Based on observation, interview, and record review during the abbreviated survey (NY00315847), the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 4 residents reviewed (Resident #7). Specifically, for Resident #7 who developed a diabetic ulcer, treatments ordered were not transcribed; ordered treatments were not implemented; attending physician #17 or nurse practitioner #1 were not notified of worsening wounds; a wound culture was not ordered as recommended, and wound culture results were not reported to the medical provider. Subsequently, the wound worsened, the resident developed osteomyelitis (bone infection) and required treatment with intravenous (IV) antibiotics and a wound V.A.C (vacuum assisted closure). This resulted in harm to Resident #7 that was not Immediate Jeopardy. Findings include: The undated facility policy Managing Skin Integrity documented any deterioration in or development of an alteration in skin integrity would be promptly addressed and individualized approaches would be implemented. Upon admission and readmission, the registered nurse (RN) would thoroughly inspect all residents' skin and document findings in the medical record. The attending physician would be notified of any alteration(s) to skin integrity and interventions/treatments would be ordered as indicated. A licensed nurse skin observation should be completed weekly, and any abnormal looking skin should be reported to the Nurse Manager/Supervisor immediately. The area of concern should be reported to the attending physician and resident's representative. If an alteration in skin was deemed to be significant, the resident would be referred to the wound team for weekly follow-up. The facility policy Consults-Outside Facility dated 5/2019 documented the medical provider would order medical appointments/clinic visits. The Nurse Manager/designee would make the appointment, notify medical records staff of the appointment, complete the consult packet, and notify the resident/resident representative of the appointment. The facility policy Laboratory, Radiology and Other Diagnostic Services revised 4/2023 documented a licensed nurse would obtain an order for the lab from the provider and the licensed nurse would complete the lab request before cosigning the order had been picked up. When a lab was received, the nurse completed the lab tracking form noting the lab result was received. When the lab result was obtained, the form would be cosigned by the provider indicating they had reviewed the results. Lab tests that had critical results would be reported to the provider immediately. Resident #7 was admitted to the facility with diagnoses including diabetes, a left below knee amputation, and peripheral vascular disease (PVD, impaired blood flow). The 9/27/2022 Minimum Data Set (MDS) assessment documented the resident's cognition was intact. The resident required extensive assistance with bed mobility and transfers, and had no pressure ulcers or venous or arterial ulcers (ulcers resulting from impaired blood flow). The 10/12/2022 weekly skin check completed by licensed practical nurse (LPN) #21 documented the resident's right heel had an open area with a large amount of clear light yellow drainage. There was no documentation in the resident's orders or Treatment Administration Record (TAR) of an ordered treatment for the resident's right heel from 10/12/2022 to 10/17/2022. The 10/18/2022 at 1:13 PM, LPN Manager #13's progress note documented a new treatment order for a deep tissue injury (DTI, full thickness depth unknown) on the resident's right heel to cleanse with normal saline, apply skin prep (protective liquid film barrier) to the peri wound (the skin around the wound), apply silver antimicrobial wound gel (hydrates wounds, protects against infection) to the open areas around the dark area in center of wound, and cover with a foam dressing daily. There was no documentation as to who gave the order to LPN Manager #13 or if the resident's wound was assessed. The 10/2022 Treatment Administration Record (TAR) documented on 10/18/2022, a new order for silver antimicrobial wound gel to open areas around the dark area in center of wound, and cover with a foam dressing daily. The 10/28/2023 nurse practitioner (NP) #1's progress note contained no documentation that NP #1 was aware the resident had a DTI on the right heel. The 11/2/2022 at 11:50 AM, LPN Manager #13's progress note documented LPN Manager #13 observed the resident's right heel wound had a foul odor and the old dressing had bloody drainage. There was no documentation LPN Manager #13 reported the foul odor or bloody drainage to a registered nurse (RN), attending physician #17, or NP #1. The 11/2/2022 attending physician #17's progress note did not document the physician was aware of the resident's right heel wound. On 11/6/2022 at 8:52 AM, RN #20's progress note documented the resident reported severe pain to their right leg and heel and received pain medication (Tylenol). On 11/6/2022 at 1:58 PM, RN #20's progress note documented RN #20 completed the treatment to the resident's right heel wound and noted some redness on their right heel and leg and no warmth was noted to the right leg. The 11/7/2022 NP #1's progress note documented the resident's right heel wound had increased foul drainage over the weekend. The plan was to start doxycycline (antibiotic) for 10 days, obtain a wound culture, and STAT (immediate) referral to wound care