**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff, Wound Care Physician, and Medical Director interviews, the facility failed to provide ongoing skin assessments, monitor consistently, and ensure treatments and interventions were implemented to prevent pressure ulcer development and worsening for a resident at risk for pressure ulcers who was admitted to the facility without pressure ulcers. On 10/02/22 Resident #67 was identified with a stage 2 pressure ulcer on his sacrum that worsened to a stage 4 pressure ulcer on 11/9/22. On 12/25/22 Resident #67 was diagnosed with osteomyelitis on admission to the hospital. In addition, the facility had a lower level of deficient practice when the facility failed to provide ongoing skin assessments, consistent wound monitoring, and to implement interventions of a low air-loss mattress and turning and repositioning as recommended by the wound care physician for Resident #5. This deficient practice affected 2 of 3 residents reviewed for pressure ulcers (Resident #67 and #5). Immediate Jeopardy began on 11/09/22 when the facility failed to assess and identify a stage 4 sacral pressure ulcer for Resident #67. The immediate jeopardy was removed on 1/28/23 when the facility provided and implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity level E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure that the education and the monitoring systems put in place are effective and to address deficient practice for Resident #5. Findings included: 1. Resident #67 was admitted to the facility on [DATE] with diagnoses which included traumatic brain dysfunction and respiratory failure. The head-to-toe skin assessment dated [DATE] at 8:28 AM revealed Resident #67 had no pressure ulcers present on the 7/11/22 admission. Resident #67's care plan initiated on 7/13/22 had a focus for potential impairment to skin integrity related to fragile skin, immobility, and incontinence. The interventions included weekly skin assessments and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. A pressure sore scale for predicting pressure sore risk dated 7/18/22 at 4:28 PM assessed the resident was at high risk. The admission Minimum Data Set (MDS) dated [DATE] revealed Resident #67 had severe cognitive impairment and was totally dependent on staff for all activities of daily living including bed mobility. The assessment noted no pressure ulcers, always incontinent of bowel and bladder, was on a scheduled pain medication regimen, received no as needed pain medication, had no weight gain or loss and received 100% nutrition through a feeding tube. The resident had no behaviors or refusal of care. He was coded to have a pressure reducing device for bed. The weekly skin assessments from 7/11/22 through 8/30/22 revealed no pressure ulcers present. The weekly skin assessment dated [DATE] revealed a stage 2 neck pressure ulcer which was treated and resolved on 9/28/22. The weekly skin assessment completed by Nurse #10 dated 9/28/22 revealed moisture associated skin damage to the sacrum. The September 2022 Treatment Administration Record (TAR) revealed the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. The weekly skin assessment completed by Nurse #2 dated 10/02/22 revealed a stage 2 pressure ulcer to the sacrum. An interview on 1/27/23 at 2:04 PM with Nurse #2 revealed she was not currently employed at the facility but had been assigned to provide care for Resident #67 three nights per week for the three months she worked at the facility. She stated that wound care treatments were completed during the day and did not remember completing the weekly skin assessment. The care plan was not updated when the sacral pressure ulcer was identified. The quarterly MDS dated [DATE] revealed Resident #67 had severe cognitive impairment and was totally dependent on staff for all activities of daily living including bed mobility. The assessment noted one unstageable pressure ulcer which was not present on admission, always incontinent of bowel and bladder, was not on a scheduled pain medication regimen, received no as needed pain medication, had no weight gain or loss and received 100% nutrition through a feeding tube. The resident had no behaviors or refusal of care. He was coded to have a pressure reducing device for bed, received pressure ulcer/injury care, and application of ointments/medications to other than feet. The October 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. An additional treatment order dated 10/14/22 read in part for Collagenase (used to remove dead tissue) ointment applied to sacrum every day. This treatment was not signed as completed