, staff failed to obtain a physician ordered treatment for an unstageable wound to the resident's coccyx, from 11/16/22 to 12/22/22, more than 30 days after the start of the PU, failed to obtain a physician ordered treatment for an unstageable PU to the resident's left hip discovered on 12/31/22, failed to follow the resident's plan of care to prevent additional pressure injuries (PI)s and promote the healing of PUs. Additionally, staff failed to document assessments, and failed to identify a new PI. The facility census was 80. Review of the National Pressure Injury Advisory Panels (NPIAP) definitions of staging showed: -Pressure Injury: localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear; -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum (liquid)-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue (pink/red tissues, bumpy in appearance), slough (liquefied or wet dead tissue, can be yellow or white in color) and eschar (dried dead tissue, can be tan, black, or brown in color) are not present; -Stage 3 Pressure Injury: Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. 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 extent of tissue loss this is an Unstageable Pressure Injury; -Stage 4 Pressure Injury: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury; -Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 1. Review of the facility's Prevention of Pressure Injuries Policy, dated April 2020, showed: -Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADLs); -Identify any signs of developing pressure injuries (i.e., non-blanchable erythema (redness); -Inspect skin pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.); -Reposition the resident as indicated on the care plan; -Keep the skin clean and hydrated; -Clean promptly after episodes of incontinence; -Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team (IDT); -Provide support devices and assistance as needed (PRN). Remind and encourage residents to change positions; -Select appropriate support surfaces based on the resident's risk factors, in accordance with clinical practice; -Evaluate, report and document potential changes in skin; -Review the interventions and strategies for effectiveness on an ongoing basis. Review of the facility's Wound Care Policy, dated October 2010, showed: -Verify there is a physician's order for this procedure; -Notify the supervisor if the resident refuses the wound care. 2. Review of Resident #52's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 10/18/22, showed staff assessed the resident as: -Severe Cognitive Impairment; -Did not have behaviors; -Did not reject care; -Totally dependent on two staff members for bed mobility, transfers, and dressing; -Did not have a Stage I PU or greater; -Clinical assessment and formal assessment completed to determine PU risk; -At risk for PUs; -No applications of ointments/medications other than to feet; -Diagnoses of displaced intertrochanteric fracture of right femur, initial encounter (hip fracture), peripheral vascular disease (a slow and progressive circulation disorder), stroke, Hemiplegia/Hemiparesis (severe and complete loss of strength/mild loss of strength); Cognitive communication Deficit (Difficulty with thinking and speaking). Review showed staff documented the resident was at risk for the development of PUs and did not document the use of pressure relief devices. Review of the resident's care plan, revised 1/25/23, showed: -Activity of Daily Living (ADL) self-care performance deficit related to activity tolerance, confusion, hemiplegia, impaired balance; -Totally dependent on one staff for repositioning and turning in bed every shift and as necessary; -Skin inspections weekly; -Turn and reposition every two hours and as needed. Keep body in good alignment; -Actual impairment to skin integrity of the right groin and coccyx; -Follow facility protocols for treatment of injury; -Follow treatment orders for dressing changes; -Heel protector to right foot while in bed; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate, include any other notable changes or observations. Review of the resident's Skin Only Evaluation, dated 10/18/22, 10/25/22, and 11/8/22 showed staff documented the resident did not have a PU. Further review, showed it did not contain documentation in regard interventions used for PU prevention. Review of the resident's Skin Only Evaluations, dated November 2022, showed staff documented: -11/13/22: -New Left Inguinal Region, Pressure Ulcer/Injury; -3 centimeters (cm) in Length (L) by 2 cm in Width (W) by 0.2 cm in Depth (D); -Wound Odor: Yes; -Wound bed: Slough; -Wound exudate: Purulent: (thin, thick, opaque, tan/yellow drainage); -Dressing saturation: Moderate: 26-75 percent (%); -11/16/22: -Left Inguinal Region, Pressure Ulcer/Injury: No change from previous assessment; -New Issue: Coccyx: Deep tissue injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm in D; -Wound Bed: Granulation tissue; -Wound exudate: Serosanguineous: thin, watery, pale red/pink drainage; -11/23/22: -Left Inguinal Region Pressure Ulcer/Injury; -3 cm in L by 2 cm in W by 0.2 cm in D; -Wound Odor: Yes; -Wound Exudate: Purulent -Dressing saturation: Moderate 26-75%; -Coccyx Deep Tissue Injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm D; -Wound Bed: Granulation -Wound Exudate: Serosanguineous. Review of the resident's wound consult, dated 11/15/22, showed: -Contractures (lower extremities), other (left above knee Amputation (AKA), open sore; -Wound Left Groin is an unstageable PI obscured full-thickness skin and tissue loss; -3 cm in L by 1 cm in W with no measurable depth; -Moderate amount of serous (thin and watery and will usually have a clear to yellowish or brownish appearance) drainage with mild odor; -Wound bed is 76% to 100% slough; -The peri-wound skin exhibits erythema; -Temperature of peri-wound skin is warm with signs and symptoms of infection; -Wound Culture & Sensitivity (C&S), laboratory test used to determine type of bacteria present, and antibiotics the bacteria is sensitive to, pending; -New problem; -Wound Orders: Cleanse wound with Hypochlorous Acid (wound care agent with powerful microbicidal, antibiofilm, and wound healing potency). No need to rinse from wound or skin. Use to irrigate or scrub the wound bed. Protect peri-wound with skin protectant, apply a nickel thick amount of Santyl (gel used remove dead tissue from wounds) to wound bed, cover with gauze pad, change dressing daily, and PRN for soiling saturation, or unscheduled removal; -Advanced wound specialist to follow up in one week to reassess progress of wound/skin issue; -Plan of care discussed with facility staff; -Laboratory: Bacteria and Fungus identified. Review of the resident's progress notes, dated November 2022, showed staff documented: -11/19/22 at 6:44 P.M., the resident requested to go to the hospital. Stated the pain from the groin wound is worse. Rated pain a 10 out of 10 on a scale of 1-10 (one being minimal pain and 10 being excruciating pain). Wound appears worse, and has a foul odor. It is deeper and wider than previously noted. 3.5 cm in L by 1.8 cm in W, approximately 0.5 cm D. Message sent to physician to approve transfer; -11/22/22 at 4:15 P.M., resident readmitted from hospital. Review of the resident's wound consult note, dated 11/22/22 showed: -Contractures (hips); -Wound to Left groin is an Unstageable PI; -Measurements are 3 cm in L by 4.2 cm in W with no measurable depth; -Moderate amount of serous drainage with mild odor; -Wound bed is 76% to 100% slough; -The peri-wound skin exhibits erythema with warmth and signs and symptoms of infection; -11/15/22 culture positive for multiple organisms. Antibiotics started 11/18/22; -Quality of tissue compared to previous visit: No change; -Wound drainage compared to previous visit: No change; -Peri-Wound tissue compared to previous visit: No change; -Length and Width compared to previous visit: Deteriorated; -Cleanse wound with Hypochlorous Acid, use to irrigate or scrub the wound bed, protect peri-wound with skin protectant, apply Santyl nickel thick to wound bed, cover with gauze pad, change daily and PRN for soiling, saturation, or unscheduled removal; -Medications prescribed: Doxycycline hyclate (antibiotic) 100 milligrams (mg) twice daily (BID) for seven days with start date of 11/18/22 and Ciprofloxacin (antibiotic) 500 mg BID for seven days with start date of 11/18/22; -Report obtained from staff nurse regarding patient. Sent to hospital 11/19/22 due to severe pain; -High risk: Wounds could potentially worsen putting client at high risk of sepsis, infection or death. Review of the wound consult note, showed it did not contain documentation in regard to the resident's coccyx wound. Review of the Physician Order Summary (POS), dated November 2022 showed: -8/16/22: Heel protector to right foot while in bed; -11/13/22: Wound culture to