for an evaluation. The resident was to start calcium alginate (a topical absorbent dressing) and an absorbent dressing (secondary dressing) to the right heel. The 11/2022 Medication Administration Record (MAR) documented on 11/7/2022, the antibiotic was ordered and administered for 10 days. There was no documentation an order was written for the wound culture, the treatment change to calcium alginate, or for the STAT wound care referral. The 11/2022 TAR documented from 11/7/2022 through 11/16/2022, the treatment to the resident's right heel DTI remained as skin prep, silver antimicrobial wound gel, and a foam dressing daily. On 11/16/2022 at 3:54 PM, LPN #22's progress note documented the resident had bloody drainage on the right heel dressing and the surrounding DTI appeared slightly red and warm to touch. The resident complained of pain during the dressing change and refused to take anything for pain. There was no documentation the resident's skin condition or pain was reported to an RN, attending physician #17, or NP #1. On 11/17/2022 at 5:57 PM, RN #11's progress note documented the resident complained of severe pain to the right heel and requested to be sent to the hospital. The 11/17/2022 hospital emergency room (ER) report documented the resident was seen for a right heel diabetic ulcer. Recommendations included a follow up with podiatry (health care provider specializing in disorders of the foot) and Bactrim DS (antibiotic) 800-160 mg for 10 days for a wound infection. The 11/18/2022 at 4:09 AM, LPN #22's progress note documented the resident returned to the facility from the ER. The 11/18/2022 at 10:18 AM, LPN Manager #13's progress note documented the podiatrist's office called with an appointment for the resident on 12/15/2022 at 2:00 PM. The 11/2022 TAR documented from 11/16/2022 through 11/21/2022, the treatment to the resident's right heel DTI remained as skin prep, silver antimicrobial wound gel, and a foam dressing daily. The 11/22/2022 weekly wound assessment completed by an unidentified RN documented the resident's right heel diabetic ulcer had declined and measured 4 cm x 7 cm with heavy serosanguinous (thin, bloody fluid) drainage. The RN recommended to change the treatment to collagenase (an enzyme that breaks down dead tissue) and a foam dressing. LPN Manager #13's progress note documented on 12/1/2022, the resident's right heel wound was necrotic (dead tissue) with slough (soft, yellow dead tissue) and had heavy purulent (pus) drainage with a foul odor. Collagenase and foam dressing continued. There was no documentation an RN, attending physician #17, or NP #1 were notified of the resident's skin condition. LPN Manager #13's progress note on 12/6/2022 at 7:33 PM documented they discussed the resident's heel wound with NP #1 and a new order was obtained for Bactrim DS twice daily for 10 days. The 12/2022 MAR documented the antibiotic was ordered and administered from 12/7/2022 through 12/16/2022. LPN Manager #13's progress note on 12/15/2022 PM documented the resident returned from podiatry and the treatment was changed to Providine iodine (antiseptic), covered with a gauze pad and gauze wrap daily. LPN Manager #13's progress note documented on 1/4/2023 at 10:47 AM, the resident's heel had a foul odor, and the NP ordered a wound culture. LPN Manager #13's progress note documented on 1/7/2023 at 10:47 AM and 1/8/2023 at 7:35 AM, the resident's heel continued with a foul odor. The faxed wound culture report, received by the facility on 1/9/2023 documented the bacteria present in the resident's right heel wound and which antibiotics the bacteria was sensitive too. There was no documentation attending physician #17 or NP #1 were made aware of the wound culture results. The 1/9/2023 at 12:42 PM, Director of Nursing (DON) progress note documented the resident had an appointment on 1/13/2023 for a magnetic resonance imaging (MRI)/ultrasound. LPN Manager #13's progress note documented the resident's right heel had foul to extremely foul odor on 1/10/2023, 1/11/2023, 1/12/2023, 1/16/2023 and 1/17/2023. There was no documentation in the progress notes that LPN Manager #13 reported the foul odor to an RN, attending physician #17, or NP #1 for evaluation. LPN Manager #13's progress note on 1/17/2023, documented the podiatrist called and said the resident's test results were received and reviewed by podiatry and the resident had osteomyelitis (bone infection) of the right foot. LPN Manager #13's progress note on 1/18/2023 at 10:07 AM, documented the resident was lethargic, cool, and clammy to touch and had delayed speech. NP #1 was notified and advised to send the resident to the emergency room (ER). The 1/18/2023 ER report documented the resident had fever, pallor (pale appearance) and malaise (general feeling of discomfort), and osteomyelitis of the right foot. The resident was scheduled to go to a different hospital for an amputation that week. The 1/31/2023 hospital report documented the resident was sent to the hospital for an amputation of their foot and the resident wanted their foot saved if possible. They had a large heel ulcer that was down to the bone and 40% of the wound had green, malodorous (foul odor), wet necrotic tissue. The resident went to the operating room and had a partial resection of the calcaneus (heel bone) and received IV antibiotics. The resident was discharged back to the facility with a wound V.A.C and IV antibiotics. The medical