**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents received the necessary treatment and services to prevent the development and worsening of pressure wounds (also called a pressure injury; skin damage which results from unrelieved pressure on the body) for 2 (R #50 and #69) of 2 (R #50 and #69) residents reviewed when staff failed to: 1. Timely identify the new wound, monitor for changes in the wound, provide daily treatments as ordered and notify the physician that the wound was worsening for R #50. 2. Complete and document weekly skin evaluations for R #69. This deficient practice likely resulted in R #50's pressure ulcer worsening and leading to an amputation. This deficient practice is also likely to lead to residents developing pressure ulcers and wounds worsening. The findings are: R #50: A. Record review of R #50's face sheet revealed R #50 was admitted into the facility on [DATE]. B. Record review of R #50's Braden Scale for Predicting Pressure Sore Risk (a tool used by healthcare professionals to assess a patient's risk of developing pressure ulcers), dated 10/04/23, revealed R #50 was at risk for developing pressure ulcers. C. Record review of R #50's facility skin checks completed by the facility's Wound Care Nurse (WCN) revealed the following: - On 10/19/23, R #50 had a skin wound to her left rear thigh. No other wounds identified. - On 11/07/23, R #50 refused the skin assessment. D. Record review of R #50's hospital wound care notes, dated 11/23/23 revealed R #50 was sent to the hospital due to a fever and altered mental status, and R #50 was admitted into the hospital. E. Record review of R #50's hospital notes, dated 11/24/23, revealed R #50 had an unstageable [a wound that has full thickness tissue loss but is covered with slough (dead tissue) or eschar (dark scab or falling away of dead skin) so that the true depth of the wound cannot be determined] posterior (further back in position) eschar pressure injury on her left heel. The hospital notes did not include measurements of the pressure injury. R #50 was also diagnosed with encephalopathy (a disease that affects brain structure or function) and sepsis (an infection in the blood stream) due to a urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra). R #50 was discharged from the hospital on [DATE]. F. Review of R #50's facility skin check dated 11/29/23, revealed staff documented R #50 had a black pressure ulcer on the left heel. Staff did not document measurements or any other information related to R #50's left heel pressure ulcer. G. Record review of R #50's facility wound evaluation, dated 11/30/23, revealed R #50's left heel pressure ulcer was unstageable and present on admission with age [of wound] unknown. R #50's left heel pressure ulcer measured 1.53 centimeters (cm) length and 0.96 cm width. H. Record review of R #50's physician orders, dated 11/30/24, revealed an order for wound care to left heel. Paint with betadine (antiseptic medication), cover with heel /foam, wrap with kerlix (bandage), and secure with tape every night shift for unstageable pressure ulcer. R #50's order was discontinued on 01/03/24. I. Record review of R #50's Treatment Administration Record (TAR), dated 12/01/23 through 12/31/23, revealed staff completed R #50's order for wound care to left heel every night R #50 was in the facility. J. Record review of R #50's hospital history and physical documentation, dated 12/07/23, revealed R #50 went to the emergency room (ER) due to R #50 experienced hypoxia (low blood oxygen levels), vomiting, and confusion. R #50's hospital documents revealed R #50 had an unstageable left heel pressure ulcer. R #50 was admitted into the ER on [DATE] and discharged back to the facility on [DATE]. K. Record review of R #50's skin and wound evaluations revealed the following: - Two evaluations, dated 12/18/23 (one completed at 12:20 pm and the other completed at 12:23 pm), staff did not document R #50's left heel pressure ulcer on either skin and wound evaluations - One evaluation, dated 12/27/23, staff did not document R #50's left heel pressure ulcer. L. Record review of R #50's facility wound evaluations (of the same document type), completed by the WCN, revealed staff documented the following: - On 12/27/23, R #50's left heel pressure ulcer measured 1.89 cm length and 0.98 cm width. - On 01/03/24, R #50's left heel pressure ulcer measured 2.6 cm length and 1.43 cm width. M. Record review of R #50's medical record revealed the record did not contain an update or change to the wound care orders for the resident's left heel pressure ulcer. N. Record review of R #50's TAR, dated 01/01/24 through 01/05/24, revealed staff completed R #50's order for wound care to left heel one time on 01/02/24. O. Record review of R #50's nursing progress notes, dated 01/05/24 at 2:42 pm, revealed R #50 was discharged with all medications to live with her niece. Further review revealed staff did not document they gave wound care instructions to R #50 prior to discharge. P. Record review of R #50's physician orders, dated 01/05/24 at 6:00 pm [after R #50's discharge], revealed an updated order for wound care to left heel. Cleanse with wound cleanser, pat dry, apply ManukaHD (natural antibiotic) honey to wound bed, and cover with foam dressing every night shift, every other day for unstageable pressure ulcer. There is no evidence in the record that this wound care was provided. Q. Record review of R #50's hospital documentation, dated 01/07/24, revealed R #50 was taken to the ER by ambulance (from R #50's niece's home) for an evaluation of a non-healing left foot ulcer with erythematous (reddening of the skin) margins and purulent (containing pus) discharge with concerns for osteomyelitis (infection in the bone caused by bacteria or fungi). R #50 was consulted and had a below the left knee amputation on 01/12/24. R. Record review of R #50's care plan dated 01/18/24, revealed R #50 was at risk for skin breakdown due to diabetes, compromised skin related to previous multiple open areas, and limited mobility. One intervention was for staff to observe R #50's skin condition daily and report any skin abnormalities. S. On 06/24/24 at 12:18 pm during an interview with R #50, she stated the facility did not routinely assess and treat her left foot, which led to it becoming infected. R #50 stated an ambulance took her to the ER in January 2024 for an evaluation, because her foot was not better. She stated it smelled badly and her left lower leg was amputated as a result of the wound. T. On 06/26/24 at 10:54 am and on 07/02/24 at 11:55 am during an interview with the WCN, she stated R #50 was in and out of the hospital multiple times in 2023 and returned to the facility in November 2023 with an unstageable pressure ulcer to her left heel. The WCN stated she evaluated R #50 weekly as much as she could, but R #50's left heel pressure ulcer began to open and deteriorated from 12/27/23 to 01/03/24. The WCN stated she was asked to work the floor due to short staffing during this time as well. The WCN stated she did not consult a wound care clinic for R #50. She stated R #50 returned to the facility on January 17, 2024, and R #50's left lower leg was amputated. The WCN stated she oversaw the facility's wound care program, but the nurses know they are supposed to complete skin evaluations for residents every week. The WCN also stated every nurse was assigned skin evaluations to complete. She stated completing the skin evaluations has been an on going issue due to staffing and staff turnover. The WCN stated R #50 did not have consistent weekly skin evaluations, and staff documented R #50's left heel pressure ulcer only one time in the weekly skin evaluations. The WCN stated staff should have monitored and documented more frequently for the status of R #50's left heel pressure ulcer. The WCN confirmed R #50's January 2024 TAR indicated the nurses completed wound care for R #50 on 01/02/24, but the nurse should have completed wound care each day R #50 was in the facility. U. On 07/01/24 at 1:05 pm during an interview with Nurse Practitioner (NP) #1, she stated her expectation was for facility nursing staff to check on resident wounds daily, conduct weekly skin evaluations, and document the progress or decline