Left Inguinal wound infection, Stat for infection to wound; -11/13/22: Wound care to evaluate and treat; -11/13/22: Apply Santyl to groin BID for wound to Left groin; -11/22/22: House supplement (health shake) two times a day (BID) for weight loss; -11/22/22: Apply Santyl to Left Groin BID; Review showed it did not contain a treatment order for the resident's coccyx wound, identified on 11/16/22. Review of the Administration Record, dated November 2022, showed: -11/13/22: Left Groin wound: Cleanse with normal saline (NS), pat dry, apply Santyl, and cover with dry dressing BID until healed; Review showed it did not contain documentation in regard to the resident's coccyx wound, identified on 11/16/22 or the heel protector to the right foot. Review of the resident's Significant Change in Status Assessment (SCSA) MDS, dated [DATE], showed staff assessed the resident as: -Severe Cognitive Impairment; -Did not have physical or verbal behaviors directed towards others; -Did not reject care; -Required extensive assistance from two staff members for bed mobility and toileting; -Totally dependent on two staff members for transfers; -Had a lower extremity impairment to one side; -Uses a wheelchair; -One Stage 3 PU; -No Arterial/Venous Ulcers (ulcers that develop from lack of blood flow); -Pressure reducing device to bed; -No pressure reducing device to chair; -Receives Hospice Care; -Has diagnoses of hip fracture, PVD, stroke, Hemiplegia/Hemiparesis, and Cognitive communication deficit, does not have malnutrition. Review of the MDS showed it did not contain documentation of more than one pressure ulcer. Review of the resident's Skin Only Evaluations, dated December 2022, showed staff documented: -12/6/22: -Left Inguinal Region Pressure Ulcer/Injury; -4.5 cm L by 3.2 cm W by 0.2 cm D; -Wound Odor: Yes; -Treatment: Santyl; -Wound Bed: Slough; -Wound Exudate: Purulent; -Dressing Saturation: Moderate 26-75%; -Coccyx Deep Tissues Injury, Stage 2; -3 cm in L by 2.5 cm in W by 0.2 cm in D; -Wound Bed: Granulation tissue; -Wound Exudate: Serosanguineous. -12/8/22: -Left Inguinal Region Pressure Ulcer/Injury -No change since previous assessment; -Coccyx Deep Tissue Injury, Unstageable; -5 cm in L by 3.5 cm in W by 0.2 cm D; -Wound Bed: Necrotic (dead tissue). Review showed it did not contain a treatment for the resident's coccyx wound. Review of the Skin Only Evaluations, dated 12/13/22, 12/20/22, and 12/27/22 showed staff documented the resident's left inguinal wound and coccyx wound had no changes in size, odor, or appearance. Review of the Registered Dietician (RD)'S Progress Note, dated 12/13/22 at 8:46 A.M., showed the RD documented, Skin: Stage 3 pressure wound to left groin. Hospice care noted. Resident receives a regular diet with house supplement BID to aid in wound healing and help maximize nutritional intake. Review showed it did not contain documentation of the resident's coccyx wound. Review of the progress notes, dated December 2022, showed staff documented: -12/2/22 at 1:34 P.M., wound to coccyx 10 cm by 2 cm Deep Tissue injury (DTI). Hospice notified of wound and need for dressing order change; -12/2/22 at 6:38 P.M., Mood is pleasant, no unwanted behaviors witnessed; -12/5/22 at 12:22 P.M., Mood pleasant, no unwanted behaviors witnessed; -12/13/22 at 3:00 A.M., Mood pleasant, no unwanted behaviors witnessed; -12/14/22 at 3:32 P.M., This resident has a wound that was reviewed in IDT; -12/31/22 at 6:49 P.M., Incident Note: Resident has a new stage 2 pressure injury on the left hip. There are two spots. One measuring 2.5 cm by 2.5 cm the other 3.5 cm by 2.5 cm. Hydro-colloid dressing (wound dressing) applied. Review of the resident's POS, dated December 2022, showed: -12/2/22: Hospice Evaluation & Treatment; -12/6/22: Admit to Hospice Services; -12/17/22: Left Groin Wound: Cleanse with normal saline, pat dry, apply MediHoney (wound gel used for antibacterial properties), cover with dry dressing BID until healed; -12/22/22: Apply MediHoney and bordered gauze to coccyx wound daily, start date 12/23/22; Review showed the POS did not contain a treatment for the resident's coccyx wound from 11/16/22 until 12/22/23, and did not contain a treatment order for the pressure wound to the resident's left hip identified on 12/31/22. Review of the resident's Administration Record, dated December 2022, showed: -12/18/22: Left Groin Wound: Cleanse with NS, pat dry, apply MediHoney, and cover with dry dressing