**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, facility policy review and interview, the facility failed to provide adequate two-person assistance with bed mobility for Resident #36 as assessed/planned resulting in an injury. Actual harm occurred on 10/05/24 when Resident #36 sustained a fractured hip when one staff member (State Tested Nursing Assistant, (STNA) #110) was providing personal care for Resident #36. The resident had been assessed/planned to require two staff members for bed mobility prior to the incident. During care, the resident complained of extreme pain when the STNA lifted the left side of her body. On 10/07/24, the resident was transferred to the hospital for follow-up care. An x-ray obtained on 10/07/24 identified the fracture which the facility determined was caused by the single person bed mobility procedures with STNA #110 on 10/05/24. This affected one resident (#36) of three residents reviewed for accidents. The census was 90. Findings include: Record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis, anxiety disorder, psychosis, major depressive disorder, quadriplegia, neuromuscular dysfunction of bladder, vitamin B deficiency, contracture, insomnia, glaucoma, and osteoporosis. Review of Resident #36's care card dated 09/20/24 revealed the resident required two-person assistance with bed mobility. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 was cognitively intact. The assessment indicated the resident was dependent on staff for bed mobility, rolling left and right in bed. Review of Resident #36's current care plan revealed the resident needed (staff) assistance with activities of daily living (ADL). One intervention within the care plan revealed she needed assistance with bed mobility. Another intervention within the care plan was for staff to follow the resident care card for assistance with her ADLs. Review of Resident #36's hospital records dated 10/07/24 revealed Resident #36 mentioned to the hospital staff that when she was being transferred/moved in her bed on 10/05/24 when she felt a sharp pain to her left hip. An x-ray was completed on 10/07/24, and confirmed she had a impacted displaced subcapital left femoral neck fracture. Review of a facility Self-Reported Incident (SRI) dated 10/07/24, revealed Resident #36 was lying in bed on 10/05/24, and used her call light to request assistance with moving from one side to the other while in bed. State Tested Nursing Aide (STNA) #110 arrived to the resident's room and attempted to assist Resident #36 with shifting her body from the left side to the right side. STNA #110 lifted Resident #36's left side of her body by herself, so she could remove the pillow and move it to the right side of the resident's body. During that time, Resident #36 expressed extreme pain when STNA #110 lifted the left side of her body. STNA #110 asked if she wanted the nurse to assess her, but Resident #36 declined. From 10/05/24 to 10/07/24, the resident received pain medication as ordered. An x-ray was not completed until 10/07/24. The results of the x-ray at the facility were inconclusive, so the resident was transferred to the hospital, where those x-rays confirmed she had a fractured hip, which was caused during the single person bed mobility procedures with STNA #110 on 10/05/24. Review of Licensed Practical Nurse (LPN) #107's interview statement dated 10/06/24 revealed Resident #36 told her about the incident the night before (on 10/05/24). She stated the aide turned her hard and quick, to the point that her left leg was not positioned correctly. LPN #107 confirmed she was still in pain. LPN #107 asked Resident #36 would like an x-ray in the morning. She also told the nurse she did not think she could attend her wound care appointment the next morning as it would be too painful to get on and off the gurney. She was given medication for pain at that time and stated she would let the daytime nurse know the next morning that they should get an x-ray. Review of LPN #105's interview statement dated 10/07/24 confirmed Resident #36 told her about the incident that happened on Saturday (10/05/24). She confirmed she had pain to her left side during the incident. LPN #105 documented she assessed her left and found no evidence of visible injury. But she contacted the nurse practitioner to report the incident and the pain; an x-ray was ordered for that day. Review of STNA #110's investigation statement dated 10/08/24 confirmed she was assisting Resident #36 with moving a pillow from underneath her left side and was going to move it to her right side as part of her turning schedule. She confirmed she was attempting to move the pillow from Resident #36 left side, and Resident #36 yelled in pain. She did not move her anymore. She ended her statement with, I was not told that 'Resident #36' required two people to assist her. Review of STNA #106's interview statement dated 10/10/24 revealed she worked the morning shift of Saturday, 10/06/24. She confirmed she was told by Resident #36 about the incident that happened the night before (10/05/24) and how her leg was hurting. She reported the incident and pain to the nurse that was working. She confirmed there was discomfort throughout her shift when they propped her up or moved her for care. There was nothing listed in the statement that the physician was notified about the incident or the resident's pain. Interview with Resident #36 on 11/09/24 at 12:00 P.M. confirmed one staff person was assisting her when she had requested to be turned/propped to the other side in bed. She stated it's usually two staff that would come in and help, but she didn't know this aide and didn't know if she could do it by herself. She confirmed she felt severe pain in her left leg/hip area as soon as the staff person (STNA #110) lifted her left side to remove the pillow. Resident #36 confirmed she was in severe pain after the incident. She stated she did not see a doctor, a doctor was not offered to her, and she did not receive an x-ray regarding her hip pain until 10/07/24. She confirmed she would have liked an x-ray sooner had it been offered. She stated the pain didn't really stop, but she received her pain medication as she typically takes it. Interview with Licensed Practical Nurse (LPN) #105 and STNA #101 on 11/09/24 at 12:10 P.M. and 12:18 P.M. confirmed each time they go in to assist Resident #36 with transferring or moving in bed, they have two people to assist. They confirmed that one person would lift the sheet that was underneath Resident #36, and the other staff would grab/move the pillow. Interview with STNA #106 on 11/09/24 at 12:46 P.M. confirmed Resident #36 told her about the incident that happened with STNA #110 and how it caused her a lot of pain. She confirmed she told the on-shift nurse about the incident and the pain. She was not certain what all the nurse did, but the nurse did give the resident as needed pain medication. She stated Resident #36 had pain, but in her opinion, she was always in pain, so she didn't feel it was different than her typical pain. But she did confirm the pain seemed to be more frequent than her typical pain, which was why she reported it to the nurse. She does not know if the physician was notified during that shift; that would be the responsibility of the nurse. Interview with LPN #107 on 11/09/24 at 12:49 P.M. confirmed she was told about the incident that happened on 10/05/24 regarding Resident #36. She asked Resident #36 if she wanted to get an x-ray the next morning; Resident #36 confirmed she would like that. She also stated she offered to send Resident #36 to the hospital that night, but stated Resident #36 declined because getting on a gurney would hurt too much. LPN #107 stated she was not given any information from the morning shift nurse at shift change about an incident with Resident #36 or any extra pain. But LPN #107 stated she did not contact the nurse practitioner or physician that night because, the x-ray technicians would not come to a facility on a Sunday night. Review of facility Condition Change Reporting, Residents policy, dated July 2015, revealed communication with the physician, the resident, and/or the responsible party was maintained when there was a significant change in condition and/or treatment. The physician, resident, and/or responsible party were notified when the resident's physical, communicative, psychosocial, or functional status changes unexpectedly, the resident is injured, or if treatment was significantly altered. This deficiency represents non-compliance investigated under Complaint Number OH00159103.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, facility policy review and interview, the facility failed to develop and implement an effective and individualized pressure ulcer prevention program to prevent the worsening of a pressure ulcer to the coccyx for Resident #37. Actual harm occurred on 05/01/24 when the facility Wound Nurse (WN) #318 identified Resident #37, who was at risk for pressure ulcer development and dependent on staff for turning and repositioning, had an unstageable (full thickness loss of tissue completely covered by dead tissue) pressure ulcer to the coccyx. The resident had been admitted to the facility on [DATE] with a Stage I (skin intact and redness to skin over a bony prominence) pressure ulcer to the coccyx. The facility failed to ensure adequate and effective interventions (including turning and repositioning) were provided to prevent the deterioration of the ulcer to an unstageable pressure ulcer. This affected one resident (#37) of three residents reviewed for change of condition. The facility census was 81. Findings include: Review of the medical record for Resident #37 revealed an admission date of 04/19/24 with diagnoses including end stage renal disease, arteriovenous fistula, hyperparathyroidism, disorder of plasma protein metabolism, iron deficiency anemia, hypotension of dialysis, atrial fibrillation, anxiety disorder, hypertrophic disorder of the skin unspecified, coagulation defect, angina pectoris, anemia, gallstone ileus and hip fracture with surgical intervention. Review