**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that a resident received care consistent with professional standards of practice, to prevent pressure ulcers, and promote healing. This deficient practice was identified for 1 of 2 residents, (Resident #197) who was identified as having a pressure right hip injury on 11/13/24, with no description of a wound, which progressed to an unstageable wound to the right hip with 30% slough (necrotic tissue that needs to be removed from the wound for healing to take place) with serosanguinous drainage. The wound measured 3 centimeters (cm) x 4 cm x 0.1 cm and was identified during routine wound rounds by a consultant on 11/20/24. The resident developed an unstageable pressure wound to the right hip on 11/20/24, which required chemical debridement when the resident was hospitalized on [DATE]. The evidence was as follows: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. According to the National Pressure Injury Advisory Panel (NPIAP), Pressure Injury Stages, the updated staging system includes the following definitions: Pressure Injury: A pressure injury is 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 that may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. 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 . According to [name of immediate care company], Types of Wound Drainage and How to Tell When It is Serious, it's important to be able to identify different types of drainage in order to best care for wounds and discuss possible treatment options with the doctor. According to Disease and Condition, 4 Types of Wound Drainage: 1. Serous Drainage, a thin, watery, and clear substance exiting the wound is classified as serous drainage. When the wound is fresh and going through the inflammatory wound healing stages, it's perfectly normal to experience this type of drainage. If notice an overwhelming amount of serous drainage, it may indicate high bioburden or the presence of unsterilized bacteria living on the wound. 4. Serosanguineous is the most common type of drainage. It is thin, watery, and tends to be pink in color, but can also be shades of darker red. The pink/red coloring has to do with red blood cells in the fluid, a sign of capillary damage. 1. On 12/02/24 at 10:12 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) for an entrance conference. The DON informed the surveyor that residents with wounds including pressure ulcers, tube feeding, tracheostomy, dialysis, and an opening in their bodies were placed on EBP (Enhanced Barrier Precautions, are an infection control intervention to reduce MDRO (mutidrug resistant organism; are germs that are resistant to many antibiotics and can cause infections) transmission in nursing homes). The surveyor asked the LNHA and DON for list of residents with facility acquired wounds. On 12/2/24 at 11:09 AM, the surveyor observed a posted sign outside the door for EBP. Inside the room, Resident # 197 was lying on the geri chair. The surveyor reviewed the medical records of Resident #197. The admission Record (an admission summary) revealed that the resident was admitted to the facility with the following medical diagnoses that were not limited to; unspecified dementia, contracture right knee and left knee, and abnormal posture. A review of the Braden scale (to measure risks of resident's developing pressure ulcers) dated 10/29/24, the resident scored 11 out of 23 which indicated high risk for developing pressure ulcers. The most recent comprehensive Minimum Data Set (cMDS), an assessment tool used to facilitate the management of care, with an assessment reference date of 10/27/24, revealed that the resident's cognitive skills for daily decision-making were severely impaired. The cMDS indicated that the resident had no wounds. A review of the Resident Evaluation for admission dated 10/21/24, revealed sacrum, left heel, and right heel redness. There was no documented evidence of sacrum or left and right heel redness measurements. A review of the Resident Evaluation for readmission dated 11/25/24, revealed left heel blanchable skin ecchymosis, right heel blanchable skin ecchymosis, sacrum skin excoriation on a pressure point, and right trochanter (hip) suspected deep tissue injury (DTI). There was no documented evidence of measurements of the mentioned skin impairments on the left and right heels, sacrum, and right hip. A review of the list of residents with facility-acquired wounds provided by the LNHA on 12/02/24 at 12:10 PM, revealed two residents which included Resident #197 for sacral wound stage 2 (sore area of skin has broken through the top layer of skin (epidermis) and some of the layer below (dermis)) pressure ulcer that started on 11/20/24. A review of the wound consultation reports revealed the following: -10/23/24: recommended moisture barrier cream to bilateral buttocks and sacrum, skin prep and offload blanchable heels. There was no documented evidence that there were pressure ulcers identified for the sacrum. -11/20/24: Unstageable right hip 3 cm x 4 cm x 0.1 cm, 40% dermis, 30% slough, 30% epithelization, full thickness, serosanguineous, cleanse with saline medihoney dry dressing daily/prn (as needed), reposition side to side, monitor for changes. There was no documented evidence that there was a pressure ulcer