**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to a. provide effective preventative treatment to a known high risk resident who was admitted to the facility with a Stage 1 (redness) pressure ulcer that progressed and developed into an open pressure ulcer (Stage 2) and, b. accurately monitor and document weekly skin assessments resulting in the development of an open pressure ulcer that had a delay in being identified and treated, for a resident who was found in pain. This deficient practice resulted in the development, progression delaying the identification and treatment of an open pressure ulcer. This deficient practice was identified for 1 of 5 resident, Resident #3 reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 1/20/23 at 10:25 AM, during the initial tour of the facility, the surveyor observed Resident #3 lying in bed on a regular mattress (not pressure releasing mattress). Resident #3 spoke to the surveyor complaining of significant pain on their sacral area for the past three days. Resident #3 could not articulate their pain level from 1 to 10. Resident #3 was able to reveal that the pain was at a level to prevent them from sleeping comfortably throughout the night. Resident #3 informed the surveyor that they had informed the nurse staff of the pain, but it was not being addressed. The surveyor alerted the Ripple 1 Unit Manager (UM) of the issue. Review of Resident #3's electronic admission Face Sheet (summary of resident's information) indicated that Resident #3 was admitted to the facility on [DATE] with diagnosis that included but were not limited to Acute Respiratory Failure with Hypoxia, Hyperlipidemia, Muscle Weakness (Generalized), and Cardiac Arrhythmia. The surveyor reviewed the Progress Note (PN) dated 1/20/23 and timed at 12:27 PM, written by RN#1 after she performed a skin assessment on Resident #3. The PN skin/wound note established, Resident c/o pain on her sacrum, Tylenol given with relief. Wound noted on her sacrum upon assessment, measurement done as follows: pressure ulcer stage 1, no drainage, one part (1 cm X 0.75 cm); other (0.50 cm x 1 cm). Barrier cream applied cover with DBP (Disinfectants and Disinfection Byproducts) for protection until wound doctor come to assess it. Family member made aware, wound consult ordered. Review of PN and Assessments previous to this assessment on 1/20/23 by RN#1 did not provide any proof that an open pressure ulcer existed with measurements. Review of RN#1 Assessment note dated 1/20/23 and timed at 12:42 PM, titled Skin check-weekly or other supported with a diagram of the body documenting the affected sights and identified as Coccyx. Further description of the wound included Right Buttocks, Pressure Ulcer, redness. Pressure Ulcer, Stage 1, redness. Review of the PN documented by RN #2 written on 1/20/23 at 12:54 PM, Resident verbal c/o (complains of) pain to sacrum. Tylenol 325 mg 2 tab was given for comfort. Wound noted on her sacrum. Measurement taken and was staged as pressure ulcer stage 1, no drainage. It was cleaned with NSS and pat dry with dry dressing applied to it. Nurse supervisor informed. A review of the admission Minimum Data Set (AMDS), an assessment tool used to facilitate the management of care, dated 12/16/22 reflected that the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating the resident is cognitively intact for daily decision making. The surveyor reviewed Section M (Skin Conditions), subsection M0100 of the AMDS, (Determination of Pressure Ulcer/Injury Risk). The documentation indicated that Resident #3 has a. Resident has a Stage 1 or greater pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. A review of Resident #3's admission summary dated [DATE] and written by the admission Registered Nurse, indicated Skin intact noted left chest pacemaker, redness to sacrum. A review of the resident's electronic Medical Record (eMR) under the assessment section, revealed an assessment titled, Skilled Documentation-V2 dated 12/14/22, indicated under Section VII Skin, that the resident's skin is intact, but is at risk for developing pressure ulcers. Further review of the resident's eMR revealed an assessment titled, Braden scale for predicting pressure sore risk located under the assessment section. Review of the Braden Score (The Braden scale assesses a patient's risk of developing a pressure ulcer) performed during admission on [DATE], reflected 17 out of 23, which indicated that Resident #3 was at risk for developing a pressure sore. Review of Resident #3's December 2022 Electronic Treatment Administration Record (eTAR) revealed a PO started on 12/18/22 for, Braden Scale every evening shift every Sunday for assessment for 4 weeks. Review of the December 2022 and January 2023 eTAR indicated that the Braden Scale was calculated and signed for by the nursing staff on 12/18/22, 12/25/22, 1/1/23, and 1/8/23. Review of the eMR Assessment section presented only one Braden Scale for Predicting Pressure Sore Risk calculated on 12/25/22 by a staff RN, with a score of 16 At Risk. No further documentation was initiated or