on 10/19/22 and 10/22/22. An interview on 1/27/23 at 8:52 AM with Nurse #9 revealed she had obtained the order dated 10/14/22 for Collagenase. She stated she did not remember if the physician assessed the sacral wound or if she called him. She stated she observed the wound when assisting the Nursing Assistant (NA) with resident care on 10/14/22. Nurse #9 also stated she did not complete wound measurements or notify management about this wound. She stated that if she completed the wound care treatments, she signed the TAR. There were no weekly skin checks or pressure ulcer assessment notes after 10/02/22 until 11/09/22. Resident #67 was first assessed and treated by the Wound Care Physician for his sacral pressure ulcer on 11/09/22. His wound evaluation and management summary dated 11/09/22 read, in part, that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 6.5 centimeters (cm) by 5.0 cm by 0.1 cm. The ulcer had moderate serous exudate with 80% necrotic tissue and 20% granulation tissue. His ulcer detail note read, in part, that the resident was seen for initial evaluation and management of recent development of unstageable necrosis pressure injury of the sacrum. His plan of care recommendations included to off-load wound, turn side to side and front to back in bed every 1-2 hours if able, and a low air-loss mattress. His dressing treatment plan recommendations were for an absorbent, antimicrobial dressing applied daily for 30 days and Collagenase ointment applied daily for 30 days. Resident #67's wound evaluation and management summary dated 11/16/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.5 cm. The ulcer had moderate serous exudate with 60% necrotic tissue, 30% slough, and 10% granulation tissue. Resident #67's wound evaluation and management summary dated 11/23/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm. The ulcer had moderate serous exudate with 70% necrotic tissue, and 30% slough. Resident #67's wound evaluation and management summary dated 11/30/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.8 cm. The ulcer had moderate serous exudate with 20% necrotic tissue, 50% slough, and 30% granulation tissue. Resident #67's wound evaluation and management summary dated 12/07/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.8 cm. The ulcer had moderate serous exudate with 70% necrotic tissue and 30% slough. Resident #67's wound evaluation and management summary dated 12/14/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm. The ulcer had moderate serous exudate with 60% necrotic tissue and 40% slough. Resident #67's wound evaluation and management summary dated 12/21/22 read, in part that Resident #67 had a stage 4 pressure ulcer to his sacrum. The sacral pressure ulcer measured 7.0 cm by 5.0 cm by 1.9 cm with undermining of 4.3 cm at 3 o'clock. There was a deep tissue injury (DTI) noted within the wound bed area. The ulcer had moderate serous exudate with 60% necrotic tissue, 30% slough, and 10% granulation tissue. An interview with the Wound Care Physician on 1/11/23 at 3:00 PM revealed he made recommendations in his wound care notes. He stated he had recommended a low air-loss mattress for Resident #67 on his 11/09/22 recommendations. He also stated that a low air-loss mattress and turning and repositioning were vital to wound healing. Another interview with the Wound Care Physician on 1/27/23 at 11:44 AM revealed he was consulted by the facility to see Resident #67. He stated he could not say how the resident's wound developed, but confirmed it was a stage 4 sacral pressure ulcer when he initially assessed it on 11/09/22. He stated the resident was at high risk for wound development due to his medical comorbidities. The Wound Care Physician stated that he followed the resident weekly and when he saw him on 12/21/22 he noted no signs or symptoms of infection, but the resident had a high biofilm (thin, slimy film of bacteria that adheres to a surface) and necrotic burden (dead tissue that is a physical barrier and is a medium for bacterial growth), so he was at high risk of developing an osteomyelitis infection. The November 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks three times per day. The treatment order dated 10/14/22 for Collagenase to the sacrum was discontinued on 11/09/22. This treatment was not signed as completed on 11/2/22 and 11/4/22. The November 2022 TAR also had an order dated 11/09/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 11/16/22. This treatment was not signed as completed on 11/11/22. The November 2022 TAR had an order dated 11/16/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This treatment