of a resident's wound for providers and the WCN to see. The NP confirmed that she was not aware of the wound worsening and would have liked to be notified sooner. V. On 07/02/24 at 12:35 pm during an interview with R #50's Sister-In-Law (SIL), she stated R #50 went to stay with her niece in January 2024. She stated R #50 was with her niece for one night due to R #50's left heel pressure ulcer smelled really bad and looked infected. The SIL stated R #50's left lower leg was amputated shortly after that. W. On 07/02/24 at 12:40 pm during an interview with R #50's niece, she stated she helped R #50 on the first night R #50 was with her. She stated R #50's left heel pressure ulcer was black and had a distinctly bad smell coming from it. R #50's Niece stated R #50 wanted to go to the hospital so they called 911. She stated an ambulance took R #50 to the hospital for her left heel pressure ulcer, which resulted in a left lower leg amputation. R #69: X. Record review of R #69's face sheet revealed R #69 was admitted into the facility on [DATE]. Y. Record review of R #69's physician orders, dated 03/13/24, revealed an order for a unstageable pressure ulcer to the right heel. Apply sureprep (skin protectant) every day shift for pressure ulcer wound care. Z. Record review of R #69's Electronic Health Record (EHR) revealed nursing staff completed a skin evaluation for R #69 on 05/28/24. Further review revealed the WCN did not complete another skin evaluation for R #69 until 07/02/24. R #69's EHR indicated the WCN did not see R #69's wound from 05/28/24 until 07/02/24. AA. Record review of R #69's care plan, reviewed on 07/02/24, revealed the following: - Focus: R #69 was at risk for skin breakdown. - Interventions: Observe skin for signs and symptoms of skin breakdown, i.e. redness, cracking, blistering, decrease sensation, and skin that did not blanche easily. Observe skin condition daily with activities of daily living (ADLs; personal care activities that most people perform daily) care and report abnormalities. BB. On 07/01/24 at 3:09 pm during an interview with the WCN, she stated nurses should complete a skin evaluation for R #69 weekly, but they did not. Based upon observation, interview, and record review, Immediate Jeopardy was identified on 07/02/24 at 3:43 pm. The facility Administrator and Director of Nursing were notified in person and by e-mail at this time. The facility took corrective action by providing an acceptable Plan of Removal (POR) and implementation was verified onsite on 07/03/24. The scope and severity was reduced to level 2, E. The plan of removal included: 1. On 7/2/24, the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility and assess for correct identification and treatment. Any identified concerns, including refusals of wound care/assessment and worsening wounds, will include change in condition documentation and notification to the provider and family. Any new orders will be followed. 2. Nurses will be educated on completion of skin assessments on admission and weekly per schedule. 3. Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). 4. Nurses will be educated on [Name of facility company] wound processes which include the DIMES (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, wound Edge preparation and wound depth), timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. 5. CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNA's (including skin changes) and stop and watch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure that 3 (R #42, 96 and 98) of 3 (R #s 42, 96 and 98) residents reviewed for pressure ulcers received monitoring and care to prevent the development and worsening of pressure ulcers by: 1. Not accurately assessing residents skin upon admission/re-admission or immediately implementing treatment and monitoring for skin issues once identified for R #42, 96 and 98. 2. Not implementing effective interventions to prevent new skin wounds from developing and worsening for R #96 and R #98. These deficient practices likely resulted in the development and worsening of resident pressure wounds, including a Stage 3 (full thickness tissue loss) pressure ulcer and Stage 4 (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) pressure ulcer. The findings are: Findings for R #98: A. Record review of R #98's medical record indicated that he was re-admitted to the facility [from the hospital] on 04/18/23. His diagnoses included fracture of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture of with routine healing; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; urinary tract infection (a common infection that happens when bacteria, enter the urethra {hollow tube that lets urine leave the body} and enter the urinary tract), site not specified; repeated falls; depression, unspecified; and adult failure to thrive. These diagnoses are not all inclusive. B. Record review of R #98's in-patient hospital stay of 04/14/23 to 04/18/23 revealed the following: R #98 was hospitalized from [DATE] to 04/18/23 due to combative behaviors. He was discovered to have a pseudomonal (pseudomonas is a type of germ found commonly in the environment) urinary tract infection (UTI). The infection was treated with antibiotics and R #98 returned to the facility on [DATE]. C. Record review of R #98's care plan dated . revealed the following: 1. Revision on 04/23/23: (name of resident) requires assistance/is dependent for Activities of Daily Living (ADL) care in: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting related to: Dementia, weakness, Update: Fracture to right femur post fall so he requires extensive assist with most ADL's .Extensive to total assist for transfers, Extension assist with locomotion in w/c (wheelchair), dressing, toileting and personal hygiene. Total care for incontinent (having no or insufficient voluntary control over urination or defecation) care . D. Record review of R #98's Electronic Health Record revealed the following scores on his Braden Scale for Predicting Pressure Sore Risk assessments (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries-mild risk: 16-18; moderate risk 13-14; high risk 10-12; and severe risk-less than 9): 1. 02/16/23 score 18 2. 02/23/23 score 18 3. 03/02/23 score 18 4. 04/08/23 score 16 E. Record review of R #98's skin checks revealed the following: 1. 04/10/23 identified no wounds on heels or sacrum (a triangular bone in the lower back formed from fused backbones and situated between the two hipbones of the pelvis). 2. 04/27/23 identified 3 new injuries: a) left heel deep tissue injury (DTI) measuring 8 centimeters (cm) by 4.5 centimeters (cm), b) a right lateral dorsum (shown in picture to be located on the side and bottom of the outer right foot) measuring 1 cm x 1 cm, and, c) a right foot dorsum (dorsum of foot, the top of the foot) fifth digit (pinky toe) deep tissue injury were identified. F. Record review of R #98's medical record did not identify that an admission skin assessment was completed by the admitting nurse upon re-admission [DATE]]. G. Record review of shower sheet for R #98 dated 04/18/23 indicated by a circled area on the body diagram that R #98 had red and macerated (maceration-the softening of skin as part of the process of skin tissue breaking down) skin on his coccyx/sacral (the shield shaped area located at the base of the spine and includes the tailbone). The sheet also indicated that the area on R #98's left heel was dark, red, and intact. The right heel indicated redness and intact. The sheet indicated a medical provider had been contacted and that barrier cream had been applied. There was no corresponding progress note regarding the skin condition, physician notification or any new orders. H. Record review of the Medication Administration Records/Treatment Administration Record (MAR/TAR) for April 2023 for R #98 revealed the following: 1. No treatment orders or interventions documented for the red and macerated skin of the coccyx/sacral area for the month of April 2023 for the damaged skin identified on 04/18/23. No orders or interventions were documented for the reddened areas of the left and right heels. 