record from 1/31/2023 through 5/25/2023 (the date of the on-site investigation) contained documentation that orders were in place for wound care and orders were implemented. On 5/23/2023 at 10:30 AM, the resident was observed for a dressing change with LPN #12 and Wound RN #14. The resident's dressing was removed from the right foot and an approximately 6 cm x 2 cm x 0.2 cm wound was observed on the right heel with red granulation tissue (new tissue) and a small amount of yellow slough on the outer perimeter of the wound. The wound was cleansed, and the treatment was applied by LPN #12 and Wound RN #14. During a telephone interview on 6/9/2023 at 3:13 PM, LPN Manager #13 stated they became the LPN Manager in 8/2022 and completed weekly wound rounds at the facility. For several weeks, NP #1 accompanied them on wound rounds but when NP #1 was not present, they completed rounds with LPN #12. LPNs #13 and 12 collected data and completed wound sheets that were given to the Director of Nursing (DON) or NP #1 to review. When they gave the wound sheets to the DON for review, they never got them back so they started making a copy for the DON and keeping their notes on the unit. LPN #13 stated they determined the best treatments for residents along with LPN #12. They did not call attending physician #17 or NP #1 to discuss the treatments, LPN #13 entered the new orders into the medical record and attending physician #17 or NP #1 signed the orders the next time they were in the facility. If NP #1 was in the building at the time a skin concern was identified, they would have NP #1 evaluate the resident but because that often took a while to get NP #1 to the unit, LPN #13 stated they preferred to look at the wound themselves. LPN Manager #13 looked at wounds weekly. When a resident had a change in condition, the RN or medical provider should be notified. On 10/12/2022, LPN #21 should have had an RN assess the resident's wound. On 10/18/2022, it was not timely when it took 6 days to obtain a treatment order for the resident's heel. LPN Manager #13 stated they determined what treatment to use that day along with LPN #12 who was present. On 11/2/2022, they did not notify anyone the resident had foul drainage from the wound. They stated it was not timely when it took 5 days for NP #1 to evaluate the resident and order an antibiotic. Sometimes it took weeks to receive NP #1's notes and because of this, NP #1 wrote what orders they wanted in the communication book. During the interview, LPN Manager #13 reviewed the communication book and stated there was nothing documented by NP #1 about the treatment order being changed, the wound culture, or the STAT wound care referral and that was why they were not ordered. LPN Manager #13 stated the communication book was used by NP #1 and the nurses documented concerns in there for NP #1 to be aware of and NP #1 documented any new orders for the nurses to enter into the electronic medical record. LPN Manager #13 stated on 12/1/2022, they did not believe they notified the medical provider. On 1/9/2023, they were not sure if they saw the wound culture results. They stated the medical provider should have been notified of the wound culture results. During a telephone interview on 6/20/2023 at 8:30 AM, NP #1 stated, when they wanted a treatment, medication or consult ordered, they wrote the order in the communication book and a nurse entered the orders in the electronic medical record (EMR). NP #1 stated they were not able to enter their own orders. Nursing or a medical records staff person were in charge of scheduling appointments for outside consults. On 10/12/2022, an RN should have assessed the resident's heel and called a medical provider for a treatment order. NP #1 stated it was not timely when it took 6 days to obtain a treatment order. On 10/22/2022, they were not sure if they were aware the resident had a right heel ulcer when they wrote their note and if they had known, they would have documented it. On 11/2/2022, they did not recall being notified the resident's right heel had foul drainage. On 11/7/2022, when they ordered a STAT referral for a wound consult, they expected the referral would have occurred within the day and if the appointment could not be made that quickly, they wanted to be notified and would have sent the resident to the ER for evaluation. They ordered the wound culture because they wanted to see what bacteria the resident's wound had so they could order the appropriate antibiotic. They expected the wound culture to be obtained immediately and was not aware it was not. Calcium alginate was ordered because the resident had a lot of drainage. They were not aware it was not ordered and the silver treatment that was ordered was not an appropriate treatment for that drainage. On 12/1/2022, they should have been notified the resident had foul odor and drainage from the wound and it was not timely when Bactrim was ordered on 12/6/2022. On 1/9/2023, they would have wanted to know about the wound culture results and would have ordered an antibiotic the bacteria was sensitive to. When the resident had extremely foul drainage that continued from 1/8/2023 to 1/17/2023, they would have sent the resident to the hospital had they been aware. All the delays in assessments, treatments and laboratory testing could have led to the resident developing osteomyelitis. During a telephone interview on 6/28/2023 at 11:39 AM, the DON stated wounds should