**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to prevent the significant worsening of a pressure area and the development of a Stage III (3) pressure area for one (1) Resident (R21) out of 19 sampled residents, who developed in house pressure areas. R21's mattress malfunctioned which led to the increase in size in one (1) pressure ulcer and the development of another. Finding include: Review of the facility policy titled, Wound Intervention and Prevention, dated 12/2023, documented, The following is meant to be a guideline and is intended to assist in the decision-making process when determining appropriate treatment and prevention according to the underlying etiology of the alteration in skin integrity, the condition of the wound, and the overall condition of the entire resident. Prevention and Intervention: General Guidelines: 1. Identify residents being At Risk for alterations in skin integrity . 2. Assure proper Tissue Load Management. a. Reposition resident when in bed or in the chair, avoiding sheer and friction, if resident is unable to reposition independently. b. Use pressure redistribution surfaces in the bed and chair as indicated for residents identified at risk for alteration in skin integrity. c. Use proper technique and positioning device when positioning resident for maximum pressure relief effort. 3. Encourage maximum Functional Mobility of Resident . 4. Manage Moisture . 5. Manage Nutrition . 6. Documentation . 7. Pain Management a. Assess the resident for pain indicators and medicate per physician order. [sic] Review of the facility policy titled, Accident/Incident Report, dated [DATE], documented Purpose: To document the events of an incident/accident Procedure: 1. Complete report when unusual event(s) occur(s). 2. Fill out report completely. 3. Physician and family must be notified and documented. 4. The QA (Quality Assurance)/Risk Manager RN will review the investigation, update the incident report, and then close the report. 5. Examples of unusual event(s), but not limited to: . b. Skin Tears/Abrasions/Lacerations . f. Injury of Unknown Origin. 6. The Director of Nursing, Administrator, and Medical Director will review incidents during the QAPI [Quality Assurance/Performance Improvement] meetings. [sic] Review of R21's medical record revealed R21 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including but not limited to: Diabetes Mellitus with Diabetic Arthropathy, Peripheral Autonomic Neuropathy, and Morbid Obesity. Review of R2's Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS identified displayed behaviors, such as little interest in doing things and he/she felt down. They were also coded as occasionally rejecting care. The MDS further revealed the resident was at risk for skin breakdown and had a Stage II (two) pressure area. Treatments documented included: pressure relieving device to chair and bed, turning/repositioning program, nutrition/hydration interventions, pressure ulcer care, and applications of ointments. Review of R2's Physician Orders revealed an order dated [DATE], which indicated to cleanse the area of the right buttock with normal saline, apply calcium arginate with silver to wound bed and cover with silicone border dressing once daily. Diagnosis of a Stage III (three) pressure ulcer. The order stated to use Dakins (1/4 strength) external solution .124% (sodium Hypochlorite) and to monitor the sacrum for signs and symptoms of infections and placement every shift. Review of R2's Care Plan, dated [DATE], documented under Focus, deep tissue injury to right buttock, Goals were Pressure injury will improve without complications through next review date. Interventions listed were to assess and record wound measurements routinely, complete Braden scale per protocol, diet as ordered, labs as ordered, observe signs and symptoms of infection, observe signs and symptoms of pain and intervene appropriately, positioning devices as indicated. Also listed on the Care Plan under Focus was [R21] is at risk for skin breakdown r/t [related to] incontinence, impaired mobility, weakness, PVD [peripheral vascular disease], morbid obesity, diabetes with neuropathy & angiopathy, venous insufficiency and edema, & refuses care & repositioning. PRD mattress and cushion in place. Protective ointment used QS [every shift] & PRN [as needed]. [He/She] uses a sling lift for transfers and uses 1/4 SRs [side rails] to enable bed mobility and positioning. [DATE] refuses turning & repositioning. [DATE] Air mattress overlay to bed. [DATE] Air mattress, heel protector boots as tolerated in bed. [DATE] alternating pressure mattress. Listed under Goals: Resident will have no skin breakdown through next review date. Interventions listed were: 1/4 SRs to enable bed mobility. [DATE] DC [discontinue] - [DATE] Air mattress, [DATE] Air mattress overlay to bed. [DATE] discontinued. [DATE] heel protector boots as tolerated in bed, Assist with turning and repositioning per facility protocol and prn., Braden scale completed per protocol., Diet as ordered., Incontinent care as needed to keep skin clean and dry, Notify physician as needed., Observe standard precautions., Pressure relieving device to bed and chair as ordered., Preventative skin care as ordered/indicated, Routine body audit, Supplements