was not signed as completed on 11/18/22, 11/23/22, and 11/26/22. Resident #67's care plan was updated on 11/29/22 with an additional focus area notation that the resident had a pressure wound to inner buttocks. The goals and interventions were not updated. The weekly skin assessment completed by Nurse #11 dated 12/07/22 revealed a stage 4 pressure ulcer to the sacrum. The wound measurements were 7.0 cm x 5.0 cm x 1.8 cm. An interview with the Nurse #11 on 1/27/23 at 11:23 AM revealed she was an agency nurse and had worked at the facility for a couple of months mostly as the wound care nurse. She stated she rarely saw the resident in a different position and did not feel he was turned or repositioned as he should have been to prevent his pressure ulcers from getting worse or not healing. She stated the hall nurse was responsible for completing the residents' weekly skin assessments. She also stated that they were responsible for completing the residents' wound care treatments if there was no wound care nurse. The Wound Care Physician's wound evaluation and management summary dated 12/21/22 did not indicate concerns about infection and noted moderate serous drainage. The wound was debrided to remove necrotic tissue and biofilm and health bleeding tissue was observed. The wound measurements were 7.0 cm x 5.0 cm x 1.9 cm. The December 2022 TAR revealed a continuation of the 8/16/22 treatment order for skin protectant ointment to be applied to buttocks every shift which was three times per day. This treatment order was discontinued on 12/30/22. The December 2022 TAR had an order dated 11/16/22 for Collagenase ointment with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 12/20.22. This treatment was not signed as completed on 12/01/22, 12/09/22, 12/13/22, and 12/17/22. The December 2022 TAR had an order dated 12/20/22 for Collagenase ointment and collagen powder with an absorbent, antimicrobial dressing to be applied every day. This order was discontinued on 12/21/22. The December 2022 TAR had an order dated 12/21/22 for Collagenase ointment and collagen powder and to pack the wound with wound cleanser moistened gauze with an absorbent, antimicrobial dressing every day. This order was discontinued on 12/30/22. This treatment was not signed as completed on 12/23/22. Review of nurses' progress note completed by Nurse #12 dated 12/22/22 revealed Resident #67 tested positive for COVID. Review of nurses' progress note completed by Nurse #2 dated 12/25/22 revealed the resident was sent to the hospital for fever and respiratory distress. Resident #67's care plan initiated on 12/30/22 had a focus for multiple pressure injuries related to incontinence and decreased mobility and was at risk for worsening of wounds and additional breakdown. The interventions included to reposition and/or turn at frequent intervals to provide pressure relief and complete a full body check weekly and document. Review of Resident #67's hospital Discharge summary dated [DATE] included admission diagnoses of Covid pneumonia and stage 4 decubitus ulcer with osteomyelitis. He was treated with intravenous (IV) antibiotics with a discharge medication list to continue two antibiotics for 32 days. Resident #67's admission skin assessment dated [DATE] indicated he had a stage 4 sacrum pressure ulcer which measured 6.4 cm by 4.0 cm by 2.1 cm. Multiple observations were made on 1/10/23 at 10:00 AM, 11:15 AM, 12:27 PM and 1:09 PM. Resident #67 was observed to lie in the same position with the head of bed at about 45 degrees, face to the right, lying on his back, pillow under left arm, pillow under right side arm/side, feet wearing protective boots, and legs straight. The resident was not observed to make any independent movements and was not interviewable. The resident was observed to be on a low air-loss mattress. An interview with Nursing Assistant (NA) #3 on 1/10/23 at 2:13 PM revealed she was assigned to provide care for Resident #67. She also revealed she was scheduled to work from 7:00 AM until 3:00 PM. She stated she had turned him one time that day during his bath right before lunch. She stated that the resident did not get turned every 2 hours today because she was trying to give other residents their baths. She stated she was familiar with the resident, and she knew he was supposed to be turned every 2 hours. An interview with NA #6 on 1/26/23 at 3:11 PM revealed she was regularly assigned to provide care for Resident #67. She stated she did not turn him completely on his side but used pillows or wedges under his buttocks to reposition him. She also stated she turned him as often as possible but was unable