**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R43's admission Record found in the Profile tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and readmitted from the hospital on [DATE], with diagnoses of type 2 diabetes mellitus with ketoacidosis without coma, acute kidney failure, pressure ulcer of right heel (unstageable), and abnormalities of mobility. Review of R43's quarterly MDS assessment located in the MDS tab of the EMR, with an ARD of 08/22/23, revealed he/she scored three out of 15 on the BIMS which indicated significant cognition impairment. He/She did not exhibit any behavioral symptoms. R43 was at risk for pressure ulcers and had one unstageable pressure ulcer. He/She received pressure-reducing devices for her chair and bed, nutritional interventions, and pressure ulcer care. R43 required extensive assistance by one staff member with bed mobility, transfers, toileting, and personal hygiene. Review of R43's EMR under Orders tab revealed a 05/15/23 physician order to float heels off bed to avoid pressure three times a day. Review of Nurse Practitioner (NP) Progress Note located under the Progress Note tab, dated 07/03/23, documented that R43 had an Unstageable pressure ulcer of right heel. Review of R43's Progress Note located under the Progress Notes tab, dated 07/06/23, prior to hospital discharge, documented Elder has pressure sore on right heel. There was no additional documentation noted. Review of R43's readmission Evaluation located under the Progress Notes tab, dated 07/14/23, revealed documentation: Right heel bandaged over black circular area that is opening at edges. Review of R43's Wound Evaluation located under the Assessments tab, dated 08/31/23, documented that the right heel wound dimensions were 2.23 cm x (by) 1.77 cm. Review of R43's Progress Note located under the Progress Notes tab, dated 09/07/23, revealed documentation Right heel has treatment order in place, appears to be healing, heels are off loaded while in bed to help with the healing process. No drainage noticed. No odor at site. Further review of the EMR revealed R43's Progress Note located under the Progress Notes tab, dated 09/14/23, documented that the resident's Pressure wound to right heel is being treated with Santyl and covered with a foam dressing, wound appearance has not changed. Review of R43's Wound Evaluation located under the Assessments tab, dated 09/15/23, documented that the stage four right heel wound dimensions were 2.15 cm x 1.83 cm. Review of R43's Wound Evaluation, dated 09/22/23, documented that the stage four right heel wound dimensions were 2.79 cm x 1.24 cm. Review of R43's Wound Evaluation, dated 09/29/23, documented that the stage four right heel wound dimensions were 3.58 cm x 2.64 cm. Review of R43's Progress Note located under the Progress Notes tab, dated 10/02/23, revealed documentation that Wound has green drainage and odor. Nurse contacting MD's office. Further review of the EMR revealed R43's Progress Note located under the Progress Notes tab, dated 10/02/23, documented that resident has foul smell and slough noted to heel with moderate purulent drainage no redness or warmth noted to R (right) heel. Review of NP Progress Note, dated 10/03/23, documented Wounds have worsened some odor and pink on edges. Keflex 500mg [milligrams] BID [twice daily] x seven days for wound with odor they will need to educate staff on showering residents with dressings on and get the Santyl in and off load heels. (sic) Review of the October 2023 Medication Administration Record (MAR) revealed a physician order on 10/03/23 for Keflex 500mg. Give one capsule by mouth two times a day for wound for seven days. Review of R43's Care Plan, located in the Care Plan tab of the EMR, dated 05/15/23, revealed I have an unstageable ulcer to R heel [was admitted with stage II]. It was last revised 09/06/23. The resident's goals were, My wound will show signs of healing by next review. The wound will remain stable. The interventions included: Elevate heels off the bed. Encourage good nutrition and hydration in order to promote healthier skin. Monitor for s/s [signs and symptoms] of infection. Pressure reducing boots to bilateral heels. Treat as ordered. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. R43's Care Plan had not been updated with the appropriate identified stage four pressure ulcer on his/her right heel documented on his admission Record on 07/14/23, nor was the identified wound infection. Review of R43's Progress Note located under the Progress Notes tab, dated 10/12/23, revealed documentation that Resident's measurements are 3 x 5 approximately, slough improving, faint foul smell seems to have improved since tx (treatment) of abx (antibiotics), moderate drainage noted purulent with some blood-tinged exudate. An observation of R43 on 10/9/23 at 1:30 PM revealed the resident sleeping in bed. The resident's calves were observed resting on a pillow, and the feet were resting directly on the mattress, not floated. An observation of R43 on 10/10/23 at 2:10 PM revealed the resident sleeping in bed. The resident's feet were placed in Podus boots, resting on the mattress. An observation of wound care was completed with LPN1 on 