as ordered. In addition, listed under Focus, Pressure injury to sacrum, Goals were listed as pressure injury will heal without complications by next review, Interventions listed were, [DATE] alternating mattress, assess and record wound measurements, complete Braden scale, diet as ordered, labs as ordered, notify responsible party, observe enhanced barrier precautions, observe for signs and symptoms of infection, observe for signs/symptoms of pain and intervene appropriately, positioning devices as indicated. Review of R2's Nursing Progress Notes dated [DATE], indicated the resident had a new wound to his/her coccyx, unstageable pressure (2x1), order in place and wound doctor to evaluate on next round [DATE]. The Wound Physicians weekly notes were as follows: [DATE] - Patient has a wound on his sacrum. Stage three (3) 2.5x3.5x.2 cm. Surface area 8.75, moderate serous exudate, 90% slough, 10% granulation. The treatment plan was to apply alginate calcium once daily, apply foam silicone border three (3) times per week, and use house barrier cream daily. Recommendations were to offload the wound, reposition per facility protocol, and use a group 2 mattress. A debridement was done to remove necrotic tissue. [DATE] - Patient has a wound on his sacrum. Stage three (3) pressure wound on sacrum full thickness 4.0x 3.5x .2cm, 14 cm surface area with moderate serous exudate, 90% slough, 10% granulation tissue. The dressing treatment plan and recommendations were the same as above. A debridement was done to remove the necrotic tissue. [DATE] - Patient has a wound on his sacrum. Stage three (3) pressure wound on sacrum full thickness, 4.1x3.7x.2 cm, surface area 15.17 cm, 90% slough, 10% granulation. The dressing treatment plan and recommendations remained the same. A debridement was done to remove necrotic tissue. [DATE] - Patient has wounds on his/her sacrum and right buttocks. Stage three (3) pressure wound on sacrum full thickness, 4.8x4x.2 cm, surface area 19.20 cm, exudate moderate serous, thick adherent devitalized necrotic tissue 100%. Listed under Additional Wound Detail, Not offloading wound Wound progress: Exacerbated due to patient noncompliance with wound care. Unstageable DTI [deep tissue injury] of the right buttock undetermined thickness, 4x4x not measurable cm, surface area 16.00 cm. Skin intact with purple/maroon discoloration. Additional Wound Detail: Air mattress broke and deflated. Dressing: Skin prep apply once daily for 30 days. Recommendation: limit sitting to 30 minutes, reposition per facility protocol, off-load wound: turn to side in bed every one to two (1-2) hours if able. [DATE] - Patient has wounds on sacrum and right buttock. Stage four (4) pressure wound to sacrum full thickness, 4.5x4x1 cm, surface area 18.00 cm, exudate moderate serous, thick adherent devitalized necrotic tissue 50%, slough 50%, wound progress not at goal. Additional Wound Detail: Patient reported significant pain, had trouble tolerating. Consider debridement in OR [operating room]. The dressing treatment plan was Dakin's, apply twice daily, wet gauze with Dakin's, foam silicone solution boarder apply three (3) times per week, house barrier cream daily, recommendations: Off-Load wound, reposition per facility protocol, group 2 mattress. Stage three (3) pressure of the right buttock full thickness 4x3.3x.1 cm, surface area 13.2 cm, cluster wound open ulceration area of 1.32 cm, exudate moderate serous, slough 10%, skin intact normal color 90%, wound improved evidenced by decreased surface area. Dressing- skin prep apply daily: alginate calcium w/silver apply once daily, gauze island w/border daily, recommendations: limit sitting to 30 minutes, reposition per facility protocol, off-load wound, turn side to side in bed every one to two (1-2) hours. Debridement was done to remove necrotic tissue. [DATE] - Patient has wounds on sacrum and right buttock. Stage four (4) pressure wound sacrum full thickness, 5.3x4.4x2cm, surface area 23.32 cm exudate moderate serous, thick adherent devitalized necrotic tissue 50%, slough 50%, wound progress not at goal. The treatment plan remained the same along with recommendations. Debridement was done to remove necrotic tissue. Stage three (3) pressure wound of the right buttock, full thickness, measured 3.8x3.5x.1cm surface area 13.3 cm, exudate moderate serous, slough 50%, granulation tissue 50%. The treatment and recommendations remained the same. Debridement was done to remove necrotic tissue. Wound progress - at goal. [DATE] - Patient has wounds on sacrum and right buttocks. Stage four (4) wound sacrum full thickness. 