2. An order to Apply Optifoam Heel (a brand of dressing applied to the heels of the feet that provides an ideal healing environment because of its well-known property of handling high fluid, provides strong protection against outside contaminants and is highly absorptive and is considered ideal for partial and full-thickness wounds, lacerations, abrasions, pressure ulcers, and foot ulcers) to bilateral (both heels of feet) heels every day shift every 3 day(s) for wound care starting 04/27/23. I. On 05/17/23 at 3:10 pm during interview with the Wound Care Nurse (WCN), she reported that R #98 went to the hospital in April and returned on 04/18/23. She confirmed the the admitting nurse did not conduct a skin assessment upon his return from the hospital and when she realized a skin assessment had not been completed, she did her own assessment as part of the weekly skin assessment on 04/27/23 in which she identified wounds to his heels. WCN confirmed that it is the Nurse on duty's responsibility to do skin assessments upon admission and re-admission. WCN also confirmed that CNA (certified nurse aides) are expected to document resident's skin condition on the shower sheets and they then give the shower sheets to the nurse. If something is identified, the nurse should assess and then should be identifying a change in condition and notifying the nurse managers and provider. Regarding what interventions were implemented for R #98's heel wounds, the WCN stated that staff were floating his heels while he was in bed and they had optifoam heels under his socks when he was in his wheelchair. When asked why heel protectors weren't ordered sooner, she replied We didn't have heel protectors in Central Supply. I don't like putting in an order for something we don't have. WCN confirmed the heel protectors were ordered 05/16/23 and implemented 05/16/23. J. Record review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) for May 2023 for R #98 revealed the following: 1. And order to apply Optifoam heel to both heels every day shift every day starting on 04/27/23 and discharged on 05/16/23 2. An order to treat Moisture Associated Skin Damage (MASD) with a start date of 05/03/23, using Calmazide (calmoseptine- used to treat red or irritated skin two to four times daily after incontinence {lack of voluntary control over urination or defecation} episodes, which protects the skin and promotes healing) ointment to buttocks twice a day. There was no documentation of application of this treatment on the MAR/TAR until 05/09/23. 3. An order to apply purple heel protectors to both heels every day and night shift starting 05/16/23. 4. An order for wound care for a stage 4 wound to the coccyx indicates to clean the wound with wound cleaner, pat dry, pack with Aquacel Ag (name brand of a primary dressing indicated for moderate to highly exuding {wound drainage} chronic and acute wounds where there is infection or an increased risk of infection), cover with Allevyn (an adhesive dressing indicated for exudate {pus} absorption and the management of partial- to full-thickness wounds every day shift starting 05/17/23. 5. An order for wound care to unstageable (full thickness tissue loss in which actual. depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed) wound on the right ankle by applying skin prep daily every day shift starting 05/18/23. 6. An order for a wound culture of the coccyx one time only for two days starting 05/16/23. K. Record review of physician orders for R #98 revealed the following orders: 1. Protein liquid two times a day for wound care starting 05/18/23. 2. House supplement 3 time a day starting 05/18/23. 3. Wound culture to coccyx starting 05/16/23. 4. Schedule for wound clinic as soon as possible for multiple deep tissue injuries, and stage 4 to the coccyx starting 05/17/23. 5. Wound care to unstageable on right ankle; apply skin prep daily starting 05/18/23. 6. Doxycycline Hyclate (a medication used in the management and treatment of a variety of infections. Oral Tablet 100 milligrams ( mg) with a start date of 05/17/23. 7. Wound care to Stage 4 to coccyx. Cleanse with wound cleanser, pat dry pack with Aquacel Ag, cover with sacral Allevyn every day shift with a start date of 05/17/23. 8. Roho cushion (cushion that is designed to decrease the amount of pressure on the sitting area on a chair) with no start date indicated, and a revision date of 05/19/23. No start date was observed. 9. Apply Purple Heel protectors to bilateral heels every day and night shift with a start date of 05/16/23. 10. Wound care for moisture associated skin damage apply Calmazide ointment to buttocks twice a day starting 05/03/23 and discontinued on 05/16/23. 11. Low air loss mattress (a mattress that provides airflow to help keep skin dry, as well as to relieve pressure to bed for pressure ulcers) for pressure ulcers with a revision date of 04/27/23. No start date was observed. 13. Float heels (means that a patient's heel should be positioned in such a way as to remove all contact between the heel and the bed) while in bed with a revision date of 04/27/23. No start date was observed. L. On 05/16/23 at 11:03 am, during an observation and interview, R #98 was observed sitting upright in a wheelchair in the common area located in front of the south nursing station. He was awake and alert, with a pleasant affect. He was not observed to be in distress. His feet were covered with socks only and no shoes were observed. M. Record review of Skin and Wound Evaluations revealed the following: 1. Lateral Right Foot a. 04/27/23 deep tissue injury: area = 1.0 centimeters squared, length = 1.0 cm, width = 1.0 cm b. 05/02/23 deep tissue injury: area = 1.2 centimeters squared, length = 1.3 cm, width = 1.2 cm c. 05/09/23 deep tissue injury: area= 2.3 centimeters squared. length = 1.6 cm, width = 1.7 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared. Length = 0 cm width = 0 cm 2. Dorsum Right foot a. 04/27/23 deep tissue injury: area = .6 centimeters squared, length = .8 cm, width = .8 cm b. 05/02/23 deep tissue injury: area = 2.5 centimeters squared, length = 1.6 cm. width = 1.5 cm c. 05/09/23 deep tissue injury: area= 4.7 centimeters squared. length = 2.0 cm. width = 3.2 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared. Length = 0 cm, width = 0 cm 3. Left Heel a. 04/27/23 deep tissue injury: area = 0 centimeters squared, length = 0 cm, width = 0 cm Notes: Area is closed with fluid-filled Deep Tissue Injury. Optifoam heel applied b. 05/02/23 deep tissue injury: area = 21.3 centimeters squared, length = 5.7 cm. width = 5.2 cm c. 05/09/23 deep tissue injury: area= 7.7 centimeters squared, length = 3.7 cm, width = 2.9 cm d. 05/17/23 deep tissue injury: area= 0 centimeters squared, Length = 0 cm, width = 0 cm 4. Sacrum Wound Evaluation a. 05/16/23 stage 4: area =18.42 cm squared, length 6.68 cm, width = 4.43 cm, depth = 4.0 cm, max undermining = 4.5 cm, undermining 4.5 cm 8 to 8 o'clock 5. Right Lateral Malleolus a. 05/16/23 unstageable: area = .9 centimeters squared, length = 1.3 cm, width = 1.0 cm N. Record review of the nursing progress revealed the following: 1. A nursing progress note dated 05/12/23, a change in condition was made by the nurse for R #98 after a Certified Nursing Assistant (CNA) reported the skin breakdown was .worse due to some open/raw areas . The progress note indicated that there was .skin breakdown on inner butt cheeks area . The primary care provider was notified and the recommendation by the provider was to continue the treatment as ordered and have resident seen by WC (wound clinic) Monday [05/15/23] . 2. A nursing progress note by Wound Care Nurse (WCN #1) dated 05/16/23 indicated that a change of condition was created after a skin check was performed following notification that CNAs were changing R #98's brief on 05/16/23 and reported R #98 had a hole in his bottom. As a result of the assessment, the following new and worsening skin injuries/wounds were identified: a stage 4 pressure injury (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) to the coccyx, with tunneling (a wound that's progressed to form passageways underneath the surface of the skin) a stage 3 (full thickness tissue loss) pressure injury to the right buttock, and a stage 3 pressure injury to R #98's right ankle. 