BID until healed; -12/23/22: MediHoney and bordered gauze to coccyx wound daily. Review of the administration record showed it did not contain a treatment for the resident's left hip pressure ulcer. Review of the resident's Skin Only Evaluations, dated January 2023, showed: -1/3/23: -Left inguinal Region Pressure Ulcer Injury; -4.6 cm in L by 3.2 cm in W by 0.6 cm in D; -Wound Odor: Yes; -Treatment: Santyl and gauze; -Wound Bed: Slough; -Exudate: Purulent; -Coccyx, Deep Tissue Injury, Unstageable; -6 cm in L by 2.6 cm in W by 0.5 cm in D; -Wound Odor: Yes; -Treatment Schedule: Daily; -Wound Bed: Necrotic; -New Issue: -Left Hip, Pressure Ulcer Injury, Stage 2; -6 cm in L by 0.5 cm in W by 0.1 cm in D; -Wound Odor: No; Review of the Skin Only Evaluations, dated 1/11, 1/17, and 1/24 showed: -Left Inguinal Region Pressure Ulcer/Injury; -Wound Odor: Yes; -Left Hip Pressure Ulcer/Injury; -Coccyx, Pressure Ulcer Injury; -Dressing Saturation: Moderate. Review showed evaluations did not contain documentation of each area of skin breakdown's width, length, depth, type of tissue, and exudate, Review of the resident's POS, dated January 2023, showed it did not contain a treatment order for the resident's left hip pressure ulcer. Review of the resident's Administration record, dated January 2023, showed it did not contain a treatment order for the resident's let hip pressure ulcer. Observation on 1/24/23 at 2:43 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of the bed. Observation on 1/24/23 at 4:56 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of the bed. Observation on 1/25/23 at 9:14 A.M., showed the resident lay on his/her left side in bed. Observation on 1/25/23 at 10:06 A.M., showed the resident lay on his/her left side in bed. Observation on 1/25/23 at 2:10 P.M., showed the resident lay on his/her left side in bed. During an interview on 1/25/23 at 2:15 P.M., Certified Nurse Aide (CNA) G said he/she thought a wound company comes in and sees the resident, but he/she did not know the last time they had been to the facility. The CNA said the resident always lays on his/her left side. He/She said the resident is not turned and repositioned, because he/she has a contracted left hip. He/She said he/she always lays the resident on his/her left side in bed, and has never been told to position the resident any other way. Additionally, the CNA said the resident is only gotten up for meals. The CNA said he/she works with the resident often. Observation on 1/26/23 at 9:03 A.M., showed the resident lay in bed on his/her left side. Observation on 1/26/23 at 9:11 A.M., showed Hospice Registered Nurse (RN) U entered the resident's room to provide wound care. During an interview on 1/26/23 at 9:15 P.M., Hospice RN U said he/she is at the facility two times week to see the resident but will now be there three times a week, to provide wound care. Additionally, RN U said the resident does not have pain with wound care, which is good and bad. Observation on 1/25/23 at 9:19 A.M., showed Hospice RN U removed gauze from the resident's left groin, measured an odorous wound, with a light pink wound bed covered with small raised bumps and white edges, cleansed the wound, as the resident cried out, and applied MediHoney and gauze. RN U said the wound measured 2.1 cm, and is hard to measure because the resident's hips are contracted. Further observation, showed a wound to the resident's coccyx, 50% of the wound bed had raised bumps and was pink in color, the wound tunneled (a passageway between the skin surface and organ spaces, caused by infection, sheer force of pressure, past surgical procedures at area of wound) at 12 O'clock (top of wound) and had yellow adherent slough near a small area of white tissue in the wound bed. A white shiny linear striation could be seen in the middle of the wound. The RN said the wound measured 10 cm x 8 cm and had a 5 cm x 4 cm area of granulation tissue, he/she said the yellow tissue was slough, and the wound had started tunneling prior to his/her current assessment. The RN did not measure the wounds depth. The resident cried out, and the RN applied MediHoney and bordered gauze to the wound. Additional observation, showed a wound to the resident's left hip, which the RN measured at 5.5 cm x 4 cm with a 2.2 cm necrotic (black) area. The wound had adherent yellow slough that pulled away from the edges of the wound, and had eschar. During an interview on 1/26/23 at 10:03 