to always turn him every 2 hours. An interview with NA #4 on 1/27/23 at 9:51 AM revealed she had been assigned to provide care for Resident #67 occasionally. She stated that she tried to turn and reposition the resident every 2 hours but that was not always possible if she got busy. An interview with Nurse #8 on 1/10/23 at 1:36 PM revealed she was the assigned nurse for Resident #67. She stated she was his assigned nurse frequently but had only been employed at the facility a short time. She did not provide wound care as there was a wound care nurse. She stated she had never seen him fully turned from one side to the other. She stated she saw pillows placed under one hip then the other to offload pressure on the sacral wound. She stated that he coughed more if turned onto his side. An interview with Nurse #10 on 1/27/23 at 12:02 PM revealed she had been employed at the facility as the wound care nurse for approximately 1 year and no longer worked at the facility. She stated when she first started working at the facility, she often worked 7 days per week, but then worked 3-5 days per week. She stated she completed weekly assessments and provided wound care treatments to Resident #67. She stated that if the TAR wasn't signed, then the treatment had not been done. She stated when she was the wound care nurse, she completed the weekly skin assessments and wound assessments. A wound care observation was completed with Nurse #11 and the Wound Care Physician on 1/11/23 at 3:17 PM revealed Resident #67's sacrum pressure ulcer was 6.5 cm (centimeters) x 4.4 cm x 1.9 cm with moderate serosanguinous exudate. The wound had 3.4 cm undermining (when the wound edges become eroded and a pocket forms beneath the wound edge) at the 3 o'clock position and contained 40% slough and 60% granulation. An interview with the Medical Director on 1/12/23 at 11:11 AM revealed he believed lack of turning and repositioning could contribute to pressure ulcer decline. He also stated he relied on the facility to ensure the wound physician recommendations in their notes were completed. A further interview with the Medical Director on 1/27/23 at 7:58 PM, he revealed he had seen and assessed Resident #67's sacral wound when it was a stage 2 but did not specify a date. He stated that the resident had multiple comorbidities which included his cerebrovascular disease, chronic respiratory failure, and tube feeding nutrition but that the lack of care he received played a part in his sacral wound development. He specified the lack of care as the resident not being turned or repositioned as frequently as necessary to prevent the sacral pressure ulcer from developing and worsening and noted that the resident did not have a pressure ulcer on admission. He also felt that weekly skin checks were important. An interview with the [NAME] President of Clinical Operations on 1/12/23 at 1:45 PM revealed the facility should adhere to the standards of wound management which included turning and repositioning. She also revealed that Resident #67 had significant comorbidities for pressure ulcer development. The Administrator was notified of the immediate jeopardy on 1/27/23 at 1:10 PM. The facility provided the following plan for immediate jeopardy removal: - Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance: Inconsistent nursing leadership led to the compliance failure. The [NAME] President of Quality Assurance completed this root cause analysis on 1/12/2023. Resident #67's skin assessment was completed on 01/27/2023 by the Unit Manager. The braden scale assessment was completed on 01/13/2023 by staff Registered Nurse and scores a 10, which indicates at risk for skin breakdown. Skin assessment shows sacrum stage IV and left heel deep tissue injury. Orders were entered for weekly skin assessments and weekly pressure wound observations, that were not previously in place. Assessments were scheduled for weekly skin and weekly pressure wound observations, that were not previously in place. Turning and repositioning as needed, not previously in place, was added to plan of care tasks, to be signed by Nursing Assistants, indicating the completion of turning and repositioning task occurred each shift. Resident continues on an air mattress. These updates were entered by the Director of Nursing 1/20-1/27/23. Interventions are in place to address pressure ulcers for Resident #67. - Heel protector boots-1/19/23 ordered, Occupational Therapy 1/5/23, turning and positioning, as needed 01/20/23, air mattress- 11/9/22, the facilty's wound care provider's recommendations were reviewed entered as physician's orders on 01/26/23, by the Director