3. A progress note dated 05/16/23 indicated a correction to a wound's status was made. The wound to R #98's right ankle was considered unstageable (an ulcer covered with slough {dead tissue, usually cream or yellow in colour}or eschar {dry, black, hard necrotic tissue}-the base of the ulcer needs to be visible in order to properly stage the ulcer, though, as slough and eschar do not form on stage 1 pressure injuries or 2 pressure ulcers, the ulcer will reveal either a stage 3 or stage 4 pressure ulcer) 4. An order was written on 05/16/23 for R #98 to be seen in the Wound Clinic, after assessing worsening wounds to the sacrum and the new ankle pressure wound. 5. An observation of a photo taken as part of the of R #98's coccyx wound assessment was observed to show a coccyx wound located at the 12:00 o'clock position, directly above the anus (the opening where bowel movement passes from the body), consisting of 3 holes (open wounds) clustered closely together, with sinewy (stringy) yellow appearance border around all three. One of the three wounds had bubbly clear fluid in it. The largest open wound appeared to be cavernous with a tunnel-like appearance going into the resident's lower backside; outside of the sinewy border is another border around all 3 wounds that is a rectangular border surrounding all three wounds and the skin there is yellow-white in color and appears to look like raw skin with the top layer of skin missing. There were red bumps throughout the rectangular border of white skin. The next border around the periphery of the rectangular shaped wound was a thin, red border (edge) of skin. Above the rectangular shaped wound was another small open wound that was separate from the large rectangular wound. It was pink with a small depression, and it had a red and pink edge. This wound was located on the right buttock at the 2:00 o'clock position above the 3 clustered, open wounds. O. Record review of Skin and Wound Evaluation completed for R # 98's sacrum and right lateral malleolus (ankle bone) dated 05/16/23 revealed the following: 1. The sacral wound had an area of 18.4 centimeters (cm) squared; length of 6.7 centimeters; width of 4.4 centimeters; depth of 4.0 centimeters; and undermining (refers to the damage underneath the wound edge that spans a wider area in multiple directions, but isn't that deep) of 4.5 centimeters. 2. The right lateral malleolus had an area of .9 centimeters squared; a length of 1.3 centimeters; and a width of 1.0 centimeter. P. On 05/17/23 at 3:11 pm, during an interview with the WCN #1, she stated she was made aware R #98 having some maceration (when the skin is broken down by moisture on a cellular level) over the weekend, on 05/12/23 of the coccyx. She had last observed R #98 in the early part of the previous week. There was only redness and maceration at that time. LPN #1 stated at 4:30 pm on 05/16/23, a CNA informed her that during a brief change of R #98 there a hole wound was observed. WCN #1 then completed a skin assessment of R #98 on 05/16/23 and R #98 with a new wound to his coccyx, which was also described as an hole (open wound). She stated that the current wound on R #98's coccyx had developed from the inside out. She stated that it was a stage 4 pressure ulcer. WCN #1 explained that a stage 4 pressure ulcer was a wound that was all the way to the bone. It was being treated by packing with Aquacel (name brand of dressing that is an antimicrobial primary dressing for use in acute and hard-to-heal wounds that are infected or at risk of infection with varying exudate {pus} levels) and covered with skin prep (moisture barrier cream) to all areas. She also assessed a new wound on R #98's ankle. Regarding how a MASD (moisture Associated Skin Damage) can so quickly turn into a Stage 4 pressure wound, WCN insisted that during the week of 05/08/23 when she observed the sacrum, the skin was still blanchable and with R #98's limited mobility, he is at high risk for deep tissue injury and it [break down] can happen quickly. Q. On 05/18/23 at 10:28 am, during an interview with the Director of Nursing (DON) regarding R #98's new heel wounds when he returned from the hospital on [DATE], the DON stated that a skin assessment had been completed for R #98 when he returned from the hospital by an agency nurse on a shower sheet. The shower sheet indicated there was redness to the bottom and to the back of R #98's heels. Also indicated on the shower sheet was red macerated skin to the coccyx, and redness to the left heel and right heel with the skin intact. The DON stated the shower sheet indicated that a MD (Medical Doctor) had been notified and that barrier cream had been applied, however she stated there was no documentation of new orders and no documentation of which medical provider was notified. The DON stated the skin information can be initially documented on a shower sheet by nurses and then transferred to Point Click Care (PCC-the medical charting system used by the facility) but that did not happen in this case. DON confirmed that there was no documentation in the progress notes by the agency nurse who completed the skin assessment. R. On 05/18/23 at 3:39 pm, during an interview, CNA #2 reported that he first noticed that R # 98 was having some skin issues while changing R #98's brief two weeks ago (the week of 05/01/23) and that he reported it to the nurse and the nurse manager. CNA #2 stated he had observed more changes in R #98's bottom last week on Wednesday (05/10/23) and that it looked like lines in R #98's skin. He informed the Unit Manager. By Friday or Saturday (05/12/23, 05/13/23) CNA #2 stated it looked like a pocket of pus that would burst if you popped it with a pin, but that the skin was flat on R #98's inner cheeks. He observed it to be about the size of a large sandwich in area and that it looked bad. It had an infection smell. There were no holes in R #98's skin. He let the nurse and Unit Manager know. He stated the Unit Manager told the nurse to complete a change in condition form. The nurse was trying to get an order. CNA #2 applied barrier cream to R #98 after his brief change on 05/12/23 after informing the nurse. CNA #2 stated R #98 always had the purple things (foam heel protectors) on his feet, no shoes. S. On 05/18/23 at 4:00 pm, during an interview, Registered Nurse (RN) #3 stated R #98 had moisture associated skin damage and an unstageable wound on his left foot and nothing on the right foot that he was aware of. RN #3 worked with R #98 the weekend of 05/12/23. He stated an order for MASD kept popping up for R #98, so the CNA applied the barrier cream. RN #3 stated he completed a change in condition form [on 05/12/23] to be reviewed by the Wound Care Nurse and kept the wound as MASD because he did not know what type of wound it was. RN #3 also stated he was not great with wounds The wound was located between both cheeks. There was some skin breakdown and the wound was light colored with raw skin on the edges. It looked fresh. The wound was flush and not puffed out. It was the CNA who brought the wound to his attention [on 05/12/23]. He informed the supervisor of the change in condition [on 05/12/23]. Barrier cream continued to be applied over the weekend but there was no change in the appearance of the wound. He does not believe it got better. R #98's heels were now covered with Optifoam (a brand of dressing applied to the heels of the feet that provides an ideal healing environment because of its well-known property of handling high fluid, provides strong protection against outside contaminants and is highly absorptive and is considered ideal for partial and full-thickness wounds, lacerations, abrasions, pressure ulcers, and foot ulcers). The left heel appeared dark in color. He did not remember anything being on the right heel. T. On 05/18/23 at 12:16 pm during an interview with RN #2, she stated R #98 had started Doxycycline (an antibiotic) yesterday on 05/17/23 for the wound on his coccyx. It had a discharge and a foul odor. Currently the wound was being treated with wound cleanser, Aquacel Ag for packing the wound, and Allevyn. She reported that R #98 was not able to be seen at the wound clinic this morning due to being late and that he was now being sent out to the emergency department because his appointment was rescheduled to Tuesday [05/23/23] of the following week. RN #2 stated, she last saw