be monitored weekly by the RN during wound rounds and daily during dressing changes by LPNs. LPNs should report any wound changes to an RN/NP so the wound could be assessed to determine if a treatment change was needed. If wound rounds were not occurring routinely or an RN/NP was not available during wound rounds, they expected to be notified to intervene. Assessments should be completed by a RN/NP because LPNs were not allowed to assess. If the NP wanted a culture ordered, the NP was responsible to notify the nurse so orders could be implemented. They stated from 11/2022 through 3/2023, the LPN Managers completed wound rounds along with NP #1. They were not aware that wound rounds were not completed routinely with NP #1. They were not aware a wound culture was not ordered timely and when the results were available, nursing should have communicated the results to the provider. They were not aware the resident's wound had a foul odor and expected that would have been communicated timely to the provider. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the abbreviated survey (NY00304851 and NY00315847), the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection, and prevent new ulcers from developing for 2 of 4 residents (Residents #3 and 6) reviewed. Specifically, Resident #3 developed pressure ulcers and treatments were not ordered, transcribed, or administered and pressure relief interventions were not provided. This resulted in harm that was not immediate jeopardy to Resident #3 when their pressure ulcers subsequently worsened to Stage 3 (full thickness tissue loss) and Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle), requiring hospitalization and (IV) antibiotics for osteomyelitis (bone infection). Additionally, Resident #6's pressure ulcer treatments were not completed as ordered. Findings include: The facility policy Pressure Injury Prevention & Management/Wound Rounds revised 12/2022 documented when a pressure ulcer was identified, the nurse was responsible to notify the physician and obtain the appropriate treatment order, initiate the Skin Tracking Assessment Sheet, notify the dietitian, and document in a nurse's note. The registered nurse (RN) Manager/designee was responsible to monitor and assess healing/deterioration minimally on a weekly basis and communicate changes to the physician so that appropriate revision to the plan of care could be implemented. The dietitian was responsible for conducting a nutrition assessment and reassessing the resident when an actual pressure injury was identified. The medical provider was responsible to complete an assessment and document findings in the medical record, conduct periodic evaluation of the pressure injury on an ongoing basis until healed, modify treatment plans and make referrals. 1) Resident #3 was admitted to the facility with diagnoses including dementia, venous insufficiency (poor blood flow) and functional quadriplegia (paralysis of both arms and legs). The 11/2/2022 Minimum Data Set (MDS) assessment documented the resident's cognition was severely impaired, they required extensive assistance of 2 with bed mobility and transfers, was at risk of developing pressure ulcers, and had no current pressure ulcers. The 8/23/2022 comprehensive care plan (CCP) documented the resident had potential for skin impairment related to incontinence. Interventions included avoid scratching, good nutrition and hydration, keep skin clean and dry, and a pressure relieving cushion in the wheelchair. The 12/1/2022 wound rounds tracking sheet by licensed practical nurse (LPN) Manager #13 documented the resident had an open coccyx (tailbone) pressure ulcer that had 90% granulation tissue (new healthy tissue) and 10% slough (tan/yellow dead tissue) and the current treatment was wound gel (water-based treatment, hydrates wounds) and a dressing daily. There was no documentation of the wound stage and no evidence the medical provider (attending physician #17, nurse practitioner (NP) #1 were contacted for a treatment for the wound. The 12/2022 Treatment Administration Record (TAR) did not include documentation of a treatment to the coccyx wound from 12/1/2022 through 12/9/2022. The 12/9/2022 at 1:13 PM LPN Manager #13's progress note documented a certified nurse aide (CNA) reported the resident had scar tissue on their coccyx that had re-opened. Nurse practitioner (NP) #1 was notified and ordered a treatment. The 12/9/2022 medical order, entered into the electronic medical record (EMR) by LPN Manager #13 documented to the open area on the coccyx, cleanse with normal saline (NS), apply wound gel and cover with a foam dressing daily. The 12/2022 TAR contained no documentation that the coccyx wound treatment order entered by LPN Manager #13 on 12/9/2022 carried over as an order onto the resident's 12/2022 TAR. The 12/2022 TAR contained no documentation a treatment was applied to the coccyx wound from 12/10/2022 through 1/4/2023. The 12/15/2022, 12/22/2022 and 12/29/2022 wound rounds tracking sheet, completed by NP #1 documented the resident's coccyx pressure ulcer was 5 centimeters (cm) x 2.7 cm with 90% granulation and 10% slough. NP #1 noted the current treatment was wound gel and a dressing. There was no documentation on the 12/2022 TAR that the treatment to the resident's coccyx wound was ordered or administered from 12/9/2022 through 1/3/2023. The 1/4/2023 and 1/5/2023 physician's order documented a treatment to a Stage 