of Nursing. Residents with a high risk braden score, were audited on 01/27/2023 by the Director of Nursing. Interventions will be reviewed and implemented, as appropriate. No new residents were identified. Braden assessments were audited for residents triggering to be at risk for skin breakdown. Plans of care will be reviewed for those residents that trigger at risk, by the Director of Nursing, Unit Manager and MDS nurse on 01/27/23, to ensure interventions are current and appropriate. - Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: Nurses are being educated by the Unit Manager, regarding documentation of skin assessments, and braden assessments upon admission, with ongoing weekly skin assessments, weekly pressure wound observations, and quarterly braden assessments. Nurses not currently available for education, will receive education by the Unit Manager or Wound Care Nurse prior to assuming their next shift assignment. Nursing education was completed on 1/27/23, and included staff nurses and agency nurses, that are on our current schedules. New hires will receive this education by the Nursing Management team, as part of their nursing orientation. The wound nurse is responsible for the wound management, Monday- Friday, and a nurse will be scheduled on the weekends, for wound care continuity. Should the wound nurse be absent, then the Unit Manager will assume responsibility for wound care. A staff nurse has been identified as the primary wound care nurse effective January 27, 2023 and has been enrolled in a wound care certification program. Date of alleged IJ removal: 01/28/2023 The credible allegation of immediate jeopardy removal was validated by onsite verification on 1/31/23. Interviews conducted with nursing staff revealed they had attended training on Wound Management- Skin and Wound Protocol. The education included Braden scale, weekly skin review which was to be completed by the licensed nurse for each resident weekly. Weekly pressure wound observation tool- to be completed by clinical managers/designee when the weekly assessment is not completed by the Wound NP. Weekly non-pressure wound observation tool -for diabetic ulcers, arterial or vascular ulcers, surgical wound, excoriations, lacerations, abrasions, bruises , or skin tears- to be completed weekly by Clinical Manager/designee if the Wound NP did not access the area. The education also included steps to take if there were changes to the resident's skin integrity or wound outside the scheduled observations. Inservice forms were reviewed and indicated the dates, topics discussed, and the trainer, and included attending staff signatures. A review of the weekly wound observation dated 1/25/23 revealed the resident was seen by the facility's wound clinic and new orders provided. A review of the physician's orders for the month of January 2023 revealed that new orders and recommendations were included on the MAR. A review of the plan of care NA task list report last updated 1/27/23 included skin care, positioning, and skin integrity. A review of the Braden scale audit and verification log revealed 100 % of the residents were reviewed on 1/27/23. The facility had appointed a nurse as Wound Nurse Monday thru Friday and the individual has been signed up for a 2-part wound care certification program effective 1/27/23. An Interview conducted with new wound nurse on 1/31/23 revealed that his schedule would be from 11AM-7PM Monday through Friday. The wound nurse stated when he was not present, there was a backup nurse or another agency nurse that would complete the treatments/wounds. He stated his job entailed being responsible for all the treatments, weekly skin checks, weekly wound assessments, and Braden scales. An interview was conducted with the Director of Nursing (DON) on 1/31/23 at 3:00 PM. The DON stated that the wound care nurse would be responsible for wound care management documentation and validation. An observation of Resident #67 on 1/31/23 at 12:35 PM revealed that he was wearing heel protector boots and a pressure relieving mattress was in place. The facility's Immediate Jeopardy removal date of 1/28/23 was validated. 