R #98's sacral area last Thursday [05/11/23] and that it was red and macerated. She first became aware of the maceration on 05/03/23 and that it was being treated with a barrier cream. Resident #96 U. Record review of the face sheet for R #96 indicated that he was admitted on [DATE] with diagnosis of Sepsis (a serious condition in which the body responds improperly to an infection), Gangrene and Necrosis of Lung (is a complication of severe lung infection that causes a secondary infection and necrosis (premature cell death)), Type II Diabetes (means that your body doesn't use insulin properly) , Stage III Kidney Disease (condition that impairs kidney function), Congestive Heart Failure (your heart can't supply enough blood to meet your body's needs), Hypertension (high blood pressure), alcohol abuse (is a pattern of alcohol use that involves problems controlling your drinking, being preoccupied with alcohol or continuing to use alcohol even when it causes problems), Anemia (deficiency of healthy red blood cells in blood). This is not all inclusive list. V. Record review of the Braden Scale Assessment (for Predicting Pressure Sore Risk. The scale consists of six subscales and the total scores range from 6-23. A lower Braden score indicates higher levels of risk for pressure ulcer development. Generally, a score of 18 or less indicates at-risk status) completed on 12/01/22 indicated resident scored a 17 which is at risk for skin breakdown, and on 12/15/22 the Braden score was 18. Scoring: at risk 15-18 moderate risk 13-14 high risk 10-12 very high risk 9 or below. W. Record review of the skin check completed on 12/20/22, 01/10/23 and 01/17/23 did not indicate that R #96 had any skin breakdown. X. Record review of the nursing progress notes dated 12/27/22 indicated the following: Resident developing Pressure ulcers to L. (left) foot Stage 1 (skin looks red or pink, but there isn't an open wound) to bottom of heel. Measuring at 1.6 x 1.1 cm (centimeter), and on side of heel is 2.0 x 1.3 cm. Left voicemail for (name of provider) for orders. Y. Record review of the History and Progress Note dated 12/27/22 indicated the physician or Nurse Practitioner (NP) knew about the stage I pressure injury to left heel and said to dress it and provide pressure relief. Z. Record review of the physician orders dated 01/02/23 indicated the following: Paint heels bilaterally with skin prep (liquid that when applied to the skin forms a protective film or barrier). Keep heels offloaded while in bed one time a day for wound care. AA. Record review of the Treatment Administration Record (TAR) for the month of January 2023 indicated that the above physician order was not on the TAR and was not getting done. BB. Record review of the nursing assessment note dated 1/18/23 indicated that the pressure wound stage 3 (the wound may go into your skin's fatty layer (the hypodermis)) in-house acquired, Location: Left Heel was assessed today. Prognosis: Healable. CC. Record review of the physician orders dated 01/19/23 indicated that the following order was in place: left heel pressure ulcer: Clean with wound cleanser, pat dry, apply Allevyn foam dressing (dressings for wound care that remove fluid faster than regular dressings). Place heel protectors every day shift for wound care. DD. On 05/23/23 at 11:56 am, during an interview with the wound care nurse she stated that R #96 was bed bound for a little while in December 2022. She stated that he had precautions in place like purple heel protectors, off loading of heels and an air mattress was put into place on 12/28/22. EE. Record review of the physician orders indicated that an order was in place for a air mattress because of new pressure area and not mobile dated 12/28/22 FF. On 05/23/23 at 3:44 pm, during an interview with the Center Executive Nurse (CNE) she stated that the order placed on 01/02/23 by the physician should have been on the Treatment Administration Record (TAR). She stated that the physicians and the nurses have access to enter orders. She stated that when you enter orders if you want it to be on the Medication Administration Record or the TAR you have to click a button indicating that when you put the order in. She stated that looking at this order neither of them were clicked so it didn't show up. She stated that ancillary was clicked and that doesn't link to anything. So the nursing staff didn't know that there were orders in place and it didn't get treated. Resident #42 GG. Record review of R #42's face sheet indicated that his initial admission date was 04/07/23. HH. Record review of the Braden Scale for predicating Pressure Ulcers had R #42 listed as a 14 on the scale which is a moderate risk. II. Record review of Hospital Records indicated that on 04/05/23 resident had skin assessment completed and stated under skin turgor epidermis thin with loss of subcanteous tissue. JJ. Record review of the skin check assessment completed 04/07/23, on admission, did not indicate any wounds. KK. Record review of the Initial Minimum Data Set (MDS) completed on 04/11/23 captured that resident had 2 stage II PU's (shallow wound with a pink or red base develops. You may see skin loss, abrasions and blisters), location not identified. LL. Record review of a skin check assessment completed on 04/15/23 indicated that resident had new wounds on right and left buttock . MM. Record review dated 04/18/23 as a Late Entry: Indicated the following note written by Wound Care Nurse Paperwork from hospital indicated he has pressure to his left and right buttock on admission here. Ulcers are not in-house acquired. NN. Record review of the physician orders indicated that on 04/18/23 an order for wound care to bilateral buttocks: Apply barrier (protects the skin) cream at each brief change every day and night shift for Stage 2 pressure ulcers. OO. On 05/23/23 at 11:56 am, during an interview with the Wound Care Nurse, she stated that R #42 was admitted on [DATE]. She stated that the MDS nurse had brought up that the stage II pressure ulcers were noted on the hospital paperwork and that he came in with those wounds, that is why she wrote the progress note. She stated that the admitting nurse should have caught it on the skin check. She stated that the skin check on 04/15/23 was when the wounds were first documented by the facility. She found out about them on 04/18/23 and orders were put into place. She stated that sometimes the Certified Nursing Assistant's will tell the nurse that an area is red or there is moisture associated skin damage and the nurse will tell them to put barrier cream on it. So, even if she has not been made aware of a new wound like a stage II, or the physician is not aware of it [on 04/15/23], they [wounds] are still being treated because the treatment for those would be barrier cream anyway which is standard practice. This resulted in an Immediate Jeopardy (IJ) a scope and severity of J which was announced in person on 05/18/23 at 6:15 pm to the Center Executive Director. The facility provided an acceptable Plan of Removal (POR) and implementation of the POR was verified through observation, interview, and record review on 05/22/23. Plan of Removal: The Immediate Jeopardy finding was identified in the following area: Failure to timely identify wounds and delaying in implementing treatment . All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 5/19/23: -On 5/18/23 the nursing team initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment . Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Systematic Measures Beginning 5/18/23 the Center Nurses will be re-educated on the following areas by the Nurse Educator/Designee: -Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). -Nurses will be educated on (name of facility) wound processes which include the DIMES, timely and accurate identification and documentation for wounds/wound changes, change in condition process, and appropriate treatment/intervention implementation upon identification of new or worsening wounds. -CNAs will be educated on how to minimize pressure, friction and shearing, change in condition process for CNAs (including skin changes) and stop and watch. As of 5/19/23 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN (As needed) staff will be educated prior to returning to their next shift. Quality Assurance and Monitoring The Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Director of Nursing/Designee will conduct 5 random wound audits weekly for wound care process compliance. An Ad Hoc QAPI Meeting will be held on 5/19/23 to approve the above plan. The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor wound for 1 (R #1) of 3 (R #'s 1, 2, and 3) residents reviewed for wound care of surgical sites by: 1. Not clarify medication and treatment orders from an outside provider and; 2. Not evaluating wound healing and wound treatment. These deficient practices likely result in the resident not receiving the appropriate type of treatment to prevent and treat infection that may possibly result in death. The findings are: A. Record review of the facility policy Skin Integrity and Wound Management, last revised 02/01/23, revealed the following: Practice Standards 4. Identify patient's skin integrity status and need for prevention or treatment interventions . 6. The licensed nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds; . 6.4 Perform and document skin inspection on all newly admitted /readmitted patients weekly thereafter and with any significant change in condition. 6.5 Complete wound evaluation upon admission/readmission, new in-house acquired, weekly, and with unanticipated decline in wounds . B. Record review of R #1's EHR (Electronic Health Record) revealed that R #1 was admitted to the facility on [DATE] with the following pertinent diagnoses: peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), onset date: 09/01/22 artherosclerosis (thickening or hardening of the arteries caused by a buildup of plaque) of the native arteries of extremities (5 lower extremity arteries- femoral artery, the superficial femoral artery, the popliteal artery, the posterior tibial artery, and the dorsalis pedis artery) with rest pain, left leg, onset date: 09/01/22 prediabetes (blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes), onset date: 11/05/22 methicillin resistant staphylococcus aureus (MRSA- Methicillin-resistant Staphylococcus aureus- an infection is caused by a type of staph bacteria that's become resistant to many of the antibiotics) infection, unspecified site, onset date: 02/2/23 cellulitis (bacterial skin infection) of left lower limb, onset date: 02/25/23 infection following a procedure, other surgical site, subsequent encounter, onset date: 02/25/23 C. Record review of hospital documentation, encounter dates from 01/09/23 to 01/16/23, revealed that R #1 was hospitalized for the status of his ischemic ulcers (slow healing wounds as a result of poor blood circulation). After previous treatments, testing revealed that amputation [surgical removal of limb] was unavoidable. On 01/11/23 he underwent an above the knee amputation (AKA) of his left leg. D. Record review of physician orders revealed the following wound care orders for R #1's LAKA (Left Above Knee Amputation) 1. 01/19/23 to 01/23/23, Wound(s): Monitor site(s) Daily for status of surrounding tissue and wound pain. Monitor for status of dressing(s), if applicable Additional Documentation in NN [nursing notes] if needed s/p [status post] LAKA every day and night shift 2. 01/21/23 to 02/25/23, Wound Care LAKA: Cleanse with wound cleanser, pat dry, apply Adaptic dressing [type of wound bandage], apply 4x 4 [inches] gauze, wrap with kerlix [type of wound bandage] and ACE bandage. Apply stump shrinker [a compression garment to help shape the limb] every other day, one time a day every other day for wound care [wound care orders began 11 days after amputation] E. Record review of the TAR (Treatment Administration Record) revealed the following documentation of wound care administration and resident refusals: January 2023: Physician order, date 01/21/23-02/25/23, Wound Care LAKA: Cleanse with wound cleanser, pat dry, apply Adaptic dressing, apply 4x4 gauze, wrap with kerlix and ACE bandage. Apply stump shrinker. every other day one time a day every other day for wound care. Wound care was not documented as being administered or if the patient refused (blank) on the following dates: 01/21/23 and 01/29/23. February 2023: R #1 refused wound care on 02/10/23 and 02/18/23. March 2023: Physician order, dated 03/11/23-03/14/23, Wound Care: Left AKA - clean with sound cleanser, pat dry, apply adaptic gauze, and cover with border gauze. one time a day for wound care R #1 refused wound care on 03/12/23 Physician order, dated 03/14/23-04/03/2023, Wound Care: Left AKA - clean with sound cleanser, pat dry, apply adaptic gauze, and cover with border gauze. every evening shift for wound care. R #1 refused wound care on the following dates 03/14/23, 03/19/23, and 03/21/23. Wound care was not documented as being administered or if the patient refused on the following dates: 03/15/23, 03/17/23, and 03/18/23. April 2023: Physician order, dated 04/05/23, Wound Care: Left Stump - clean with wound cleanser, apply thick layer of Santyl to all necrotic areas of the wound. Apply Opticell AG(ok to use Maxosorb Ag) to wound and cover with border gauze. every day shift for left stump wound care R #1 refused on the following dates: 04/07/23, 04/09/23, 04/13/23, and 04/15/23. Wound care was not documented as being administered or if the patient refused on the following dates: 04/10/23 and 04/12/23. F. Record review of the weekly wound assessments revealed the following documentation for all LAKA wound assessments: 11/17/22- Venous wound [A wound on the leg or ankle caused by abnormal or damaged veins to left shin]. Total area: 42.6 cm. 8.2 X 5.2 0.3 (length by width by depth in centimeters). Improving. 11/28/22- Venous wound to left shin. Total area: 41.6 cm. 8.0 X 5.2 X 0.1(length by width by depth in centimeters). Improving. 12/15/22- Venous wound to left shin. Total area: 37.5 cm. 7.5 X 5.0 X 0.3 (length by width by depth in centimeters). Stable. 02/08/22- Surgical wound to left knee. Total area: 21.9 cm. 7.2 X 4.3 X N/A (depth not applicable on surgical wound). Wound bed: eschar 100%. Edges: attached. Surrounding tissue: black and blue. Goal of care: monitor/manage- wound healing not achievable due to untreatable underlying conditions. Deteriorating. 04/04/23- Surgical wound to left knee. 0 sutures, Incision Approximated. Total area: 43.4 cm. 10.4 X 6.5 X N/A (depth not applicable on surgical wound). 30% granulated [the development of new tissue and vessels], 40% slough [the accumulation of dead cells that are yellow/white in appearance], 30% eschar [necrotic tissue that needs to be removed to promote wound healing], moderate drainage- seropurulent [a type of drainage that is a usual sign of infection]- no odor, non-attached edges [open wound], surrounding skin- erythema (redness to skin), no swelling, dressing intact. Generic wound cleanser. Debridement- enzymatic. MD [medical doctor] diagnosed infection. Using santyl ointment for enzymatic debridement [the application of a prescribed topical agent that chemically liquefies necrotic tissues with enzymes]. Resident on antibiotics. Practitioner notified. G. Record review of nursing notes related to wound care of the left limb revealed the following: 12/06/22- wound assessment done 12/13/22- IDT [Interdisciplinary Team meeting]- [Name of R #1] has refused wound assessment and treatments. He states that clinic will change. Educated him increased risk of infection and that the clinic wrote orders for wound care to be done here. He states that he doesn't care. 12/19/22- wound assessment done 12/22/22- wound care done by wound clinic 12/28/22- wound clinic did wound care 01/04/23- Resident went to wound clinic today. New orders given. Wound to left lower leg measures 6 cm (centimeters) x (by) 3.8cm x 0.3cm with a moderate amount of serous exudate [a thin liquid that drains from the wound, usually a part of a normal wound healing process] and is erythematous [redness of the skin]. 