completed for the PO. A review of Resident #3's Care Plan (CP) with an initiation date of 12/11/22 and target completion date of 12/27/22 did not reveal upon admission or at any time after that a CP was developed that addressed the resident's sacral redness, protective and preventative treatments for a Stage 1 pressure ulcer or the need for continued skin assessments. A review of the Physician Order (PO) Summary dated 1/24/23, identified an order with an original date of 12/11/22, for Weekly Skin Assessment every evening shift every Sunday for assessment. Review of the December 2022 eTAR presented the PO that began on 12/18/22 documented as, Weekly Skin Assessment, every evening shift every Sunday for assessment. Documentation on the December 2022 and January 2023 eTAR recorded that the facility nurses signed performing skin checks on Resident #3 for 12/18/22, 12/25/22, 1/1/23, 1/8/23, 1/15/23 and 1/20/23. Continued review of the two months of documentation in the Assessment and Progress Note (PN) sections of the EMR, revealed that there was no further information related to the facility nursing staff performing skin checks for 12/18/22, 1/1/23, 1/8/23 and 1/15/23. Review of the eMR Assessment section written by a staff RN on 12/25/22 revealed, Skin intact, no pen area noted, oral cavity intact, denies pain. No further information or documentation was noted. Review of the December 2022 and January 2023 electronic Medication Administration Record (eMAR) revealed that pain levels for Resident #3 were monitored every 6 hours. Pain levels were documented as 0 (no pain) on all days for the month of December 2022 and January 2023 except for 4 days with level 1-3 (mild pain) documented in December and 5 days in January 2023. Continued review of the January 2023 eMAR revealed a documented pain level of 4 (moderate pain) on 1/24/23 at 12:00 PM. The surveyor reviewed the PO for Acetaminophen 325 mg (2) tablets every 6 hours as needed for mild pain scale 1-3 with a start date of 12/11/22, documented on the December 2022 and January 2023 eMAR. Resident #3 was documented as receiving the Acetaminophen 325 mg (2) tablets on 12/19/22 at 5:46 PM with a 3 pain level (mild), on 1/18/23 with a 3 pain level at 6:30 PM, 1/20/23 with a 6 pain level (moderate) at 11:39 AM, and 1/23/23 with a 6 pain level at 9:07 AM. On 1/25/23 at 9:46 AM, another surveyor interviewed RN #2 who stated that she has been working in the facility for a year. The surveyor also interviewed the CNA who stated that she had been working in the facility for 7 months. The surveyor viewed the wound with the permission of the Resident, and the aid of RN#2 and the CNA in the privacy of the Resident's room. The surveyor observed RN #2 remove a white bordered dressing on Resident #3's sacrum area. The surveyor observed the sacrum area having a small opening (yellow in appearance) and redness to the surrounding area. RN #2 informed the surveyor, there's a small opening in the sacrum. RN #2 explained that RN#1 was the nurse who assessed and staged the wound. RN #2 acknowledged, Stage 1 is when there's an opening in the area. Review of pressure ulcer staging practice defines Stage 1 Pressure Ulcer as, Intact skin with discoloration of the skin that does not turn white when pressed, redness of a localized area, usually over a bony prominence. Review of pressure ulcer staging practice defines Stage 2 Pressure Ulcer as, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. On 1/25/23 at 11:15AM, surveyor interviewed the Certified Nursing Assistant (CNA), who routinely takes care of Resident #3 on the day shift (7:00 AM to 3:00 PM). The CNA stated she has not been assigned to Resident #3, in a few weeks. The CNA informed the surveyor that when assisting residents during changing their clothes, bathing and/or use of the bathroom, she would report any skin conditions found to the resident's nurse and/or the Unit Manager. On 1/25/23 at 11:22 AM, the surveyor interviewed the Ripple 1 Registered Nurse (RN #1). RN #1 stated that she was the nurse that performed the skin assessment for Resident #3 on 1/20/23, when the Stage 1 pressure ulcer was discovered. RN#1 explained that she documents information related to the pressure ulcer in the Assessment and PN section of the EMR. The surveyor discussed the four missing weekly PN and assessments as well as the three missing Braden Scale evaluations with RN#1. RN#1 could not explain why the nurses on duty did not enter information evaluating the residents skin assessment in the eMR as well as calculate the Braden Scale related to the resident's risk of developing pressure sores. RN#1 stated that if the nursing staff signs the eMAR and eTAR documenting that the task was completed, there should be documented proof of the task. On 1/25/23 at 11:27 AM, the surveyor interviewed Ripple 1 RN#2, who also assessed Resident #3's pressure ulcer on 1/20/23. RN#2 informed the surveyor that when performing a skin assessment the facility protocol includes: writing the skin assessment note in the eMR PN and Assessment section, documenting the appearance of