of the facility document titled Baseline Care Plan, dated 04/19/24, revealed Resident #37 was alert and at times confused, required assistance from two staff for bed mobility, transfers, walking and toileting and used a wheelchair for mobility. Resident #37 was continent of bowel and bladder and had a Stage I pressure wound to her coccyx. Interventions included turning and repositioning every two hours, pressure reducing mattress to the bed, pressure reducing cushion to the wheelchair and a zinc cream with foam dressing to the coccyx wound. Resident #37 had pain present in her right hip (status post fracture with surgical intervention) and coccyx with oxy (oxycodone: a narcotic pain medication) as the pharmacological intervention for the pain. Review of the facility document titled Skin Grid, dated 04/19/24 and authored by Licensed Practical Nurse (LPN) #337, revealed Resident #37 was admitted with a Stage I pressure ulcer to the coccyx. The epithelial tissue was pink, there was no drainage and no odor. There were no wound measurements noted on the skin grid. Review of the facility document titled Braden Scale for Predicting Pressure Ulcers, dated 04/19/24, revealed Resident #37 was at risk for development of pressure ulcers. Review of the Medication Administration Record (MAR) dated 04/01/24 to 04/30/24, for Resident #37 revealed she was being medicated for pain with Oxycodone-Acetaminophen oral tablet 5-325 milligrams one tablet every six hours as needed for pain which ranged between a pain level of four to seven (the pain scale was zero to 10 with ten being the worst pain) on 11 out of 12 occasions for assessment of pain. The pain medication was noted to be effective at treating the pain. The documentation on the MAR did not specify the location of the pain or specify there was an associated nurse's note to reflect the location of the resident's pain. In addition, review of the medical record/MAR revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Review of the Treatment Administration Record (TAR) dated 04/01/24 to 04/30/24 revealed an order dated 04/19/24 for zinc to the coccyx, pad and protect with silicone border every night shift and every other day. The treatments were signed off as being completed as ordered. Review of the TAR revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Review of the progress notes dated 04/19/24 to 04/30/24 revealed on 04/19/24 Resident #37 was admitted to the facility with a reddened area to coccyx. Zinc was applied and a pad and foam border dressing placed. On 04/25/24 at 6:10 A.M. it was noted Resident #37 was sent to the hospital emergency room due to low blood pressure and increased nausea and vomiting. On 04/25/24 at 5:15 P.M. Resident #37 returned to the facility with no new orders. Further review of the progress notes and medical record revealed a skin assessment was not completed on 04/25/24 upon the resident's return from the emergency room. Review of a progress note dated 04/26/24 at 6:05 P.M. revealed the dressing to the resident's coccyx was soiled. New foam dressing applied. Daughter in facility and concerned about coccyx wound. The note documented the area was present from recent hospital stay. Small slit in skin observed with small amount of redness noted to area. Advised daughter this nurse would notify facility wound nurse. Patient education given on interventions to promote wound healing. There was no information in the progress notes to indicate the resident was noncompliant with wound care or turning and repositioning. In addition, there was no evidence the facility wound nurse had assessed this wound from 04/19/24 through 04/26/24. Review of the facility document titled Skin Grid, dated 05/01/24 and authored by (facility) Wound Nurse (WN) #318 revealed this was the first observation by WN #318. Resident #37 was admitted with a Stage I pressure ulcer and currently had an unstageable pressure ulcer. The description of the wound included the wound had 100 percent light yellow slough (dead skin that impedes healing) covering the wound base. There was a small amount of serosanguinous (fluid containing both blood and liquid part of blood) drainage and no odor. The wound edges were well defined, well attached to the wound base and irregular in shape. The area around the wound had slow blanching (skin that remains white or pale for longer than normal when pressed) erythema (redness) without temperature change. The wound measured 2.0 centimeters (cm) in length, 0.5 cm in width and depth was 0.1 cm. Treatment was changed to cleanse with normal saline, apply Santyl (medication that removes dead tissue from wounds) ointment to the wound base and cover with adaptive dressing and secure with silicon dressing. Review of the physician order dated 05/01/24 revealed wound treatment orders for Santyl external ointment 250 units per gram (collagenase); apply to sacrum topically every night for wound care and cleanse open area with normal saline solution, apply Santyl to wound base, cover with adaptic, secure with sacral size foam dressing every