**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record, facility policy and procedure, hospital record reviews and staff interview, it was determined the facility failed to monitor and assess a pressure ulcer present upon readmission causing actual harm to Resident 1 when the wound deteriorated and became infected causing septic shock for one of three residents reviewed. (Resident 1) Findings Include: Review of facility policy and procedure titled Prevention of Pressure Ulcer/Injuries, revised July 2017, revealed conduct a comprehensive skin assessment upon admission, including skin integrity- any evidence of existing or developing pressure ulcers or injuries. Skin assessments should be done weekly by a licensed nurse. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. Review of Resident 1's clinical progress notes revealed nursing entry dated August 17, 2023 at 7:15 p.m. stating Resident 1 was readmitted to the facility from the hospital and the left buttock noted to have an open area 1.2 x 1 x 4. Other wounds noted upon admission included the residents left foot, left ankle, right foot, and excoriation (skin becomes red and often painful and begins to come off) to the buttock and sacrum (bone at the base of the spine in the middle of the lower back). Further review of Resident 1's clinical record including readmission documentation failed to document condition, or stage for wound of the left buttock. Review of Resident 1's documentation from the hospital upon readmission to the facility on August 17, 2023 revealed the resident had left ischial (lower and back region of the hip bone) deep tissue injury (DTI-an injury to the soft tissue under the skin due to pressure and is usually over bony prominence). Review of Resident 1's Nursing Admit/Readmit assessment, dated August 17, 2023, the skin integrity section had no documentation of wounds with a comments section stating left buttocks measuring 1.2 x 1 x 4. Additional review of Resident 1's assessments revealed Weekly Skin assessments completed on August 20, 2023, September 2, 2023, September 10, 2023 and September 14, 2023. Review of Resident 1's skin assessments mentioned above revealed in the section for observation of skin wound or open ulcers (indicate even if being treated) were documented as no indicating the resident had no current wound. Review of Resident 1's progress notes revealed a Skin/Wound note dated August 29, 2023 at 1:29 p.m. revealed the other wounds noted upon readmission were addressed but failed to mention the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a Skin/Wound note dated September 9, 2023 at 2:26 p.m. stating wound rounds with wound physician assessed sacrum MASD (Moisture Associated Skin Damage- superficial irritation and damage caused by long term exposure to moisture) continue current tx (treatment) and interventions. Further review of Skin/Wound note dated September 9, 2023 failed to mention the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a Skin/Wound note dated September 12, 2023 at 1:16 p.m. revealed the wounds the resident was admitted with were addressed but failed to indicate the left ischial wound documented on admission. Review of Resident 1's progress notes revealed a nursing note dated September 13, 2023 at 11:21 p.m. stating L (left) ischium wound measuring 2.8x4x2, wound bed with slough (dead tissue with a yellow/white color that can be wet or dry) and necrosis (dead tissue) and moderate drainage. Wound cleansed with NSS (Normal Saline Solution- sterile salt water), gently packed with hydrogel gauze (used to keep the wound moist to promote healing), applied triad (paste applied directly to skin to provide protection to area) to peri (surrounding) wound and covered with border gauze (sterile gauze with adhesive surrounding to hold to the skin). Further review of Resident 1's clinical record revealed there was no documented evidence whether the wound had a deterioration documented in the same location on admission or identified a new wound. Review of the entire clinical record revealed there was no physician's order for the wound care provided as stated in the progress note of September 13, 2023 and no documented evidence the physician was notified of the wound status. Further review of Resident 1's progress notes revealed a Skin/Wound note dated September 14. 2023 stating wound rounds with wound physician .assessed left ischium/buttock area. Review of the wound physician consult report, dated September 14, 2023 revealed left buttock is an Unstageable pressure ulcer injury (bed sore that occurs due to prolonged pressure on a specific area where the depth of the wound or bed sore is completely obscured by eschar in the wound bed) .measurements are 2cm (centimeter) length x 3cm width x 2cm depth .there is moderate amount of sero-sanguineous (thin watery fluid pick or red in color due to presence of blood) drainage noted which has no odor) with 100% slough. Further review of Resident 1's progress notes revealed a nursing entry dated September 19, 2023 at 5:40 p.m. stating assessed the resident and noted temperature 102.3 resident diaphoretic (sweating). Resident