the skin, information related to informing the physician, and identifying the physician's recommendations. The surveyor discussed the four missing weekly PN and assessments as well as the three missing Braden Scales, which should have been documented in the eMR, with RN#2. RN#2 could not explain why the nurses on duty did not enter information evaluating the residents skin assessment in the eMR as well as calculate the Braden Scale related to the resident's risk of developing pressure sores. RN#2 acknowledged that all nursing staff documenting in the eMAR and eTAR that the task was completed, should be documented proof of the task. On 1/26/23 at 11:18 AM, the surveyor interviewed the Director of Nursing (DON). The DON explained that when a resident is admitted to the facility with sacral redness (Stage 1 pressure ulcer), the protocols include: Alerting the physician, possibly providing an air mattress, turning and repositioning are added to the resident's plan of care. We also do skin assessments, which are automatically started for new and re-admitted residents. We may also add a foam dressing with padding and Periguard (barrier cream) if needed. The DON stated that Resident #3 should have had an individualized Care Plan (CP) upon admission that addressed the sacral redness noted during admission. The CP should have included preventative measures to avoid the development of an open pressure ulcer. The DON acknowledged that Resident #3 was admitted with a Stage 1 pressure ulcer that had progressed to a Stage 2 pressure ulcer. The DON verified that after review of RN#1 and RN#2's PN and Assessment Notes, once the pressure ulcer was open, it was staged wrong by RN#1 and was no longer a Stage 1 pressure ulcer, but rather a Stage 2. The DON verified that Resident #3 should have had those protocols in place on admission when the sacral redness was discovered. The DON established that the weekly skin assessments should be completed on the eMR under the Assessment area. The DON could not explain why four weekly skin PN and assessments as well as the three Braden Scale Scores for Resident #3 were missing and not performed. On 1/23/23 at 2:40 PM, the DON provided the surveyor with a facility policy titled, Pressure Injury Risk Assessment, last reviewed on 11/11/2022. Under the Purpose section of the policy it states, The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing new pressure injuries or worsening of existing pressure injures (PIs). Continued review of the policy under General Guidelines identifies; 1. The purpose of a pressure injury risk assessment is to identify all risk factors and then to determine which can be modified and which cannot, or which can be immediately addressed, and which will take [NAME] to modify. 3. The risk assessment should be completed as soon as possible after admission, but no later than eight hours after the admission. 4. Use only a facility-approved risk assessment tool to obtain risk assessment data. 5. Supplement the risk assessment tool with assessment of additional risk factors. 6. Once the assessment is conducted and risk factors are identified and characterized, a resident-centered care plan can be created to address the modifiable risks for pressure injuries. 7. Repeat the risk assessment weekly for the first four weeks, if there is a significant change in condition, or as often as is required based on the resident's condition. Documented under Steps in the Procedure, it explains; 1. Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. 4. Conduct a comprehensive skin assessment with every risk assessment. a. When conducting a skin assessment, provide for the resident's privacy. b. Once inspection of the skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. 5. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. a. The interventions must be based on current, recognized standards of care. b. The effects of the interventions must be evaluated. c. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Explained under the Documentation it states, The following information should be recorded in the resident's medical record utilizing facility forms: 1. The type of assessment(s) conducted. 2. The date and time and type of skin care provided, if appropriate. 5. The condition of the resident's skin (i.e., the size and location of any red or tender areas), if identified. 11. Initiation of a (pressure or non-pressure) form related to the type of alteration in skin if new skin alteration noted. On 1/26/23 at 1:37 PM, the DON provided an additional facility policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, which was last updated on 11/11/22. Under the Assessment and Recognition section, it states, 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcer; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall assess and reassess, describe and document/report on PCC (computer program used by the facility) / Paper and upload weekly assessments On 1/26/23 at 1:35 PM, the surveyor met with the DON to further discuss the issue. No further information was provided. NJAC 8:39-27.1 (a)