10/12/23 at 10:10 AM. LPN1 stated the nurse from the night shift had changed the resident's dressing, but she had to redo it because it was not wrapped correctly. During the treatment R43 was noted to have his/her right heel wrapped in Kerlix, dated 10/12/23 7:00 AM, which he/she stated was not the treatment order. The wound was measured at 3.0 cm x 5.0 cm. LPN1 stated that R43 required antibiotic medication for the wound, because it had been infected. He/She stated that the wound appeared better, but there was still an odor. He/She said he/she would be communicating with the nurse practitioner who monitored the wounds. During an interview on 10/12/23 at 9:29 AM the CP1 stated the staff tried to float R43's heels when he/she was in bed and also had Podus boots to wear. CP1 said that R43 did not like to have his/her feet raised when in his/her wheelchair. He/She said the staff tried but the resident did not like it. CP1 stated that for the showers that were scheduled early in the day the Care Partners would have the nurse help undress wounds and then the nurse would help rebandage them afterwards. He/She stated nurses changed bandages daily. He/She stated that if a new skin concern was noted during the shower, they would inform the nurse. CP1 said that R43 had a foot wound after coming back from her last readmission from the hospital, and then went on to hospice care. He/She confirmed that some staff had not been removing the bandages from the heel wound on R43, but the staff had been reeducated. An interview on 10/12/23 at 11:25 AM with the Administrator confirmed the Infection Preventionist (IP) handled and tracked resident wounds. She stated the facility had a wound tracking program that took photos, and helped keep everyone on the same page with how a resident wound was doing. She stated that if a resident's wound was really bad they could send them out to a wound care company. An interview on 10/12/23 at 12:28 PM with the Medical Director revealed he had not been managing the right heel wound for R43, but that the Nurse Practitioner that worked with him was monitoring that. He stated that he had R43 on his list to see next week but was not currently familiar with his/her current right heel wound status. During an interview on 10/12/23 at 1:02 PM the IP stated the facility had a new Performance Improvement Plan (PIP) regarding wounds and ensuring residents had the right interventions in place, communicating the wound assessments with the physicians, and monitoring the weekly wound assessments. The IP stated that R43's right heel wound had deteriorated and had been on an antibiotic recently for an infection with it. She stated R43 had a physician order for calcium alginate if the wound was draining, which the IP said it was. The IP stated the wound was a few months old and was identified in September. The IP confirmed the wound was stage four. She stated that the facility staff had figured out that the Care Partners were keeping the wound wrapped during the showers. The IP stated they had discussed with the staff the proper way to do care. The IP confirmed that she believed a big part of the deterioration was at least in part because of the showering. She stated that during the next all staff mandatory training they would be going over those skills with care staff. The IP stated that the Medical Director had given informal oversight for the resident wounds in the facility to the Nurse Practitioner. She confirmed that LPN1 had requested a continuation of the antibiotic treatment for R43 and had reached out to the physician since the wound had not yet healed. During an interview on 10/12/23 at 1:13 PM the MDS Coordinator (MDSC)1 confirmed that R43 had a right heel wound and that they used Santyl with border foam dressing and calcium alginate if the wound had drainage. MDSC1 stated that R43 had recently finished a round of Keflex antibiotic. She stated the Medical Director used to handle the wounds at the facility, but they were now handled by the Nurse Practitioner (NP). MDSC1 stated that the facility was reviewing wound tracking in their Quality Assurance program, but the NP did not attend those meetings. On 10/12/23 at 2:03 PM the DON stated that she had spoken to the nurse that placed Kerlix on R43 in the morning to find out why it had been done. The DON said that the nurse informed her that the dressing on R43's heel had rolled up underneath, so the nurse had placed the Kerlix around the foot to protect the dressing. The DON stated she had reminded the nurse that it was not a part of the treatment orders for R43 and should not have been done. The DON stated that no resident should have received a shower with a dressing kept in place because it could make things worse. During an interview by phone on 10/12/23 at 2:40 PM the NP stated that she had more recently started doing the wound rounds at the facility, instead of the Medical Director. She stated she had been working with R43 since his/her July readmission. She stated she thought R43 had been admitted with the wound to the right heel from his/her last hospital stay. NP confirmed that the Care Partners had been reeducated because they had been showering R43 with her dressings in