identified for the sacrum. -11/27/24: Stage 2 right hip 3 cm x 3 cm x 0.1 cm, 100% dermis, partial thickness, cleanse with saline medihoney dry dressing daily/prn, reposition side to side, monitor for changes. There was no documented evidence that there was a pressure ulcer identified for the sacrum. A review of the physician orders (PO) revealed the following: -Calmoseptine external ointment 0.44-20.6% apply to sacrum topically every day and evening shift for redness with a start date of 10/22/24 and discontinued (d/c) on 11/22/24. -Weekly skin observations every day shift every Wed (Wednesday) 0-NO skin breakdown, 1-Previously identified wound 2-Newly identified wound with an order date of 10/22/24 and d/c order on 11/22/24. The above order for skin observations revealed that the nurse every Wed at 7:00 AM-3:00 PM (day shift) will code 0 if there was no skin impairment, code 1 if there was a previously identified wound, and code 2 if a newly identified wound was identified. -Offload heels while in bed as tolerated every shift with an order date of 10/21/24 and d/c on 11/22/24. -Optifoam to left hip every day shift for protection with a start date of 11/14/24 and d/c 11/21/24. -apply optifoam to right hip everyday shift for protection with an order date of 11/13/24 and d/c order on 11/21/24. -Cleanse Right ischium (hip) with NSS, pat dry, apply Medi-honey ointment (wound and burn gel made from honey that has antibacterial and bacterial resistant properties, meaning it prevents bacteria from building a tolerance to its beneficial effects) to the wound bed, and cover with Opti foam (is a foam dressing that has a silicone adhesive border, waterproof backing and can stay in place up to 7 days, depending on the amount of wound drainage) every day shift for Pressure with an order date of 11/21/24. -Weekly skin observations every evening shift every Thu (Thursday) 0-NO skin breakdown, 1-Previously identified wound 2-Newly identified wound with an order date of 11/25/24. -Offload heels while in bed every shift with a start date of 11/25/24. -Skin prep right heel every day and evening shift with a start date of 11/26/24. -Skin prep left heel every day and evening shift for protection with a start date of 11/26/24. -Cleanse right trochanter/hip wound with NSS (normal saline solution), pat dry, apply Medi-honey ointment, cover with optifoam dressing every day shift for wound care with a start date of 11/26/24. -Apply optifoam dressing to sacrum every day shift for protection with a start date of 11/27/24 and d/c 12/03/24 -Apply optifoam dressing to left hip every day shift for protection with a start date of 11/27/24 and d/c 12/03/24. The above PO were transcribed to the electronic Treatment Administration Record (eTAR) for November and December 2024 and revealed: -on 11/13/24, the Licensed Practical Nurse (LPN) signed the eTAR and coded 1 (previously identified wound) of the weekly skin observations for the day shift. A review of the Pressure Injury Documentation in the electronic medical record revealed: -11/21/24 at 3:23 PM, the first observation: right hip stage 2, measurement: 3 cm x 4 cm x 0.1 cm, 30% epithelial, 30% sloughed, 40%dermis, serosanguineous drainage, and electronically signed by the Registered Nurse (RN). -11/27/24 at 3:42 PM, the first observation: right hip stage 2, measurement 3 cm x 3 cm x 0.1 cm, 100% dermis, serous drainage, and electronically signed by the RN on 12/02/24 at 3:44 PM. Further review of the above medical records revealed that there was no documented evidence that the facility staff identified the right hip wound prior to the wound doctor identifying the pressure injury. The unstageable wound to the right hip was identified during the wound rounds. A review of the personalized care plan (CP) revealed that there was no documented evidence that the actual new pressure injury in the right hip was identified and initiated an intervention to promote healing and prevent further development of new pressure injury. Further review of the medical records revealed that there was no documented evidence that the physician was notified of the new pressure injury to the right hip. A review of the most recent hospitalization records revealed that Resident #197 was seen by the Advance Practice Nurse (APN) on 11/22/24, for wound evaluation. The APN documented on her assessment that the resident was dependent on mobility, and skin characteristics: right trochanter with a full-thickness wound, stage 3 pressure injury (prior to admission to the hospital) approximately 2.5 cm x 2.5 cm, wound based appeared 70% viable tissue and 30% yellow fibrinous debris, and with a scant amount of serosanguinous exudate. The APN also documented the topical care: apply collagenase to the site for enzymatic debridement and cover with a silicone dressing to promote moist wound healing and for protection, change daily. On 12/04/24 at 12:54 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) of 2 North. The RN/UM informed the surveyor that it was the responsibility of the nurses to initiate a care plan upon admission, and he was responsible for updating the care plan. The surveyor notified the RN/UM of the above concerns that there was no CP initiated for the right hip pressure ulcer when it was first identified by the wound doctor on 