B/P (Blood Pressure) has been running low, call placed to 911 to send to hospital. Review of Resident 1's hospital documentation from his admission on [DATE] revealed an Infection Disease consult on September 20, 2023 at 9:34 a.m. with an impression of septic shock/severe sepsis (widespread infection causing organ failure and dangerously low blood pressure) secondary to presumed infected left buttock and sacral decubitus ulcer (pressure ulcer) with probable osteomyelitis (infection of the bone). Stage 4 (extend below the subcutaneous fat into your deep tissues, including muscle, tendons, and ligaments) left buttock/sacral decubitus ulcer/presumed osteomyelitis I believe the patient has severe sepsis to primarily be from secondary to his necrotic stage 4 sacral and left gluteal wound which will need debridement (surgical removal of dead tissue) as soon as possible- hopefully once he is more hemodynamically stable (the blood pressure and heart rate are at safe levels). Interview with the Director of Nursing and the Nursing Home Administrator on October 3, 2023 at 1:00 p.m. confirmed the resident clinical record has no complete documentation of the wound upon readmission from the hospital on August 17, 2023 until seen by the wound consultant on September 14, 2023 which the ischial wound was documented as an unstable wound and a larger size then what was documented on readmission. The facility failed to thoroughly assess Resident 1's wound upon readmission from the hospital on August 17, 2023 so a clinical baseline was unable to be established to determine the need of changes to the status of the residents wound to determine proper care of the wound. The facility also failed to assess weekly, per policy, to determine the appropriateness of the current wound treatment and whether healing was being achieved or not. This caused harm to Resident 1 when they were admitted to the hospital with a diagnosis of septic shock and osteomyelitis secondary to a presumed infected stage four pressure ulcer present when admitted to the hospital needing surgical debridement when stable. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Based on clinical record review, facility policy and procedure review and staff interview it was determined the facility failed to implement interventions to prevent pressure ulcers for three of 10 residents reviewed (Residents 12, 16, and 99) causing actual harm of a Stage 3 and two unstageable Pressure ulcers for Resident 12. Findings Include: Review of facility policy and procedure titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, Revised March 2014, revealed the nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores, for example, immobility. Review of Resident R12's significant change MDS (periodic assessment of resident needs) dated February 6, 2023 revealed the resident was recently placed on hospice service (end of life care) and determined to be at risk of developing pressure ulcers. Review of Resident 12's Progress Notes revealed a nursing note on January 8, 2023 at 10:37 a.m. stating x-ray results received and show suspected right femur fracture, RP (Responsible Party) notified and requested to be sent to the ER (Emergency Room). Review of documentation from the hospital stay revealed Resident 12 was seen by an Orthopedic physician on January 9, 2023 due to fracture of the right distal femur (knee). They were going to continue with conservative measures with bracing. Review of Resident 12's Progress Notes revealed a nursing note dated January 11, 2023 at 9:41 p.m. stating patient re-admitted at 5: 15 p.m. from the hospital with Fx (fracture) Femur .brace to right knee to be worn at all times. Review of Resident 12's physician orders revealed an order dated January 12, 2023 for RT (right) leg immobilizer on at all times, observe for redness or skin integrity. Review of Resident 12's Skin Integrity care plan failed to reveal goal/interventions to address newly ordered leg immobilizer or monitoring of right leg for redness and skin integrity under the immobilizer. Review of Resident 12's Medication and Treatment Administration Records for January, February, and March 2023 failed to reveal any skin integrity or redness observation documentation. Review of Resident 12's Progress Notes revealed a nursing note dated April 6, 2023 at 5:39 p.m. revealed open R (right) knee areas and posterior (back) ankle areas observed under residents leg brace Review of Resident 12's Weekly Wound Observation Tool dated April 6, 2023 at 3:48 p.m. revealed an unstageable pressure wound (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) on the top of the right knee cap that was 40% slough (dead white or yellow tissue) with a small amount of bloody drainage that was 5 centimeters wide and 4 centimeter long. Another wound on the right side of the kneecap was an unstageable pressure wound that was 40% slough and was 4 centimeters wide and 4 centimeters long with no drainage. Another wound on the posterior right ankle was a stage 3 (full-thickness skin loss potentially extending into the subcutaneous (fat) tissue layer), there was no description of the wound base on the