place. NP stated they did not think the wound looked very different but did confirm that R43 had been recently on a prescribed order of antibiotics for the right heel due to an infection. NP stated that she came out to the facility about once a month, and as requested by the facility. Based on observations, interviews, record review, and facility policy review, the facility failed to conduct timely identification, assessment, and treatment of a wound for two of five residents (Residents (R) 47 and 43) reviewed for pressure sores out of a total sample of 21 residents resulting in the progression of the wound to advanced stages (stage IV - a deep wound reaching the muscles, ligaments, or bones which can cause pain, infection, invasive surgeries, or even death; or unstageable - a term that refers to an ulcer that has full thickness tissue loss but is covered by extensive necrotic (dead) tissue). This failure resulted in harm to R43 and R47 for the development and worsening of stage IV pressure ulcers to the heels. Findings include: Review of the facility's policy titled, Wound Treatment Management, with a revised date of December 2015, revealed To promote wound healing of various types of wounds, it is the policy of this community to provide evidence-based treatments in accordance with current standards of practice and physician orders. The policy further revealed a section for Pressure Injury Prevention and Management. The community is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heel the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injury. Review of the facility's policy titled, Pressure Injury Prevention and Management, with a revised date of December 2015, revealed This community is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. Assessment of Pressure Injury risk revealed Licensed nurses will conduct a pressure injury risk assessment, using the Cottages Skin and Wound assessment, on all elders upon admission/re-admission, weekly x four weeks, then quarterly or whenever the elder's condition changes significantly. The policy further revealed Licensed nurses will conduct a full body skin assessment on all elders upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented on the Cottages Skin and Wound assessment. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS. Record review of the Interventions for Prevention and to Promote Healing section of the policy revealed Evidence-based interventions for prevention will be implemented for all elders who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include, but are not limited to: . Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.); Minimize exposure to moisture and keep skin clean, especially of fecal contamination; Provide appropriate, pressure-redistributing, support surfaces; Provide non-irritating surfaces; and maintain or improve nutrition and hydration status, where feasible . Review of the facility's policy titled, Skin Assessment, with a revised date of December 2015, revealed 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. Review further revealed Documentation of skin assessment should Include date and time of the assessment, your name, and position title .Document observations (e.g., skin conditions, how the elder tolerated the procedure, etc.) . Document type of wound .Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain) .Document if elder refused assessment and why .Document other information as indicated or appropriate. 1. Review of R47's admission Record, found in the Profile tab of the electronic medical record (EMR), revealed he/she was admitted to the facility on [DATE], with diagnoses including unspecified fracture of lower end of right femur, subsequent encounter for closed fracture with routine healing, type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene, generalize muscle weakness, difficulty walking, unspecified lack of coordination, and pressure ulcer of sacral region, unspecified stage. Review of R47's Braden Scale located in the EMR under Assessments tab, dated 08/21/23, revealed a score of 16, which indicated the resident was at risk for skin breakdown. His/Her ability to walk was severely impaired and he/she was unable to bear his/her own weight. His/Her bed mobility was very limited and could only make occasional body positioning changes. Friction and Shearing required moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequent sliding down in bed or chair, requiring frequent repositioning with maximum assistance. Review of R47's admission Minimum Data Set (MDS) assessment located in the MDS tab in the EMR, with an Assessment Reference Date (ARD) of 08/28/23, revealed a Brief Interview for Mental Status (BIMS) assessment with a score of 12 out of 15 which indicated moderately impaired cognition. R47 required extensive assistance from two staff with bed mobility and transfers and was unable to ambulate. R47 used a wheelchair for locomotion in his/her room and on the unit with set up help only. R47 had only one pressure ulcer on admission, and it was on a bony prominence. However, he/she was at risk of developing pressure ulcers. No deep tissue injury, arterial, or venous ulcers were present. He/She had a