2 (partial thickness loss of skin layer) pressure ulcer on the resident's coccyx including wound gel and cover with foam dressing daily and to deep tissue injuries (DTI, purple/maroon intact skin, or blood-filled blister due to damage from pressure) on both heels, both ankles, and the right outer foot, apply skin prep (a liquid protective film) every shift. The 1/17/23 at 4:16 PM LPN Manager #13's progress note documented the resident's right heel had a DTI and the left ankle had an open area that measured 0.1 cm and appeared to be lifting. The note documented to start wound gel and collagen (a protein, stimulates new tissue growth), cover with abdominal pad (ABD) and secure with gauze wrap (dressing) daily. The 1/18/23 medical order documented to the right heel and left ankle, cleanse right heel and left ankle, apply skin prep (treatment), mix wound gel and collagen to open area and cover with an ABD pad, and secure with gauze wrap daily. The 1/2023 TAR documented treatments were not administered: - on 1/5/2023 through 1/11/2023 to the coccyx pressure ulcer; and - on 1/18/2023 through 1/23/2023 to the right heel and left ankle DTIs. There was no documented rationale why the treatments were not administered as ordered. The 1/24/2023 physician's order documented the coccyx pressure ulcer treatment was changed from once daily to every shift. Wound tracking sheets documented: - on 2/7/2023 by registered nurse (RN) #19 the resident's coccyx pressure ulcer had minimal drainage and wound gel continued as the treatment. - on 2/14/23 by RN #19, the coccyx, right ankle had minimal drainage, left outer ankle, left outer foot and right ankle had 100% eschar, and the left heel had 25% eschar (black necrotic tissue). - on 2/21/23 (unsigned), the coccyx continued with wound gel and dressing, the left outer ankle was red and warm with moderate drainage and all other areas were unchanged. - on 2/28/2023 (unsigned) documented the resident's foot and ankle wounds were DTI's and the coccyx wound was a Stage 2. The 2/28/23 at 8:24 AM, LPN Manager #13's progress note documented the resident had multiple wounds including the right heel wound had bloody drainage; the right ankle wound continued with a black scab; the left ankle wound had bloody drainage; the left foot outer aspect wound continued with a black scab, and the resident continued with a Stage 2 on the coccyx. LPN Manager #13 noted there was no dressing on the resident's coccyx wound at the time of wound rounds and all treatments continued as previously ordered and were rendered at that time by LPN Manager #13. The updated 3/11/2023 CCP documented the resident had a Stage 2 pressure ulcer on the coccyx and unstageable pressure ulcers on both heels and ankles. Interventions included an air mattress, monitor/document/report any changes in skin status; appearance, color and wound healing, signs and symptoms of infection, wound size, and stage. The 3/13/2023 at 5:41 PM, RN #6's progress note documented a CNA asked them to assess the resident's right heel, left outer foot, and left outer ankle area. The resident's right heel DTI was necrotic (dead tissue) and had a thick area that was lifting at the distal (furthest) end. The area appeared to have some depth and a foul odor. The left outer ankle had shiny moist skin and yellow slough. The lateral (outer side) foot was necrotic and not open. The note documented they would notify the interdisciplinary team. There was no documentation the medical provider was notified of RN #6's concerns. The 3/15/2023 at 3:32 PM LPN Manager #13's progress note documented NP #1 was on the unit and assessed the resident's foot wounds and ordered Bactrim DS (antibiotic) twice daily for 7 days. The treatment was changed to cleanse the ulcers on the left and right heels and ankles, cover with a petroleum dressing and silver alginate (a highly absorbent antimicrobial dressing) and wrap with gauze dressing daily. There was no documented evidence the petroleum dressing was ordered as noted in LPN Manager #13's progress note on 3/15/2023. The 3/2023 TAR and Medication Administration Record (MAR) documented: - wound gel and collagen treatment to the right heel and left ankle was discontinued on 3/15/2023. - Skin prep was to be applied to all pressure areas every shift from 3/16/2023 to 3/21/2023. - Bactrim DS 800-160 milligrams (mg) every 12 hours for infected wounds on both feet for 7 days. There was no documentation that petroleum and silver alginate dressings were ordered and/or added to the resident's TAR. The 3/16/2023 at 10:53 AM LPN Manager #13's progress note documented all the resident's foot wounds had a foul odor. The coccyx dressing was noted to be off. The surrounding tissue was uneven, had broken edges and was macerated (softening/breaking down of tissue from prolonged moisture). The 3/21/2023 physician's order documented to wounds on left and right heels and ankles apply petroleum dressing then silver alginate and wrap with gauze dressing daily. The order was written 6 days after LPN Manager #13 noted the planned order change. The 3/24/2023 at 1:42 PM LPN Manager #13's progress note documented the resident's right heel wound had brownish green drainage; the left ankle wound had greenish yellow drainage, a foul odor, and 60% slough; the left outer foot wound had brownish green drainage and a foul odor; and the coccyx wound had 75% slough. There was no evidence the medical provider was notified the resident's