5.1x4.4x2cm surface area 22.44 cm. undermining 2cm at 12 o'clock exudate moderate serous, thick adherent devitalized necrotic tissue: 40%, slough:20%, granulation tissue 40%, wound progress: improved. Additional wound detail revealed now has type 2 (two) mattress, treatment remained the same. Debridement of necrotic tissue. Stage three (3) pressure wound of right buttock full thickness 3.5x3.1x.01 cm surface area 10.85, exudate moderate serous, slough 50%, granulation tissue 50%, wound progress; improved evidenced by decreased surface area. The dressing treatment and recommendations remained the same. The wound was debrided to remove necrotic tissue. Review of the Nursing Notes, [DATE] through [DATE], revealed that there was no specific documentation addressing the resident's refusal to be turned or repositioned. During an interview on [DATE] at 2:30 PM, the Wound Physician, when asked how the wound occurred on [DATE] and how the sacral wound increased in size, stated there was a malfunction in the mattress the resident was using at the time, the mattress went flat. The Wound Physician stated that within four (4) hours a pressure area could occur. The Wound Physician thought that contributed to the sacral wound getting larger and the development of the right buttock ulcer. The Wound Physician also stated that the resident doesn't always cooperate with care or turning. He/She stated the resident doesn't like to turn by him/herself either. He/She stated that when the mattress malfunctioned it was like the resident was sitting on a bunch of rocks for a few hours. During an interview on [DATE] at an unspecified time, the Wound Care Nurse (WCN) stated the area on the sacrum was discovered as an unstageable pressure injury on [DATE]. The WCN stated the Wound Physician saw it on [DATE] at a stage three (3). The WCN stated that a malfunction of the mattress happened during the night and when discovered, the mattress was plugged in again. The WCN thought this contributed to the sacral wound getting larger and the development of the right buttock area wound. The WCN stated the resident now has a new mattress as of three (3) weeks ago. The area is looking better, he/she stated. Prior to the new mattress, the resident had a wedge in place, a turning schedule, heel protectors, and nutritional supplements. During an interview on [DATE] at 3:00 PM, R21 stated he/she didn't remember the incident with the mattress. R21 also stated he/she didn't mind being turned and repositioned; R21 didn't recall refusing turning and repositioning. During an interview on [DATE] at 11:00 AM, the Director of Nursing (DON) stated they didn't do an Incident Report on the mattress malfunction. The DON stated that the staff had R21 up and fixed the mattress as soon as it was discovered. The DON didn't know how long the mattress had been deflated and mentioned that they checked the mattress every shift. During an observation and interview on [DATE] at 11:15 AM, of wound care conducted for R21, with the WCN revealed, upon entering the room, R21 was being repositioned onto his/her right side with the assistance of two (2) staff members. A sacral pressure injury was observed to R21's sacrum which was packed with gauze. There was no secondary dressing covering the wound. A silicone border dressing was observed to R21's right buttock. The WCN removed the gauze packing from R21's sacral pressure injury revealing a Stage IV, full-thickness injury. There was a moderate amount of serosanguineous exudate noted to the gauze. The visible aspects of the wound bed consisted of approximately 25% red granulation tissue with three (3) scattered islands of slough noted throughout. There was approximately 75% red/pink connective tissue observed. When asked whether there was any tunneling or undermining, the WCN explained there was undermining from the 10-2 o'clock margins to a depth of approximately 3 centimeters. The wound edges appeared callused and were not attached to the wound bed. The immediate peri wound skin was noted to be flaky, dry, and pink in color. There were no obvious indicators of infection at the time of the observation. Following care for the sacral injury, the WCN removed the border dressing from R21's right buttock revealing a partial-thickness pressure injury. There was a scant amount of serous exudate noted to the dressing. The wound bed consisted primarily of pink epithelial tissue. The wound margins were clearly demarcated. The immediate peri wound skin was noted to be flaky and dry and was deep pink in color. There were no obvious indicators of infection at the time of the observation. During an interview on [DATE] at 1:32 PM, the WCN explained that the pressure injury on R21's right buttock was initially discovered on [DATE] after an incident occurred with the resident's air mattress losing air. The WCN added that the resident's sacral pressure injury also worsened significantly on or around [DATE]. Photographs of R21's wounds were reviewed. A comparison of the photographs on [DATE] and [DATE], revealed significant decline of R21's sacral injury on [DATE]. The wound edges, wound bed, and immediate peri wound were noted to be deep purple in color indicating prolonged, unrelieved pressure consistent with staff statements that R21's air mattress had been discovered without air in it while R21 was in the bed. During an interview on [DATE] at approximately 1:30 PM, the DON stated that the facility should have done an Incident Report on the mattress malfunction. The DON stated he/she didn't know how long the mattress had been deflated before being discovered. During an interview on [DATE] at 1:30 PM, the WCN stated that the CPR (cardiopulmonary resuscitation) strings at the top of the mattress can be accidentally pulled, and the bed can deflate quickly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the Medical Provider of urinalysis results ordered on 06/25/24 and 07/2/24, resulting in subsequent