pressure reducing device for his/her chair and bed. Pressure ulcer triggered as a care area. Review of R47's Care Plan, located in the Care Plan tab of the EMR, dated 08/24/23, revealed Resident has the potential/actual impairment to skin integrity. The resident's goal was, The skin will remain intact with a target date of 10/31/2023. There were no interventions listed until they were added on 09/06/23. Review of R47's EMR under the Assessments tab revealed on 08/30/23 a Skin & Wound Evaluation was completed and there was no indication of any heel wounds. Record review of the EMR under Physician Orders revealed: -On 08/21/23 A hinged knee brace should be locked at 30 degrees at all times. -On 09/05/23 Prevalon boots to the right foot at all times, right heel offloading measures to heel float, and wound care including use of skin prep and foam dressing. Further review of the Care Plan revealed on 09/06/23 heels off the bed and monitor for signs and symptoms of infection were added as approaches. Another focus area was Physical mobility needs, the resident will remain free of complications related to immobility including contractures, thrombus formation, skin breakdown, falling related injury .The resident is NON-WEIGHT bearing (right) . Locomotion: The resident uses a manual wheelchair for locomotion. Another focus area was, I have ADL [activities of daily living] self-care need. The resident's goal was, The resident will improve current level of function in ADL's. One of the approaches was, BED MOBILITY: The resident requires extensive assistance by (2) staff to turn and reposition in bed. An additional focus area was added on 09/06/23, I have pressure ulcer to my bilateral heels. The resident's goal was, My heels will show signs of healing through next review. The approaches included: Prevalon boots for offloading and Administer treatments as ordered by MD. Record review of the EMR under Physician Orders revealed: -On 09/07/23 A Low Air Loss [LAL] mattress. -On 09/15/23 Weight-bearing status to increase to 50%. Review of R47's Skin & Wound Evaluation, dated 09/13/23, revealed a Stage 2 pressure sore with partial thickness skin loss with exposed dermis was on the left heel. The assessment revealed the pressure sore was in-house acquired. The evaluation revealed there was a right heel pressure ulcer that was in-house acquired. The area was 4.5 cm (centimeters) in length and 2.1 cm in width with an area of 8.9 centimeter squared [cm2]. Review of R47's additional Skin & Wound Evaluation, dated 09/13/23, revealed there was an unstageable in house acquired pressure area to the left heel with no measurements obtained. Review of R47's Skin & Wound Evaluation, dated 10/01/23, revealed a Stage 1: nonblanchable erythema of intact skin in-house acquired pressure area to the left heel. Area was 9.3 cm, length was 3.3 cm, width was 3.5 cm, and depth is 0.1 cm. Review of R47's Cottages Skin & Wound Total Body Assessment, dated 10/04/23, located in the EMR, under the Assessment tab, revealed a blister to left heel is minimal and closed with no open area to measure. Right heel is now a stage 2 wound as skin has broken. Covered with Xeroform gauze and bordered foam dressing. The area was 8.9 cm2, length was 4.5 cm, and width was 2.6 cm. Review of a fax from the physician to the facility revealed the physician saw the resident on 10/10/23 and documented there was a pressure injury to bilateral heels with darkened, well-defined border with each measuring 3x4 cm (centimeters). Physician orders for 10/03/23 revealed a consultation with Wound Care Plus was ordered. The treatment for the right heel was to cleanse the wound with wound cleanser, apply Xeroform gauze and cover with a bordered foam dressing. Physician orders for 10/10/23 revealed the treatment for the bilateral heels was to cleanse with the wound cleanser, apply Xeroform and cover with bordered foam dressing. Observation of R47 on 10/09/23 at 10:05 AM revealed he/she was sitting up in a wheelchair in the hall with a boot on the right foot. At 4:00 PM, the resident was sitting up in a wheelchair and asleep with a boot on the right foot. Review of R47's Skin & Wound Evaluation, dated 10/10/23, for the right heel, revealed a Stage 4: full thickness skin and tissue loss. The measurements were 11.5 cm2 for area, length was 5.0 cm, and width was 3.4 cm. Review further revealed the left heel was a stage one in-house acquired pressure sore. The measurements were 20.9 cm in area, 5.3 cm length, and 5.0 cm width. Observation of R47 on 10/10/23 at 10:37 AM revealed he/she was wheeling himself down the hall and stated he/she had a rash on both heels that he/she did not have before he/she arrived at the facility. R47 believed the rash was from the sheets lying against his/her feet. Observation of R47 on 10/10/23 at 4:30 PM revealed he/she was lying in bed on his/her back with the head of the bed up. Resident was lying on a LAL mattress. A Prevalon boot was on his/her right foot and the left foot was floated on a pillow. Interview on 10/11/23 at 10:21 AM with Licensed Practical Nurse (LPN)2 revealed the areas on the heel were discovered in September. He/She revealed he/she took pictures of the bilateral heel