wounds continued with foul odor 2 days after the course of Bactrim was completed. The 3/28/2023 at 5:54 PM, LPN Manager #13's progress note documented the resident's right heel wound had brown/green drainage and foul odor; right ankle wound had brown/green drainage; left ankle wound now had depth, red/pink wound bed, broken edges, green-brown drainage, and no odor; left outer foot wound now had depth, 60% slough, green-brown drainage, and no odor, and coccyx wound had depth increased from 0.2 cm to 0.5 cm. There was no documentation the medical provider was notified for consideration of a treatment change when the wounds worsened and continued with foul odor. The 3/30/2023 at 4:53 PM LPN Manager #13's progress note documented they discussed the resident's right heel odor and drainage with NP #1. A new order was received for doxycycline (antibiotic) 100 mg twice daily for 10 days for an infected ulcer. The 3/30/2023 NP #1's progress note documented a urinary catheter (drains urine form the bladder) would be placed to promote better healing to the resident's coccyx ulcer. The resident had been given rounds of oral antibiotics for the left and right heel and ankle DTIs. Wound tracking sheets from 3/14/23 to 4/4/23 were incomplete or blank and did not document assessment of the resident's wounds. The 4/4/2023 NP #1's progress note documented the resident presented with an infection to the left heel and left ankle DTIs. The resident was currently on doxycycline and prior to that had completed a regimen of Bactrim DS twice daily for 10 days. The left heel and ankle had ongoing DTIs that progressed over the last month. Both wounds had foul thick brown drainage, and the surrounding tissue was very red, warm, and tender. The wound beds were necrotic, boggy (spongy), and had slough. The right heel DTI and coccyx appeared to be doing poorly, were not progressing, and did not appear infected. The 4/4/23 at 1:45 PM LPN #13 Manager note documented NP #1 was on the unit and assessed the following wounds: coccyx had depth to the tailbone, right heel was boggy, pink and necrotic with foul odor, left outer heel and left ankle had very foul odor. They had given report to the hospital nurse and informed them of impending transfer. The resident was transferred to the hospital emergency department on 4/4/23 for evaluation of worsening pressure ulcers. The 4/10/2023 hospital discharge summary documented the resident was admitted on [DATE] with acute osteomyelitis of the right and left feet and wound cultures showed Proteus Mirabilis (bacteria). The resident was treated with intravenous (IV) antibiotics during their stay. They were to continue daily wound care, continue oral doxycycline and Augmentin (antibiotic) and were stable for discharge. On 5/24/2023 at 10:20 AM, the resident was observed during a dressing change with Wound RN #14 and LPN #12. The resident was positioned on their left side and their adult brief was removed. There was no dressing on the resident's coccyx. LPN #12 and RN #14 both stated the dressing frequently fell off and the staff did not always report when that happened. The resident's coccyx wound was approximately 2.4 cm x 2.8 cm x 0.2 cm with 100% slough. Wound gel, a highly absorbent dressing and a bordered gauze dressing was applied. During a telephone interview on 6/1/2023 at 9:53 AM, the Assistant Director of Nursing (ADON) stated the order for wound gel was not entered correctly in the EMR by LPN Manager #13, so it did not show up as an order on the 12/2022 TAR. During a telephone interview on 6/9/2023 at 8:30 AM, CNA #23 stated the resident required assistance with bed mobility and transfers. They had an air mattress, a pillow between their knees, was on a turning and positioning program, and had booties on their feet while in bed for pressure relief. The resident had an open area on their buttocks and if the dressing fell off when they did care, they would notify the nurse to apply a new one. During a telephone interview on 6/9/2023 at 10:21 AM, LPN #12 stated there was a period when the facility did not have a wound team and LPN #12 and LPN Manager #13 completed wound rounds together. They rounded weekly and documented their findings. They never had an RN or NP accompany them during wound rounds. They believed LPN Manager #13 had NP #1 or the DON sign off on the wound round tracking sheets. They stated when a treatment was not available, they should notify the medical provider for an alternate treatment. They were not sure why they had missing documentation on the TAR in 1/2023 on multiple dates and stated it could have been because the order dropped off the TAR. They stated if they were not able to complete their treatment during their shift, they stayed late to complete the treatments. During a telephone interview on 6/9/2023 at 3:13 PM, LPN Manager #13 stated they completed wound rounds at the facility for several months. NP #1 accompanied them on wound rounds for several weeks but otherwise, they completed them with LPN #12. They documented on the wounds and gave the wound sheets to the DON or NP #1 to review weekly. LPN Manager #13 stated they and LPN #12 determined the best treatment when they saw residents and they did not call the medical provider to discuss the treatment plan. The medical provider signed any new orders the next time they were in the facility. If a medical provider was in the building at the time a skin concern was identified, they