11/20/24. The RN/UM stated, I missed it. He also confirmed that there was no stage 2 pressure injury to the sacrum and the facility-acquired wound was the right hip. At that same time, the surveyor notified the RN/UM of the concern that there was no documented evidence in the 10/21/24, admission that there was right hip skin impairment and 11/25/24, readmission resident's evaluations (assessment) that the skin impairment in the right hip was measured. The RN/UM responded that the nurse should have documented wound measurements. The RN/UM stated that the right hip had a previously healed wound which was why on 11/13/24, optifoam dressing was ordered as protection. The RN/UM further stated that he would get back to the surveyor as to why there was no documented evidence that there was a previously identified wound to the right hip. On 12/04/24 at 02:27 PM, the surveyor notified the DON of the concern that the resident's unstageable right hip wound was identified on 11/20/24, by the wound doctor during the routine wound rounds. The surveyor asked the DON why there was an order for optifoam dressing on 11/13/24, and the DON responded that there was no wound or redness on the right hip on 11/13/24, it was ordered for protection. At that same time, the DON stated that she understood the concern of the surveyor as to why the facility did not see the right hip wound, and it was the wound doctor who identified it, when the wound doctor saw the wound, it was unstageable with slough and drainage. The DON stated that she would get back to the surveyor. On 12/05/24 at 10:46 AM, the surveyor interviewed the RN regarding skin and wound assessment. The RN stated that she knew that for an open wound, the nurse should measure the wound, but she was unsure if she had to measure intact skin or intact skin impairment like redness or bruise. She further stated that it was the responsibility of the wound doctor to stage the wound every Wednesday during wound rounds. The surveyor asked the RN, what would happen for residents who developed new wounds, new admission, and readmission with wounds, who would stage the wound and document appropriate wound description to obtain the correct treatment if the wound doctor came on Wednesday only. At that same time, the RN acknowledged that she was the nurse who documented pressure injury documentation for the dates 11/21/24 and 11/27/24, for the right hip. She stated that the 11/21/24, right hip documentation was based on the 11/20/24 wound consult notes documentation. The surveyor then asked if she copied the wound documentation from the wound doctor, and why she documented stage 2 as not unstageable considering that there were no changes from the description of the wound doctor, and the RN did not respond. On 12/05/24 at 10:54 AM, the surveyor observed the wound treatment of Resident # 197 done by RN/UM and was assisted by the RN. The RN/UM read the order: to cleanse the right hip wound with NSS (normal saline solution), pat dry, apply medihoney ointment, and cover with optifoam dressing everyday shift for wound care (start date 11/26/24). The RN/UM removed the right hip dressing and informed the surveyor that the wound was beefy red, and the measurement was 0.5 cm x 0.5 cm. The RN did not perform hand hygiene in between gloves use, after direct contact to resident's environment (garbage receptacle), and prior to exiting the resident's room. The RN/UM did not disinfect the marker used to sign the dressing applied to the resident before and after use, and did not disinfect the container of medihoney that was brought inside the resident's room prior to returning inside the treatment cart. On 12/05/24 at 11:26 AM, the surveyor interviewed the LPN. The LPN confirmed that she was the nurse on 11/13/24 and 11/20/24 who signed the eTAR for a weekly skin evaluation. She stated that she coded 1 which meant that there was a previously identified wound. The LPN further stated that the previously identified wound was the right hip and she remembered it was definitely not a redness, it was more than that, it was worse and open. She further stated that on 11/13/24, she remembered that was the time the resident was moved to her side and assignment, and she did the skin evaluation and signed the eTAR. The surveyor asked why she coded it a previously identified wound that was not identified in the admission, and the LPN responded that when she notified the RN/UM at that time, the RN/UM told her that they knew about it, and they had been monitoring it and the RN/UM took care of it that was why she coded 1 as previously identified wound for the right hip. Further review of the EMR revealed the following: -The Late Entry Progress Notes (PN) with an effective date of 11/30/24, created on 12/08/24 at 4:23 PM, that was electronically signed by the Medical Doctor (MD) revealed that the right hip wound was covered with a dressing. -The PN with an effective date of 12/08/24, that was electronically signed by the MD revealed that the MD was called by the nurses on 11/13/24, that the resident had right hip pressure noted, optifoam dressing daily was ordered, the staff was advised to monitor for worsening changed of the area, wound care consult advised, and monitor for fever. -The Late Entry PN with an effective date of 11/20/24, created on 