A.M., Hospice RN U said the resident's Left hip wound looked worse. He/She said sometimes the facility staff tell him/her the resident refuses care. He/She said he/she has tried to educate them on how to reapproach the resident, and other things to try. He/She said the resident has orders for pain medications and received the medication before wound care. He/She said the resident yells out that his/her bottom hurts when he/she's in the wheelchair. The RN said staff should turn and reposition the resident. He/She said the resident's wounds would get worse if the resident was not turned and repositioned regularly. RN U said the resident's PU to his/her coccyx was a Stage 3. He/She said the resident is so thin, you could palpate bone, but he/she does not have any meat on his/her bones. He/She said the resident's left hip, and left groin PUs were unstageable. Observation on 1/26/23 at 2:16 P.M., showed the resident lay on his/her left side in bed. Observation on 1/26/23 at 2:43 P.M., showed the resident lay on his/her left side in bed. Further observation, showed a blue heel boot on the floor at the head of his/her bed. Observation on 1/26/23 at 5:55 P.M., showed the resident lay on his/her left side in bed. Observation on 1/27/23 at 10:06 A.M., showed the resident lay on his/her left side in bed. Observation on 1/27/23 at 10:58 A.M., showed LPN I and NA N entered the resident's room to provide wound care. NA N pulled back the blankets on the bed and showed the resident's bottom. A urine saturated dressing peeled away from the resident's skin on his/her sacrum/coccyx. The resident's mattress was saturated with urine through the wet sheets. During an interview on 1/27/23 at 1:33 P.M., Certified Medication Technician (CMT) K said the resident has wounds to his/her bottom and groin. He/She said the resident is supposed to wear to boot to his/her right foot. He/She said the CNAs are responsible for ensuring the boot is on and the resident is turned and repositioned. He/She said staff should turn and reposition the resident. He/She said staff has access to care plans, but he/she could not figure out how to get to it. During an interview on 1/27/23 at 1:34 P.M., CNA G said staff should turn and reposition residents every two hours. He/She said the resident has a wound to his/her bottom and groin. He/she said the smell of the wound to the resident's groin has improved, but you can still smell it. He/She said the wound to the resident's left hip is new. He/She said the resident does not have any skin issues to his/her right foot. The CNA said the resident does not wear a heel boot to the right foot. He/She said if the resident refuses care, staff are supposed to document the refusal, and tell the charge nurse. CNA G said the resident does not refuse to be turned and repositioned, and he/she is always positioned on his/her left side because of the wound to his/her bottom. He/She said he/she thought the resident should always be positioned on his/her left side because of his/her wounds. He/She said he/she has not been directed to position the resident any other way. Observation on 1/27/23 at 1:40 P.M., showed CNA G entered the resident's room, pulled back the blankets, and removed the resident's sock to his/her right foot. Further observation, showed a an approximate 1 cm x 1 cm pink and purple area to the resident's medial malleolus (bony prominence on inner side of the ankle). When asked the CNA said the resident has had the area for a while. He/she said he/she could not remember if it was reported to the charge nurse. The CNA touched the area and it did not change color (unblanchable). He/She said he/she does not know what caused the area. During an interview on 1/27/23 at 1:52 P.M., LPN I said he/she is an agency nurse and works at the facility from time to time. He/She said he/she is familiar with the resident. He/She said the resident did not have any skin issues to his/her right foot that he/she was aware of. He/She said he/she does not know if the resident should have a heel boot on when in bed. He/She said there is not a treatment order for the heel boot. He/She said he/she would expect a heel boot to have a physician's order, be on the care plan, and be on the treatment record. The LPN said if staff found a new skin issue, they should report it the charge nurse. He/She said no one has reported a new skin issue for the resident to him/her. He/she said if an area was reported, he/she would