would have them assess the resident. LPN Manager #13 stated they were responsible to enter treatment orders in the EMR and the order transferred to the TAR. When the resident developed DTIs on their feet and a Stage 2 pressure ulcer to their coccyx in 12/2022, they entered the orders and was not aware the orders did not transfer to the TAR to alert the nurses to the orders. LPN Manager #13 stated there was an issue in the past with orders falling off the TAR and they did not report the issue to anyone. On 12/28/2022, they noted the area to the resident's right heel was opening and they thought they got an order for wound gel and was not aware there was no order entered. If a treatment product was not available, the DON should be notified to determine next steps. LPN Manager #13 stated they were not aware treatments were not signed as completed on multiple occasions in 1/2023 and not doing treatments increased the resident's risk of infection. On 2/28/2023 and 3/16/2023, the resident's dressing probably fell off during incontinence care and they believed they spoke with the CNA at the time but could not be sure. LPN Manager #13 stated they were responsible for implementing and updating CCPs. When a resident developed pressure ulcers, interventions should be added immediately to the CCP. On 3/11/2023, they implemented an alternating air mattress for the resident for pressure relief, it had never been discussed prior to that date, and it was not added to the plan of care timely. On 3/15/2023, they were not aware the orders for petroleum and silver alginate were not implemented and it was not timely when they were added 6 days later. On 3/24/2023 and 3/28/2023, they did not ask a RN to assess the resident when their wounds had a change in condition and was not sure if NP #1 assessed them. They stated the ADON read progress notes daily and should have been aware to do an assessment. When orders were obtained 2 days later on 3/30/2023, it was not done timely. During an interview on 6/20/2023 at 8:30 AM, NP #1 stated, they were a part of the wound team for a short time along with LPNs. During wound rounds, they got called away frequently for resident emergencies and when they would return to complete the rounds, the LPNs were already done. They were supposed to review the LPN's documentation on wounds but sometimes the sheets were not available for up to a month. They reported the issue to the DON and the DON was aware LPNs were doing wound rounds on their own. The protocol was a RN was to be present during wound rounds. They expected a RN to assess new wounds or deteriorating wounds and wanted to be contacted so they could intervene and determine a treatment. If treatments were not available for any reason, they should be contacted for an alternate treatment. If no treatment was available and they were not contacted, the resident could be at risk of infection or worsening wound condition. From 12/1/2022 to 1/5/2023, 6 weeks was not timely to obtain a treatment order for the resident. They were not made aware that staff did not administer treatments from 1/5/2023 through 1/11/2023 and 1/18/2023 through 1/23/2023 and they should have been notified. The resident should have had an alternating air mattress added to their CCP after they developed pressure ulcers and it was not timely when it was added in 3/2023. On 3/13/2023, they expected the RN to call them for orders and the resident's heel wound was probably infected at that time. They were not aware on 3/15/2023 that the order for petroleum dressing and silver alginate was not carried through and skin prep was not an appropriate treatment for foul odor and drainage. On 3/24/2023, they should have been notified to assess the resident to determine if they needed another antibiotic. On 3/28/2023, when the wound depth increased, the wound was deteriorating, and they expected to be notified. On 3/30/2023, it was not timely when the antibiotic was ordered. That day they ordered a urinary drainage catheter to assist with healing and to prevent worsening of the resident's Stage 3 coccyx pressure ulcer. The cumulative effect of untimely care could have led to the resident developing osteomyelitis. During a telephone interview on 6/28/2023 at 11:39 AM, the DON stated, pressure ulcers were to be monitored weekly by the RN during wound rounds and daily during dressing changes by LPNs. LPNs should report any wound changes to a RN/NP so the wound could be assessed to determine if a treatment change was needed. If wound rounds did not occur routinely or a RN/NP was not available during wound rounds, they expected to be notified to intervene. Assessments needed to completed with a RN/NP because LPNs could not assess. Back in 11/2022 through 3/2023, the LPN Managers completed wound rounds along with NP #1. They were not aware that wound rounds were not completed routinely with NP #1. The air mattress was not added timely and should have been added when the resident initially developed pressure ulcers. They were not aware the resident had foul odor from their wounds on multiple occasions and the medical provider should have been notified. 