2. Resident #5 was admitted to the facility on [DATE] with diagnoses which included cerebrovascular accident and seizure disorder. The baseline care plan dated 8/29/22 had a focus for pressure ulcers present upon admission 8/26/22 and is at risk for further pressure injury development. Resident #5 was initially evaluated and treated by the Wound Care Physician on 8/31/22 for three deep tissue injuries (DTI) and one unstageable sacral pressure ulcer. The Wound Care Physician's evaluation and management summary dated 8/31/22 included recommendations to off-load wound, turn side to side and front to back in bed every 1-2 hours if able, and a low air-loss mattress. Review of Resident #5's electronic medical record census indicated he was sent to the hospital on 9/01/22 and returned to the facility on 9/14/22. Review of Resident #5's head to toe skin check dated 9/14/22 revealed the resident returned to the facility with an additional wound and changes to the previous wounds. The Wound Care Physician's evaluation and management summary dated 9/21/22 had additional wound detail which read in part that the resident returned to the facility after hospitalization for sepsis due to presumed endocarditis complicated by wound infection and strong suspicion for osteomyelitis underlying stage 4 pressure wound of the sacrum. Resident's overall prognosis is poor. There were no weekly skin checks or pressure ulcer assessment notes from 10/06/22 until 10/26/22. Resident #5's quarterly MDS dated [DATE] revealed he had 1 stage 3 pressure ulcer which was present on admission. He had 3 stage 4 pressure ulcers, 2 of which were present on admission. He had 2 unstageable pressure ulcers, none of which were present on admission. He also had 8 unstageable suspected deep tissue injury pressure ulcers, 1 of which was present on admission. Review of Resident #5's head to toe skin check dated 12/30/22 revealed he had eleven pressure areas. The Wound Care Physician's Wound Evaluation and Management Summary note dated 1/04/23 for Resident #5 included staging, measurements, notations of exudate, etiology and the treatment plan for each wound. The summary included that the resident returned to the facility after hospitalization for sepsis likely secondary to urinary tract infection/possible aspiration pneumonia complicated by heart attack likely secondary to sepsis/acute on chronic anemia, acute hypoxic respiratory failure likely secondary to aspiration pneumonitis and acute deep vein thrombosis (DVT) of left subclavian vein. As such, resident has returned to facility with deterioration in surface area and/or depth, and/or increase DTI/slough/necrosis in several wound. Multiple observations were made on 1/10/23 at 10:02 AM, 12:27 PM and 1:09 PM. Resident #5 was observed lying in the same position with the head of bed about 30 degrees, facing upright, lying on his back, arms crossed over lower body, towel under left arm, legs contracted with knees bent. The resident was not interviewable. The was no low air-mattress observed on the resident's bed. An interview with Nursing Aide (NA) #3 on 1/10/23 at 2:13 PM revealed she was assigned to provide care for Resident #5. She stated she had turned him one time that day during his bath right before lunch. She stated that the resident did not get turned every 2 hours today because she was trying to give other residents their baths. She stated she was familiar with the resident, and she knew he was supposed to be turned at least every 2 hours. An interview with Nurse #8 on 1/10/23 at 1:36 PM revealed she was assigned to the hall for Resident #5. She did not provide wound care as there was a wound care nurse. She stated he did not like to be moved and she did not know if the physician was aware of this. She confirmed that Resident #5 did not have a low air-loss mattress and stated his low air-loss mattress was on order and did not know the status. An interview with the Supply Clerk on 1/11/23 at 1:59 PM revealed she ordered a low air-loss mattress when she received a physician's order. She stated she had received an order today for a low air-loss mattress. An interview with the Wound Care Physician on 1/11/23 at 3:00 PM revealed he made recommendations in his wound care notes. He stated he had recommended a low air-loss mattress for Resident #5 and did not know why he did not have one at this time. He also stated that a low air-loss mattress and turning and repositioning were vital to wound healing. He also stated that the resident had multiple medical comorbidities and contractures which contributed to his pressure ulcers. An interview with the Medical Director on 1/12/23 at 11:11 AM revealed he relied on the staff to obtain the low air-loss mattress. He also revealed that Resident #5 had contractures and general decline which contributed to his pressure ulcers. An interview with the [NAME] President of Clinical Operations on 1/12/23 at 1:45 PM revealed the facility should adhere to the standards of wound management which includes turning and repositioning. She also revealed that Resident #5 had significant comorbidities for pressure ulcer development.