night shift for open area. Review of a progress note dated 05/01/24 at 11:10 A.M. and authored by WN #318 revealed she saw Resident # 37 due to worsening area to sacrum (coccyx) present on admission. The resident's daughter stated the area started as a skin tear in the hospital before coming to the facility. Resident #37 expressed slight discomfort when sitting for long periods of time. Resident #37 had expressed discomfort when sitting for long periods in dialysis. The nurse practitioner was notified. Low air loss mattress was to be placed (recommended on 05/01/24) and a gel wheelchair cushion was in place (present from admission). Resident was on a turning schedule, and incontinence program. Resident's daughter agreed. Review of the MAR and TAR for May 2024 revealed on 05/01/24 an order to cleanse open area to sacrum with normal saline solution, apply Santyl to wound base, cover with adaptic, secure with sacral size foam dressing every night shift for open area and Santyl ointment to sacral area every night shift. The treatments were signed off as completed as ordered. The resident's pain level was assessed between a level two to four with Oxycodone-Acetaminophen noted to be effective treatment for the pain. Further review of the medical record revealed no documented evidence of turning and repositioning being provided for the resident every two hours. Interview on 05/01/24 at 11:30 A.M. with facility WN #318 revealed she was not aware of Resident #37's Stage I pressure ulcer that had been present on 04/19/24. WN #318 revealed she was notified by phone to look at Resident #37's skin on 04/26/24 but felt it was not a priority, therefore WN #318 assessed Resident #37's skin on 05/01/24. WN #318 stated because there was not a comprehensive assessment completed upon admission she could not assess if the wound had become better or worse. WN #318 also verified the dialysis center had not been notified Resident #37 had a pressure ulcer and there had been no communication to the dialysis center as to what interventions were needed during treatment. WN #318 also verified she was unaware if Resident #37 was compliant with every two hour turns. Interview with the Director of Nursing (DON) on 05/01/24 at 2:31 P.M. verified WN #318 was notified on 04/26/24 of wound concerns for Resident #37, but the resident was not assessed by the wound nurse until 05/01/24. The DON verified Resident #37 was admitted to the facility with a pressure ulcer Stage I, but a complete skin assessment was not done on 04/19/24. Interview on 05/01/24 at 3:30 P.M. with Director of Dialysis #422 revealed since admission, Resident #37 had received five treatments of dialysis lasting three hours each. Director of Dialysis #422 revealed the facility did not communicate Resident #37 had a pressure ulcer or interventions that were needed. Interview on 05/01/24 at 5:30 P.M. with Resident 37's family member revealed she had requested the wound nurse to evaluate Resident #37 since admission on [DATE] because Resident #37 had a tear on the buttocks during the hospital stay before admission. Resident #37's family member stated Resident #37 was not observed to be turned every two hours, and she visited the resident daily. Interview with Resident #37 on 05/01/24 at 5:30 P.M. revealed she had pain in her tailbone and felt like her wound was not getting better. Interview on 05/02/24 at 9:45 A.M. with LPN #311 revealed skin should be assessed twice a week with a full assessment and documentation on the Skin Grid assessment in the electronic medical record. LPN #311 revealed she notified WN # 318 by phone on 04/26/24 after Resident #37's family approached her with concerns and Resident #37's dressing was soiled. LPN #311 stated she did not think the wound was concerning so she did not do any measurements on it at that time. LPN #311 verified she did not notify any physician regarding Resident #37's skin. LPN #311 said Resident #37 was compliant with the turning and repositioning, but the aides were not required to document when this intervention was performed. Interview on 05/02/24 at 11:00 A.M. with State Tested Nursing Assistant (STNA) #420 revealed Resident #37 was compliant with turning and repositioning, but stated staff were not required to document the provision of turning and repositioning. Interview on 05/02/24 at 11:50 A.M. with LPN #337 revealed she did not notify the wound nurse or the physician of Resident #37's Stage I pressure ulcer on admission. LPN #337 also verified she did not document measurements of the wound on admission. Observation on 05/02/24 at 4:30 P.M. with WN #318 revealed Resident #37 had a pressure ulcer to the coccyx. The ulcer contained yellow slough and the dressing in place was observed to be soiled. Review of the facility policy titled Pressure Ulcers Identification and Suggested Treatment Protocols, dated June 2015, revealed pressure ulcers would be identified and treatments would be ordered for proper healing of the wound. This deficiency represents noncompliance investigated under Master Complaint Number OH00153187.