wounds yesterday. He/She stated the right heel measured 11.5 cm for the area, 5.0 length, and 3.4 width. He/She stated the left heel was a blood blister and it burst. He/She stated the measurements were area 20.9 cm2, length 5.3 cm, and width 5.0 cm. He/She revealed they did the treatment once a day and weekly skin assessments. Interview on 10/12/2023 at 12:25 PM with LPN2, by phone, revealed on 09/06/23 a Care Partner (CP) informed him/her about the heels. He/She stated he/she assessed the heels and called the physician to get new orders. He/She stated the orders were skin prep and foam dressing. He/She stated his/her skin assessment was due that day. LPN2 stated R47 liked to sit in his/her wheelchair and used his/her feet to help propel the wheelchair. He/She stated he/she needed assistance of one to turn in bed. LPN2 revealed he/she did not think shearing was a factor in the pressure formation because the resident would help when staff pulled him/her up in bed. Interview on 10/12/2023 at 9:51 AM with CP11 revealed he/she had taken care of R47. He/She stated he/she was non-weight bearing when he/she first came in and he/she needed the assistance of two staff for mobility. He/She stated once he/she became 50% weight bearing he/she was able to do a lot more for himself/herself. He/She stated he/she wore a brace to the right knee all the time. CP11 stated R47 did not move much because it hurt him/her to move. He/She stated he/she had to have the assistance of two staff to turn over in bed at first. CP11 revealed he/she did not have any pressure areas to his/her heels on admission. He/She stated he/she went on vacation at the last of August and when he/she returned in September, he/she saw the heels and reported it to the nurse. He/She stated he/she was not sure why his/her heels broke down, but it was probably because he/she was not moving his/her right leg very much, however he/she could move the left leg. He/She revealed shearing was sliding back and forth on surfaces, but he/she did not think shearing was a factor in the formation of the wounds. He/She stated it was probably from the pressure of being in bed. During an interview on 10/12/23 at 12:08 PM the Director of Nursing (DON) reviewed the EMR and stated R47 was admitted to the facility on [DATE] with no skin issues to the heels. She reviewed the 08/30/23 skin assessment and stated there was no documentation of any heel skin issues. The DON revealed on 09/06/23 documentation showed there were wounds to bilateral heels. Prevalon boots were ordered by the physician. She revealed there were no measurements taken on this skin assessment. The DON revealed from the documentation that the areas to the heels were deep tissue injuries, and it was an error in labeling the staging. She stated she reviewed the physician notes for that day, and he went in to see the resident. The DON stated a low air loss mattress was ordered and was received on 09/07/23. The DON continued to review the pressure assessment and revealed there were no measurements on the 09/13/23 skin assessments, only a picture which looked like a deep tissue injury. She reviewed the skin assessments on 09/27/23 and stated there were no measurements done, only pictures. The DON stated she was not sure if the nurses were supposed to put in measurements. She stated she did not see any skin assessments on 09/20/23. The DON revealed her expectations would have been that skin assessments be done weekly, and measurements should have been taken. But there were pictures. The DON revealed it put the resident at risk if skin assessments and measurements were not done because you could not tell if the wound was healing or worsening. The DON further revealed if skin assessments and measurements were not done you could not tell if the care and treatment was working. Interview with the DON on 10/12/23 at 3:13 PM revealed the initial care plan should have included nutrition and dietary interventions, proper hydration, head to toe assessments, turning and repositioning, pain management, and a low air loss mattress. She revealed R47 did not receive the mattress until 09/07/23 and he/she definitely needed it before that because he/she had a locked brace and would need heel intervention. She stated a low air mattress would have been beneficial sooner to not have the pressure points like a regular mattress did. The DON stated, As a nurse I would advocate for the air loss mattress to help prevent pressure on the heels. During an interview, by phone, on 10/12/23 at 1:54 PM the In-House Physician (PHY) revealed R47 had a pressure ulcer on the left heel and the right heel. He stated the right heel was the side he/she had surgery on. He stated R47 utilized a brace that was locked at 30 degrees, which made it extremely difficult to get the pressure off the heel. He stated the resident was also non weight bearing, for a time, and was up in a wheelchair and bed which contributed to his/her pressure ulcer. PHY stated the staff notified him of the worsening of the wounds, and he thought he ordered consult for him/her. PHY stated he ordered a LAL mattress. PHY stated everything was avoidable, but it was highly likely that he/she would develop pressure ulcers.