hospitalization of a Resident (R)12 with a Urinary Tract Infection. This deficient practice affected one (1) of one (1) residents reviewed for indwelling urinary catheters from a total of 19 residents sampled. Findings include: Review of R12's medical record revealed an initial admission date of 04/20/23. R12's primary medical diagnosis was Incomplete Paraplegia. His/her secondary medical diagnoses included Neuromuscular Dysfunction of Bladder. Review of R12's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 06/28/24, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R12's cognition was intact. The assessment also identified the presence of an indwelling urinary catheter. During an observation on 10/10/24 at 12:34 PM, R12 was observed in his/her wheelchair in the common area of the 6B unit watching television. R12's catheter drainage bag was hanging from the right side of his chair. A subsequent interview was conducted with R12. When asked about the care and services he/she was receiving for the indwelling urinary catheter, R12 explained that the catheter had been in place for a while and was placed due to his/her inability to empty his/her own bladder. R12 went on to explain that he/she had suffered a few Urinary Tract Infections since the catheter was placed and that he/she had been hospitalized for antibiotic treatment. A preliminary review of R12's Plan of Care revealed a focus area for Urinary Tract Infection risk related to the presence of a suprapubic catheter. Related interventions directed nursing staff to observe and report any signs or symptoms of Urinary Tract Infections such as burning, pain, fever, and foul odor, and to notify the Physician as needed. Review of R12's nursing progress notes revealed an entry dated 06/25/24 at 12:46 PM, which indicated the Nurse Practitioner had been in to see R12 and that a STAT (immediate) urinalysis with culture and sensitivity was ordered due to the presence of cloudy urine. Review of R12's Urine culture and sensitivity results dated 06/26/24, revealed the results were signed by the Director of Nursing and were dated 07/1/24 with a statement that read, Will repeat. The urine culture results suggested that the urine sample was contaminated and instructed staff to consider appropriate recollection if clinically indicated. Continued review of R12's nursing progress notes revealed no entries on or around 06/26/24, indicating that the Medical Provider had been notified of the results or that another urine sample had been collected. Review of R12's Physician Orders revealed an order dated 07/01/24, for a urinalysis with culture and sensitivity. An additional order dated 07/01/24, was noted for Macrobid (an antibiotic) 100 milligrams (mg) to be administered for a total of seven (7) days. Review of R12's Medication Administration Records (MARs) for July 2024, revealed that the entire course of Macrobid was documented as administered. Review of R12's Urine culture and sensitivity results dated 07/04/24, revealed the results were not signed or acknowledged by a nursing or medical professional. The results indicated that mixed flora was isolated in the specimen and included a recommendation to recollect a clean-catch specimen if clinically indicated. Continued review of R12's nursing progress notes revealed an entry dated 07/05/24 at 12:22 PM, which indicated that the urinalysis results were reviewed by the Nurse Practitioner and that a new order was obtained to repeat the urinalysis on 07/10/24, after the course of Macrobid was completed. Continued review of R12's nursing progress notes revealed an entry dated 07/10/24 at 6:56 AM, indicating that dark, bloody urine was observed in the catheter drainage bag. Review of R12's Urine culture and sensitivity results dated 07/10/24, revealed the results were reported to the facility on [DATE]. The results identified the presence of Klebsiella Pneumoniae and was noted to be resistant to Macrobid. Continued review of R12's nursing progress notes revealed no entries on or around 07/13/24, indicating that the Medical Provider had been notified of the results or that the identified organism was resistant to the recently completed course of antibiotics. Continued review of R12's nursing progress notes revealed an entry dated 07/15/24 at 3:33 PM, that the most recent urine culture and sensitivity results were reviewed by the Nurse Practitioner and that new orders were received to transfer R12 to the hospital for treatment and evaluation of the culture and sensitivity report. According to a readmission assessment by the Medical Provider dated 07/22/24, revealed R12 was admitted to the hospital and was treated for a Complicated Urinary Tract Infection. The condition required treatment with intravenous antibiotic therapy. During an interview on 10/11/24 at 1:45 PM, the Director of Nursing (DON) confirmed that the urinalysis results on 06/26/24, should have been called to the Medical Provider as soon as they were received - particularly because the Medical Provider ordered the test to be completed STAT (immediately). The DON acknowledged that waiting a period of approximately five (5) days before the Medical Provider reviewed the results likely contributed to R12's hospitalization for a Complicated Urinary Tract Infection on 07/15/24.