02/08/23- A deteriorating [worsening] surgical wound in-house acquired Location: Left Knee was assessed today 03/07/23- Wound vac removed by [name of outside prosthetic consultant] and dressing change done at this time as well 04/04/23- Left Knee was assessed today 04/05/23- Resident refused to shower this shift and refused dressing changes 04/06/23- Wound care provided 04/07/23- Refused wound care 04/13/23- Resident asked 3x [three times] to do wound care and refused 04/14/23- Wound dressing changed 04/15/23- Resident refused X 3 today stating 'Can you just do it tomorrow' 04/17/23- Resident refused to let writer do his dressing H. On 04/24/23 at 12:13 pm, during an interview with the Wound Nurse, she explained that she recently stepped into the position of being the wound care nurse. When asked to explained her role in the facility she explained, I became the skin health lead [wound nurse] in April [2023]. Before I became the skin health lead, the staff who would do the assessment would be the floor nurse. The floor nurse would be the ones who would have charted and communicated with the doctor . It was up to the floor nurse to assess the wounds. When asked to explain her interactions with R #1, she explained According to the nurses on duty, he was refusing wound care pretty often. He started off with a venous wound and they had to do the amputation [01/11/23], he was refusing a lot of the time. He was very persistent and would say 'no, not today or how about tomorrow'. At that time, I wasn't the team lead yet. Then he had a further amputation [02/23/23] and after that he would refuse treatments fairly often. I would tell the nurses to document his refusals. The last time I saw him [04/04/23], he went to the hospital, his surgical site was completely necrotic [dead tissue]. When he came back [02/25/23] they must have debrided [to remove damaged tissue] it because it was open and raw. I. Record review of nursing notes, dated 01/16/23, revealed Resident re-admitted to facility today after LLE [Left Lower Extremity] AKA . When I informed resident that I would need to check his skin and do his admission, he states 'I just don't want to be bothered today. I just want to relax, smoke a cigarette, and watch the football game. Just do it all tomorrow.' Further review of nursing notes dated 01/18/23, revealed Spoke with [name of outside prosthetic consultant] regarding leg amputation care. [Name of outside prosthetic consultant] will visit resident tomorrow [01/19/23] and will contact surgeon for dressing orders. Will continue to monitor surgical site and notify surgeon with concerns/changes. J. On 04/24/23 at 12:37 pm, during an interview with Licensed Practical Nurse (LPN) #2 (the author of the nursing note dated 01/16/23), when asked if R #1 returned with wound care orders on 01/16/23, she explained There should be orders, a lot of time, if he returns from the hospital and you see that he has a bandage, there should be orders. When he (R #1) re-admitted on 1/16 [2023] he didn't want to do his skin assessment, so I passed that onto the night nurse. I let the night nurse know that she would have to do it. K. Record review of hospital documentation, encounter dates from 02/20/23-02/25/23, revealed that R #1 returned to the hospital due to poor wound healing. The surgical wound was found to be dehisced (a partial or total separation of previously sutured wound edges, due to a failure of proper wound healing) and infected. On 02/23/23 he required a revision (additional amputation) of his LAKA stump. During his stay, hospital documentation revealed that R #1 was ordered to receive Clindamycin [type of antibiotic] in 300 MG [milligrams] capsule. Take 1 capsule (300 mg total) by mouth every 6 hours for 21 days. Further review revealed that on 02/25/23, R #1 received a wound vac [a medical device used to suction out drainage to promote wound healing] to the LAKA. L. Record review of physician orders revealed the following: 1. An order, dated 02/25/23, for Clindamycin HCl Powder (Clindamycin HCl (Bulk)) Give 300 milligram by mouth four times a day for Wound Infection for 21 Administrations [not 21 days] 2. R #1 did not have any orders for wound vac care after his return from the hospital on [DATE], however; there was a physician order, dated 03/11/23, to Discontinue wound vac to left AKA one time only for post-op wound care for 1 day per [name of outside prosthetic consultation services]. M. Record review of hospital documentation, encounter dates from 03/22/23-04/02/23, revealed that R #1 returned to the hospital for stump pain where he was evaluated and treated for sepsis [a body's reaction to infection that causes chemicals to be released in the bloodstream to fight an infection but also triggers inflammation throughout the body leading to organ failure and often death]. Further review of the assessment and plan revealed plan for IV (intravenously) vancomycin [a type of antibiotic] until 4/20/23, followed by a few weeks of PO (oral administration) Zyvox 600 mg [milligrams] PO, BID [twice a day] (EOT [End of Treatment] 5/4/23). N. Record review of physician orders revealed that R #1 did not have an order for antibiotics after his return from the hospital on [DATE]. O. On 04/24/23 at 2:13 pm, during an interview with the Director of Nursing (DON) , when asked what nursing staff are expected to do for wound assessments, she explained that nurses are expected to document a skin assessment on a weekly basis and if a resident refuses, the nurse should document that the resident refused. When asked to describe the process nurses follow when admitting a resident form the hospital, she explained that the nurses call the facility's physician group to confirm orders and enter the orders into the resident's EHR. When asked if the progress notes from the hospital packet are reviewed, she explained that the hospital is not consistent in sending progress notes. Sometime they do and sometimes they do not send progress notes so, it depends on what information is available. When asked if R #1 returned on 04/02/23 with a Peripherally Inserted Central Catheter (PICC) (a form of intravenous access that can be used for a prolonged period of time or for administration of medications) for vancomycin, she explained I believe there was a progress note where they said he would not be discharged with the PICC line and he would instead receive oral antibiotics. He got here and didn't have a PICC, so we just followed the discharge orders however; the antibiotics were not listed on the discharge orders. P. On 04/25/23 at 9:52 am, during an interview with the DON, when asked why R #1 didn't have wound care orders until 01/21/23, she explained, He returned on the 16th [01/16/23]and the orders didn't start until the 19th [01/19/23]. We can't put orders in, so we have to call the on-call [physician group] to get them. For him, we had numerous refusals from [name of R #1] so I think that his refusals held up the process. If we can't assess the patient then we can't let the doctor know the status, and then we can't get orders. The person who did his admission [on 01/16/23] was an agency nurse and if she didn't know that he had a wound and he was refusing, then she wouldn't have known to requested them. When asked if she should have been aware of his amputation through the hospital documentation, she explained For admissions, we don't usually get packets [hospital stay documentation] with the residents. We can call and call and they [the hospital] will never answer the phone. When asked if the nurse should have notified the physician of his refusal to assess him upon admission, she stated Yes, she should have notified the physician. Q. On 04/25/23 at 12:09 pm, during an interview with the DON, when asked if R #1 should have received physician's orders for wound vac care, she explained We didn't have wound vac orders until 03/01/23. It [the physician's order] should have been more specific from the hospital. We cannot put the wound vac on [without a doctor's order] because it is a specialty device. The doctor should have given us a clear order. We did not call to get clear orders. We should have called to get clear orders. R. On 04/25/23 at 2:59 pm, during an interview with the DON, when asked if the order for Clindamycin should have been administered for 21 days, she confirmed yes and explained that while entering the order into the EHR, it was done incorrectly for 21 Administrations. S. Record review of nursing notes, dated 04/14/23, revealed Resident [R #1] approached this nurse [RN #1] with a paper from an appointment he had on 4/11/23. The