assess the area, and obtain a treatment order. He/She did not know the resident did not have a treatment order for the left hip wound. He/She said the charge nurses are responsible for obtaining orders from the physicians. He/She said the resident does not refuse any care or treatment, but he/she said he/she is patient with the resident, and some of the staff is not. The LPN said if the resident did refuse care, he/she would stop, wait, and reapproach the resident at a later time. If that did not work, he/she said he/she would ask for help, and let the Director of Nursing (DON) know. LPN I said the resident has a Stage 3 or Stage 4 PU to the coccyx, a Stage 2 PU to the left hip, and another Stage 2 PU to the left groin. He/She said the resident has contractures to his/her left hip, and he/she assumes that is what caused the left groin pressure ulcer. He/She said he/she does not know if staff had anything in place to try and prevent the left groin PU. He/She said all residents should be turned and repositioned every two hours. He/She said staff should turn and reposition the resident because the resident is not able to do it himself/herself. He/She said staff is probably not turning and repositioning the resident because it's not in the charting. He/She said when he/she was in the resident's room earlier today he/she did notice the resident did not have a wedge or other positioning devices in the room. He/She said since the resident receives hospice care, he/she would think hospice would provide positioning wedges, or an air mattress. He/She said the resident should have something, and he/she does not. He/She said if staff are not turning and repositioning the resident, and not putting a heel boot on him/her, it can lead to further skin breakdown. He/She said the resident's hip wound could be from staff not turning and repositioning him/her. Additionally, he/she said the resident's wounds are worse than they were the last time he/she was at the facility, which could also be a result of the resident not being turned and repositioned. He/She said the resident eats, and staff have to feed him/her because he/she can't feed himself/herself. During an interview on 1/27/23 at 2:29 P.M., the DON said said hospice care was considered because the resident was not doing well, and family approved it. He/She said the resident was not eating and was refusing wound care. He/She said staff completed wound treatments and assessments until January, and since then hospice has completed them. He/She said the last wound documentation in the computer system is from 1/3/23 because hospice completes all the wound assessments. He/She said facility staff does not complete the wound assessments. He/She said the facility does not have a dedicated wound nurse, and wound assessments are the responsibility of the charge nurse. He/She said the hospice nurse will be coming to the facility daily now. He/She said the resident was seeing a wound consultant but that was discontinued in December due to the resident qualifying for hospice services. The DON said he/she expects staff to turn and reposition residents every two hours, and if the resident refuses it should be charted. He/She said due to the resident's wounds to his/her hip, groin, and bottom he/she should be kept off of his/her hip as much as possible. He/She said he/she expects staff to use pillows, wedges or anything to position the resident. He/She said he/she did not know staff were not turning and repositioning the resident. He/She said no one has told the staff not to turn and reposition him/her due to his/her contractures. He/She said he/she assumes the resident does not have an air mattress because he/she rolled out of bed. During the interview, the Assistant Director of Nursing (ADON) came in the room and said a Nurse Practitioner was in the facility, and suggested the facility contact hospice because the resident's wounds are not healing, and he/she suspected the resident had osteomyelitis to the left groin and left hip. The DON said if the resident has an order for ankle boot staff should ensure the ankle boot is in place. He/She said the resident had blue ankle boots at one time, but he/she did not know what happened to them. He/She said the order should be on the POS, Administration Record, and in the care plan. He/She said he/she does not know why it is not on the administration record. He/She said he/she has not seen the resident with an ankle boot on.