**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, interviews with staff, a family member and Nurse Practitioner (NP) #263, and review of information from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to implement pressuring relieving interventions for a resident at risk for further skin breakdown due to existing pressure ulcers and failed to complete weekly skin assessments. This resulted in Actual Harm when staff failed to implement pressure relieving interventions to prevent further skin breakdown for Resident #49 resulting in the development of an avoidable Deep Tissue Injury (DTI) to the left heel. Resident #49 also had increased measurements in the coccyx and heel pressure ulcers and experienced discomfort during a dressing change. This affected one (#49) of four residents reviewed for pressure ulcers. The facility identified 10 current residents with pressure sores. Facility census was 91. Findings include: Review of the medical record for the Resident #49 revealed an admission date of 05/14/21. Diagnoses included cognitive impairment following cerebral infarction, Type II diabetes, muscle weakness, lack of coordination, disorder of muscle, cognitive communication deficit, aphasia, hyperlipidemia, metabolic encephalopathy, and neuromuscular dysfunction of the bladder. Review of the Braden skin scale (an assessment tool to measure resident risk for developing skin impairments) dated 11/19/21 revealed Resident #49 scored a 14 and was at a moderate risk for developing pressure injuries. Review of the plan of care dated 11/30/21 revealed Resident #49 is at risk for alteration in skin integrity as evidence by pressure ulcer of the right heel with interventions to encourage and assist resident to elevate heels in bed as needed and tolerated, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. The care plan also documented alteration in skin integrity as evidenced by pressure ulcers present to left and right buttock, and according to the focus section of the care plan, since this care plan was written, the two wounds on the buttock have combined to form one on the coccyx, with interventions to assess and complete wound care, encourage resident to turn and reposition as needed, provide assistance with activities of daily living and positioning as tolerated. There is no mention on the care plan of resident having behaviors, refusals of care and non-compliance. No updates have been made to the care plan since the development of the new coccyx wound and new left heel wound. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 had cognitive impairment and required extensive assistance of two staff members for bed mobility and transfers and required extensive one person assist with ambulation, toileting, and hygiene. The MDS revealed Resident #49 had two unstageable pressure wounds that were facility acquired, one of which presented as a DTI. Resident #49 has a pressure reducing device for his bed, was not involved in a turning or repositioning program, has nutrition and hydration interventions and wound care including ointments and application of dressings. Resident #49 has a urinary catheter and is always incontinent of bowels. Review of Resident #49's physician orders for 05/14/21 identified orders to encourage and assist to turn and reposition as tolerated with instructions to complete every shift. Review of physician orders for 05/18/21 until 02/02/22 identified orders to ensure pressure reduction socks were on bilateral feet with instructions to complete every shift. Review of Resident #49's physician order from 01/03/22 to 01/10/22 revealed an order for right heel to cleanse with normal saline and apply foam and change daily and as needed. Review of Resident #49's Physician orders from 01/10/22 to 02/01/22 identified orders for right heel cleanse with normal saline apply Calcium Alginate with foam with instructions to change daily and PRN (every night shift and as needed). Review of Resident #49's physician orders for 01/10/22 identified orders for coccyx cleanse with normal saline. Pat dry. Apply Aquacel to wound bed and cover with foam dressing with instructions to complete every night shift and as needed. Review of physician orders for 01/28/22 until 02/12/22 identified orders for flagyl tablet 500 milligrams (mg) with instructions to provide one tablet by mouth three times daily for Coccyx wound infection. Review of Resident #49's physician order for 02/01/22 revealed orders for left heel to cleanse with normal saline and apply cover with ABD and kerlix and change daily and as needed. Review of Resident #49's physician order for 02/01/22 revealed orders for right heel to cleanse with normal saline and apply calcium alginate and cover with ABD and Kerlix and change daily and as needed. Review of Resident #49's physician order for 02/02/22 identified orders to apply bilateral soft cut boots as tolerated. Review of Resident #49's progress notes revealed no mention of resident or family behaviors, refusals, or non-compliance with interventions for pressures reduction. Review of Physician/NP notes dated 01/24/22 revealed Resident #49 presented for wound assessment. The barriers to wound healing include resident cannot self-position, cannot always verbalize needs, and chronic disease state. The medical provider recorded the resident with Stage 3 wound on right heel with wound treatment order. The NP provided education on the importance of offloading and good nutrition to prevent re-injury with the recommendation to continue offloading boots. It is mentioned new and worsening wounds may be unavoidable due to non-compliance with positioning. To note, there is no additional documentation of resident non-compliance and behaviors in the medical record besides what the NP is reported being told. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a left buttock wound with origination date of 11/29/21, described as unstageable with length and width measuring at 0.7 centimeters (cm) x 0.7 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right buttock wound with origination date of 10/08/21, described as unstageable with length and width measuring at 1.5 cm x 0.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 3.5 x 3.5 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note left buttock and right buttock have connected making one pressure area to coccyx. Review of skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue current treatment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 8.0 cm x 4.5 cm with serosanguineous drainage and was noted to have declined from the previous assessment with note to continue orders. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a coccyx wound with origination date of 11/29/21 described as unstageable with length and width measuring at 3.0 cm x 4.2 cm with serosanguineous drainage and was noted to be unchanged from the previous assessment with note to continue current treatment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as Stage II with length and width measuring at 0.3 cm x 0.5 cm with scant serosanguineous drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length and width measuring at 3.0 cm x 3.5 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.5 cm x 4.0 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. There was no skin grid assessment available for the week of 01/17/22. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width and depth measuring at 2.0 cm x 4 cm x 0.1 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a right heel wound with origination date of 10/08/21 described as a DTI with length, width, and depth measuring at 1.0 cm x 3.0 cm x 0.2 cm with no drainage and was noted to be improved from the previous assessment. Review of the skin grid assessment dated [DATE] revealed Resident #49 had a new left heel wound with origination date of 02/01/22 described as a DTI with length and width measuring at 5.0 cm x 2.5 cm with no drainage with note for 100% intact blister noted. Review of the Behavior tasks tracking revealed Resident #49 had no documented behaviors daily from 01/06/22 to 02/03/22, except on 01/25/22, when the resident was documented to have repeated movements and was comforted and redirected. Review of the Ulcer/Injury unavoidability checklist dated 07/29/21, 11/29/21 and 02/01/22 revealed a Registered Nurse (RN) and Licensed Practical Nurse (LPN) signed the form with e-signatures. The checklist marks the implemented interventions that were consistent with residents needs and goals and included turning and repositioning as needed or resident turning themselves independently or the pressure ulcer is not related to turning. Review of the facility provided timeline of the wound revealed on 01/31/22, Resident #49 and spouse revealed the resident would not wear the offloading boots due to being too bulky and new boots were given to the resident. Resident #49 continues to refuse, and spouse is known to remove the boots after staff place them on resident. There was no mention of any of these events documented in progress notes or the behavior section of the resident's electronic medical record. Observation on 01/31/22 at 12:00 P.M., revealed Resident #49 lying in bed flat on his back looking up at the ceiling. Resident #49 did not have any pillows in bed for repositioning and offloading of his coccyx or heel wounds. Interview on 01/31/22 at 3:30 P.M., with Resident #49's family member revealed concerns related to the resident's wounds. Resident 49's family member revealed he has a new wound on his left heel, that the family member informed staff about, and expressed concerns the resident is not turned and repositioned throughout the day. Observation on 01/31/22 at 4:20 P.M., revealed Resident #49 sitting in his wheelchair and wearing gray non-slip socks. Resident #49 was observed to be holding his feet up off the ground. Observations on 02/01/22 at 8:05 A.M., revealed Resident #49 was lying in bed flat on his back with no pillow or devices for offloading the heals. Resident #49 had blue pressure relieving boots sitting on a chair in his room. Observation on 02/01/22 at 8:56 A.M., revealed Resident #49 was sitting in his wheelchair, he did not have the wheelchair foot rests on his chair or the blue pressure relieving boots on his feet, but did have non-slip socks on both feet. Observation on 02/01/22 at 12:25 P.M., revealed Resident #49 remained in his wheelchair and was eating lunch. Resident #49 did not have blue pressure relieving boots on and was wearing non-slip socks. Observation on 02/01/22 at 1:55 P.M., revealed LPN #151, LPN #159, and Assistant Director of Nursing (ADON) #109 entered Resident #49's room and washed their hands. LPN #151 cleansed the resident's bedside table with a bleach wipe and allowed to dry. LPN #159 pulled the resident's blankets back and the resident was noted to have one gray non-skid sock on the right foot with red drainage to the sock. Resident #49 had no heel protectors in place. Pillows were placed under the resident's calves; however, the resident's heels were observed to be pressing into the resident's bed. Resident #49 was positioned on his back with no offloading of the coccyx or his heels. Resident #49 was placed on his right side by LPN #159. LPN #151 removed the soiled dressing dated 02/01/22. ADON #109 measured the coccyx wound at 3.0 cm by 5.0 cm by 0.2 cm with 50% slough with a pinkish-red wound bed. ADON #109 sanitized her hands, donned gloves, and cleansed the coccyx wound with normal saline (NS) and four by four gauze. ADON #109 sanitized her hands, donned gloves and applied calcium alginate and covered with a foam dressing. The nurses washed their hands and donned gloves, LPN #151 attempted to remove the