paper appears to be a copy of a progress note from a wound care visit. The paper requested the resident be admitted to the hospital for wound treatment. This nurse along with unit manager [RN #4] discussed this with the resident and he refused to go to the hospital. T. Record review of hospital follow-up visit, as noted by the infectious disease doctor, dated 04/11/23, revealed We may presume the wound problem is related to MRSA (methicillin resistant staphylococcus aureus) though at this point he could have secondary nosocomial pathogens superimposed. Also high risk for osteomyelitis [infection from nearby tissue that spreads to the bone] at femur [thigh bone] . Further review revealed 76 yo [year old] man with severe PAD [Peripheral Arterial Disease]. Here for wound and antibiotic assessment. His wound isn't better . He says he is NOT on IV medications (vancomycin). Assessment and Plan: Refractory LAKA stump wound infection now with dehiscence [partial or total separation of wound edges, due to a failure of proper wound healing] and necrotic eschar [dead tissue]. He is not systemically ill acutely, but wound appears worse now than he did in hospital. He has not been receiving the Rx [prescription] I advised. Seems he isn't on any antibiotics and has not had good wound care. Recommend: Readmit to hospital for wound care, debridement, antibiotics. I indicated this in writing to the SNF [Skilled Nursing Facility] (don't know medical contact there) and gave letter to patient. As advised in hospital: Zyvox 600 mg po BID for 10-14 days . U. Record review of EHR revealed that R #1 passed away on 04/17/23 while in the facility. V. On 04/26/23 at 2:21 pm, during an interview with the DON, when asked how communication is executed between the facility and outside care, she explained that if there is a change in treatment, she expects the outside care provider to send the facility documentation of treatment changes. When asked about the note from R #1's follow-up visit on 04/11/23, she explained that the facility did not receive the note and that the outside care provider should have been more clear with his recommendations. When asked why a facility nurse didn't call to request notes from the follow-up visit, she explained, We have a lot to do in the facility. I would expect them [outside clinic] to send it. We probably did assume that there were no changes for him. When asked if the facility should have some type of communication process between outside providers, she confirmed yes. W. On 05/01/23 at 10:54 am during interview with the Administrator and Director of Nursing, the Administrator (DON) stated It was common knowledge that his [R #1] wound was infectious. Administrator and DON stated that R #1 would consistently refuse wound care. X. On 05/01/23 at 11:57 am during interview with the Wound Nurse (WN), regarding R #1, she stated I wasn't the only one seeing his [R #1's] skin. They [nurses] are supposed to be doing the wound assessments. The WN confirmed that she had heard [from staff] that he [R #1] was refusing wound care but wasn't aware that it was happening consistently. She confirmed that she had seen the wound one week and then the next week, he (R #1) let her look at his skin except the wound. The WN confirmed that she only saw the wound one time. When asked how can she be sure the wound care orders were still appropriate if she hadn't seen the wound, she said that the nurses would be expected to let her know. This resulted in an Immediate Jeopardy (IJ) at a scope and severity of J which was announced in-person on 04/28/23 at 2:00 pm to the Center Executive Director. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 04/28/23. Implementation of the POR was verified onsite on 05/01/23 at 4:20 pm by conducting record reviews and staff interviews. Plan of Removal: The Immediate Jeopardy finding was identified in the following area: Failure to consistently document, assess, monitor and notify the physician when a wound became worsened potentially because antibiotic treatments were not accurately provided . All residents have the potential to be affected by this alleged deficient practice. The following measures and monitoring will be completed by 4/29/23: - On 4/24/23 the nursing team (Director of Nursing responsible) initiated a 30-day audit on all antibiotics to ensure all orders are accurate with the correct duration/routes. Any discrepancies will include a provider notification and review to ensure accurate medication orders are in place. - On 4/25/23 the nursing team (Director of Nursing responsible) initiated a whole house resident skin sweep to identify all current wounds in the facility, and assess for correct identification and treatment . Any identified concerns, including refusals of wound care/assessment and worsening wounds will include change in condition documentation and notification to the provider and family. Any new orders will be followed. Systematic Measures: Beginning 4/28/23 the Center Nurses will be re-educated on the following areas: - Nurses will be educated on their responsibility with communication with management and the change in condition process/documentation when a resident is having a change in condition (including new or worsening wounds). - Nurses will be educated on proper wound processes which include accurate documentation for wounds/wound changes, change in condition when a wound is new or worsened, appropriate treatment options, weekly skin checks, wound measurements, and signs and symptoms of a wound infection. If a resident is consistently refusing needed interventions such as wound assessments and treatment, the provider needs to be notified immediately so further interventions can be placed if necessary. All communication needs to be documented in the change in condition documentation, or follow-up documentation. All refusals need to be documented in the chart, and the care plan should be updated including interventions. - Medication reconciliation process, and reviewing clinic notes when a resident returns from an appointment. If there are clarification questions at that time, the nurse should call the clinic and get clarification immediately. Clear documentation needs to occur for medication reconciliation, as well as when communication occurs to providers or outside clinics. Clinic notes and follow-up will be reviewed by nurse managers to ensure correct orders and plan of treatment are initiated. The IP Nurse will track all new antibiotics on admission and as they are ordered within the center to ensure the order is correct, being tracked for antibiotic stewardship, and that providers have been involved and want to continue therapy after 48 hours. The Director of Nursing/Designee will send a letter to all outside providers/clinics requesting that documentation from resident appointments be given to the van driver following the appointment. Documentation will be given to the Receptionist/Designee for distribution to Nursing and Medical Records. If there is no documentation delivered following an appointment, the Receptionist will follow up with the provider and work with Medical Records to get the documentation needed to provide continuity of care. The Nurse Educator/designee will begin education 4/28/23. As of 5/1 /23 100% of available staff have been educated on these processes. Any staff member that has not been scheduled, on leave of absence (FMLA), vacation, or PRN staff will be educated prior to returning to their next shift. Quality Assurance and Monitoring The Director of Nursing/Designee will audit education sign-off sheets to ensure that all nursing staff receive the education mentioned above. The Medical Records Director will audit resident appointments for follow-up documentation. The Director of Nursing/Designee will conduct random audits weekly for wound care and antibiotics and will provide any needed immediate interventions. An Ad Hoc QAPI Meeting will be held on 5/1/23 to approve the above plan. The DON/designee and the Administrator/designee will bring the results of the audits to the QAPI committee for tracking, trending and further recommendations to ensure compliance with plan. The audits will be brought to the QAPI committee for 3 months. The Administrator will oversee the QAPI committee.