assessment, with no drainage and 3 centimeters long and 2 centimeters wide. Interview with Licensed Nursing Employee E5 on April 12, 2023 at 11:32 a.m. revealed the wounds that were found on Resident 12's knee and ankle were significant wounds that were caused by pressure of the brace. Employee E5 further stated staff would be expected to remove the brace twice a day to check for skin integrity but there was no documented evidence this was occurring as expected. Interview with Licensed Physical Therapy Employee E6 on April 13, 2023 at 9:30 a.m. revealed they were not consulted until after the wounds were discovered. Employee E6 further stated that the type of immobilizer Resident 12 was wearing had straps that could be undone to allow staff to check Resident 12 skin integrity under the immobilizer as needed. Interview with Licensed Practical Nurse Employee E7 on April 13, 2023 at 9:45 a.m. revealed he/she was currently assigned to Resident 12 and had been assigned to Resident 12 prior to the development of the pressure ulcers. Employee E7 reported he/she did not check under Resident 12's immobilizer for skin integrity because there was no order in the system to do so. Interview with Licensed Nursing Employee E4 on April 13, 2023 at 12:30 p.m. revealed staff completed a weekly skin assessment on April 2, 2023 at 3:50 p.m. and this was the last documented evidence Resident 12's skin integrity had been checked under the immobilizer until the discovery of the wounds on April 6, 2023. The facility failed to assess Resident 12's skin integrity under an immobilizer on the right leg resulting in actual harm to Resident 12 when two unstageable and one stage 3 pressure ulcer were discovered on April 6, 2023. Review of Resident 16's clinical record revealed a diagnosis of hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or inability to move on one side of the body) following cerebral infarction (stroke) affecting the resident's dominant right side. Review of Resident 16's progress notes revealed a nurse's note dated March 17, 2022, which stated: This nurse alerted by therapy of a 1cm x 1cm area to R outer foot. [Suspected Deep Tissue Injury (persistent non-blanchable deep red, purple or maroon area of intact skin, non-intact skin or blood-filled blisters caused by damage to the underlying soft tissues)] is purple in color with red peri-wound. Therapy suspects it is from an ill-fitting brace, and a call was placed by PT to have brace fitted/replaced. Resident [complains of] pain when area is touched. Resident is unsure of how injury was acquired but states it's been hurting for like 4 days. NP and supervisor notified, new order entered to apply skin prep to area until seen and evaluated by podiatry. Review of Resident 16's physician orders, care plan, and Medication/Treatment Administration Records failed to reveal evidence that the resident was ordered a brace, how often the brace should be worn, or that skin checks were being done while the resident was wearing the brace. Interview with the Nursing Home Administrator and Director of Nursing on April 13, 2023, at approximately 10:40 a.m. confirmed there was no documented evidence related to any orders for Resident 16's right foot brace or skin checks for the brace. Review of Resident 99's clinical record revealed diagnoses including dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), generalized muscle weakness, and reduced mobility. Further review of Resident 99's clinical record revealed the resident had a pressure ulcer that healed on March 13, 2023. Review of Resident 99's progress notes revealed a nurse's note dated December 16, 2022, which stated: Reviewed with IDT [(Interdisciplinary Team)] has a [stage 2 pressure ulcer (superficial with a pale pink wound bed and serous, or clear, drainage and presents itself as an abrasion or blister or shallow crater)] on sacrum. [Resident 99] is incontinent of [bowel and bladder], prefers to lay on her back will order a air mattress. A Skin/Wound note on the same date stated: Wound rounds with IDT ST2 sacrum 5x2x0.1cm. Wound bed pink and with small amt (amount)of yellow material. No drainage noted and no [signs or symptoms] of infection. [Nurse Practitioner] aware of area and husband notified. New order for Xeroform dressing daily. Further review of Resident 99's progress notes revealed a nurse's note dated December 29, 2022, which stated: Wound rounds with IDT and [Wound Physician] [unstageable] 2x1x0.1cm. [Deterioration] with peri wound breakdown. Continue with therahoney daily cover with bordered gauze. Further review of the nurse's notes from December 29, 2022, revealed: air mattress requested for worsening wound. Further review of the resident's clinical record failed to reveal a date when the air mattress was provided to Resident 99. Interview with the Nursing Home Administrator and Director of Nursing on April 13, 2023, at approximately 10:40 a.m. failed to reveal an explanation for the delay in obtaining an air mattress for Resident 99, or what was done in the meantime while awaiting an air mattress for Resident 99. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services