12/03/24 at 12:47 PM, that was electronically signed by the DON revealed that the RN/UM reported to her that during wound rounds with the wound team, the resident was noted with right hip pressure ulcer, 3 cm x 4 cm x 0.1 cm with small amount of serosanguineous drainage, 40% dermis, 30% slough, 30% epithelialization. Further review of the above EMR revealed that the advice of the MD on 11/13/24, to consult the wound doctor was not followed for the right hip pressure wound. On 12/05/24 at 12:25 PM, the survey team met with the LNHA and DON. The surveyor notified the facility management of the concerns with Resident #197's right hip facility-acquired wound. On 12/09/24 at 11:34 AM, the survey team met with the LNHA and DON. The DON informed the surveyor that she asked the RN/UM to create another wound timeline that would include more information on Resident #197's right hip facility-acquired wound. The DON stated that the nurses should be able to assess, describe a wound, stage a wound, and relay to the doctor the wound to obtain an appropriate treatment order promptly. She further stated that the nurse should measure any skin impairment either a bruise, pressure ulcer, or skin tear as part of the assessment. At that same time, the DON stated that there was no documentation from the nurse why the order for optifoam dressing was obtained and it was missed by the nurse. The DON further stated that there was no documentation from the facility before the wound doctor identified the facility-acquired unstageable pressure injury to the right hip. The DON stated that there was a knowledge deficit on the part of the nurse on how to describe and assess the appearance of the wound, because if the nurse had seen that it should have been documented and notified the doctor to obtain a proper treatment for that skin impairment. Furthermore, the surveyor asked the LNHA and the DON if they were able to verify with the LPN that she was able to identify the right hip wound on 11/13/24, during weekly skin observation, why it was not investigated, and why the LPN did not notify the physician of the observation that the right hip was an open wound and non-intact skin. The DON stated that she would get back to the surveyor. On 12/09/24 at 01:29 PM, the surveyor interviewed the DON regarding the Pressure Injury Investigation Form (PIIF) dated 11/13/24, the PIIF revealed an investigation for right hip pressure injury with no description of the pressure injury, no measurements, and did not include what stage the wound was. In the summary, it was documented that the pressure injury was unavoidable. The PIIF instruction included in the summary was if unavoidable, a box should be checked off for a yes or a no if the physician has completed the physician documentation form or written a progress note, and it was not checked off. The DON stated that she had to ask the RN/UM who did the PIIF because she did not have a copy of the PIIF. The surveyor also notified the DON of the concern that the PIIF investigation on 11/13/24, did not match what was previously provided information of the DON and the RN/UM about the right hip and that no wound was why the order for optifoam the physician was for protection. On 12/09/24 at 01:33 PM, the DON provided a copy of the Pressure Injury investigation dated 11/20/24, which was prepared by the DON for the right hip that was identified during wound rounds, that the incident was unwitnessed, and that no statements were found. Attached to the investigation were the Pain Evaluation and Braden Scale assessment with an effective date of 11/20/24, which was electronically signed by the DON on 12/03/24. The surveyor asked the DON why the pressure injury investigation on 11/20/24, was incomplete, with no staff statements, and was not completed until 12/03/24, after the surveyor's inquiry. The DON stated that she had to get back to the surveyor. On 12/11/24 at 8:49 AM, the surveyor called and left a message for the Wound Doctor (WD#1), and the doctor did not return the call. On 12/11/24 at 10:50 AM, the surveyor interviewed WD#2 and notified that WD#1 did not return the call of the surveyor. WD#2 informed the surveyor that she was the covering wound doctor of the facility and acknowledged that WD#1 was the other doctor who was caring for the resident. WD#2 stated that she was familiar with the resident and had seen the resident since last week. She further stated that the wound team rounds were every Wednesday between 7:00 AM-9:00 AM. On that same date and time, the surveyor asked WD#2 about the identified unstageable pressure injury to the right hip on 11/20/24, and WD#2 stated that a resident would be possible to develop an unstageable open wound or intact DTI if the resident was immobilized for 6 hours that was why it was important to turn and reposition the resident. A review of the facility's Pressure Ulcers/Skin Breakdown-Clinical Protocol Policy with a revision date of March 2014 that was provided by the DON revealed: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; 3. Staff will examine the skin of a new admission for ulcerations or alterations in skin . On 12/11/24 at 01:21 PM, the survey team met with the LNHA and DON for an exit conference. The facility management did not provide additional information. NJAC 8:39-27.1 (a,e)