non-skid sock from his right foot, however the sock was stuck to the wound to his heel. LPN #151 soaked the sock off the wound using normal saline (NS). Resident #49 was observed moaning out in pain while LPN #151 removed the sock from the wound. ADON #109 cleansed the wound with NS and four by four gauze, sanitized her hands, covered the wound with calcium alginate, padded with ABD pad and secured with Kerlex wrap and tape. Resident #49 was also noted to have a DTI to his left heel measuring 5.0 cm by 2.5 cm with a 100% intact blister. ADON #109 padded the left heel with an ABD pad, wrapped with Kerlex and secured with tape. ADON #109 verified the facility was unaware of the newly developed DTI to his left heel, the heels not being elevated and the lack of off-loading to his coccyx. Observation on 02/01/22 at 2:54 P.M., of Resident #49's room revealed a black wheelchair footrest on the couch and had light blue padded booties also sitting on the couch. Interview on 02/01/22 at 3:28 P.M. with LPN #159 revealed Resident #49 has wounds on his coccyx and right heel and a newly found left heel wound. LPN #159 revealed facility is looking at getting an air mattress and revealed Resident #49's family puts pillows under the resident's legs. LPN #159 revealed Resident #49 had large green boots, but the resident and his family did not like them due to being too big. LPN #159 confirmed Resident #49 does not have pillows, or a device used to off load pressure from his coccyx or his heels. Interview on 02/01/22 at 3:49 P.M. with Resident #49's family revealed she has never seen the resident wear the blue pressure relieving boots sitting on the chair and revealed she has never actually seen them in his room before. Observation on 02/01/22 at 3:49 P.M., revealed Resident #49 was lying in bed with pillows under his feet with wound bandages on both heels and his feet were without any covering such as socks or pressure relieving boots. Resident #49 was lying flat on his back with no devices or interventions for coccyx offloading. Observation on 02/02/22 at 8:40 A.M., revealed Resident #49 was sitting in his wheelchair with non-slip socks on and holding his feet up off the ground. Observation on 02/02/22 at 12:27 P.M., revealed Resident #49 sleeping in his wheelchair. Resident #49 was wearing non-slip socks and his blue pressure relieving boots were sitting on the chair in the resident's room. Interview on 02/02/22 at 1:20 P.M., with Director of Nursing (DON) #130 and Corporate RN #107 revealed Resident #49 had orders for the blue relieving boots to be worn only at nighttime, which was why he has not worn them during any observations. DON #130 and Corporate RN #107 confirmed during interview and observation, the blue medial boots were sitting on Resident #49's chair and were not being worn. DON #103 and Corporate RN #107 stated Resident #49 is non-complaint with interventions but could not provide further information why offloading was not being used for his wounds and could not provide examples of Resident #49's non-compliance. DON #130 and Corporate RN #107 revealed Resident #49 has pillows available for offloading and pointed to a closet (when asked where they were). DON #130 and Corporate RN #107 were unable to explain why the pillows have not been used during any observations for off-loading of his coccyx wounds or heels. Interview on 02/02/22 at 4:00 P.M., with Corporate RN #107 revealed the physician order for compression socks to bilateral feet to be worn during each shift should be assumed to be the blue pressure relieving boots, and confirmed no actual order is present for the boots. Interview on 02/03/22 at 3:50 P.M., with the facility NP #263 revealed the previous facility NP recently resigned from her position and NP #263 is filling in for the interim. NP #263 revealed her expectations for a resident with confusion would be for staff to check on resident every two hours and staff should be providing offloading support for wound healing. NP #263 revealed a pressure reducing sock is a type of medical device and confirmed it is different than the pressure relieving boots that were present in Resident #49's room. NP #263 revealed the typical treatment for heel pressure wounds would be for resident to wear off loading boots each shift. NP #263 revealed if a resident was resistant to care, showing signs of aggression, or signs of non-compliance, she would expect this to be clearly documented in the medical record. NP #264 confirmed at times staff will tell the NP's or physician about a resident's behaviors during visits, and this may be documented in their record but was not necessarily first-hand knowledge. NP #263 revealed Resident #49 was assessed on Monday for wound care and denied seeing any aggressive behavior or compliance concerns during this visit. Review of information from the NPUAP revealed an unstageable pressure injury is a full thickness skin and tissue loss and the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (dead dry harden tissue). If slough or eschar is removed a stage three of stage four is revealed. This injury results from intense and or prolonged pressure and shear force at the bone-muscle interface. A DTI is intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. The NPUAP indicated to use a structured risk assessment such as the Braden scale to identify individuals at risk for pressure injury as soon as possible (but within eight hours of admission) and based on the identified risk factors a care plan should be developed and implemented. Further review of the NPUAP revealed the facility should assess pressure points, such as the buttocks, heels, ischium, trochanter's elbow, and beneath medical devices. The NPUAP also indicated that the heels are free from the bed and use of heel offloading devices or polyurethane foam dressing on individuals at risk for heel ulcers.