2) Resident #6 was admitted to the facility with diagnoses including end stage renal disease (kidney disease), diabetes, and cellulitis (infection) of the right leg. The 9/19/2022 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance of 2 for bed mobility and transfers, and had 2 unhealed unstageable (depth unknown) pressure ulcers that were present on admission. Physician orders documented treatments were ordered to wounds on the resident's right heel and coccyx including: - on 9/13/2022, to the right heel, cleanse and apply calcium alginate (absorbent dressing for wound healing), and wrap with gauze, one time daily. - On 9/15/2022, to the coccyx: cleanse wound with NS (normal saline), apply calcium alginate, cover with DSD (dry sterile dressing), and wrap with gauze daily. The 9/2022 Treatment Administration Record (TAR) did not document the right heel treatment was not completed on 9/14/2022 and 9/19/2022 and the coccyx treatment was not signed as completed on 9/20/2022. Physician orders documented treatment changes were ordered to the wounds on the resident's right heel and coccyx including: - on 9/21/22, to the right heel, apply skin prep (protective barrier/film), float heels, every shift. - On 9/21/22, to the coccyx, cleanse with NS, apply Santyl (collagenase, an enzymatic debriding treatment) and calcium alginate to the wound bed followed by superabsorbent dressing. The 9/2022 TAR documented the heel wound treatments were not signed as completed on 9/23/2022 and 9/25/2022 during the day shift and on 9/29/22 during the evening shift. The coccyx wound treatment was not signed as completed from 9/23/2022 through 9/27/2022 and on 9/29/2022. There were no documented progress notes related to the multiple heel and coccyx treatments that were not signed/completed in 9/2022. There was no documented evidence the medical provider was notified of the missed treatments in 9/2022. The 10/3/2022 registered nurse (RN) #6's progress note documented nurse practitioner (NP) #1 ordered a new treatment for wounds to bilateral feet: calcium alginate (highly absorbent treatment) and cover with transparent film until healed. The 10/4/2022 NP #1's progress note documented the resident was noted with 2 half dollar sized deep tissue injuries (DTIs, dark/purple areas, depth unknown) to the bottom of their bilateral feet. The coccyx pressure ulcer continued to worsen, and daily dressings remained in place. Physician orders documented: - on 10/4/22, to the bilateral feet, calcium alginate dressing with a transparent film cover to bilateral foot wounds daily. - On 10/3/2022, to the sacrum, cleanse with NS, fill with hydrogel (adds moisture to a wound and encourages removal of dead tissue), and cover with a foam dressing, every day. - On 10/6/2022, to the coccyx, cleanse with NS, apply calcium alginate to wound bed followed by superabsorbent dressing, every day shift. The 10/2022 TAR documented multiple treatments were not signed as completed including: - the bilateral heel treatments on 10/4/2022 and from 10/22/2022 through 10/24/2022. - The right heel treatment for 17 shifts. - The coccyx treatment from 10/1/2022 through 10/4/2022 and 10/22/2022 through 10/26/2022. - The sacral treatment on 10/4/2022 and from 10/22/2022 through 10/26/2022. The 10/6/2022 Weekly Wound Assessment documented a treatment change for the coccyx wound, to discontinue hydrogel. There were no documented progress notes related to the multiple heel/feet and coccyx treatments that were not signed/completed in 10/2022. There was no documented evidence attending physician #17 or NP #1 were notified of the missed treatments in 10/2022 and no documentation treatment orders were clarified when multiple treatments were ordered to the same wounds. During an interview on 6/12/2023 at 1:59 PM, the Director of Nursing (DON) stated when treatments were completed, the TAR would be signed. If the TAR was not signed, a nursing progress note should be documented related to the reason the treatment was not completed and what the plan was, such as medical provider notification. When the resident had a new order for bilateral foot treatments, the DON was unaware of the location of the areas to be treated. They stated the order did not clarify the location of the foot wounds and was not aware if the treatment for the right heel should have been discontinued. The orders should have been clarified to show the location of each treatment for each foot. The resident's coccyx wound, and sacral wound were likely the same area. The DON was not able to clarify which treatment was to be completed for the areas and stated there were 2 different active treatment orders. The treatments were different, and the DON stated both treatments could not have been completed at the same time. There was no documentation of clarification, and the orders should have been clarified by the medical provider. The treatments that were not signed should have a progress note documenting the reason why the treatments were not completed. During a telephone interview on 6/20/2023 at 8:30 AM NP #1 stated when they entered the new order on 10/4/2022 for Resident #6's feet, it was for DTIs on both heels. The NP ordered calcium alginate because both heels were on the verge of opening. The order for skin prep should have been discontinued at that time and the NP was not sure why it was not. NP #1 was not able to enter or discontinue their own orders into the electronic medical record (EMR). NP #1 was not notified of the missing treatments and should have been notified. Hydrogel should have been discontinued when calcium alginate started. There was only one wound on the sacral area. The NP was not aware there were missing treatments and expected to be notified. 10 NYCRR 415.12(c)(2)