**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the facility failed to protect the resident's right to be free from neglect when one of one sampled resident's (1) physician orders following a left lower extremity (LLE) fracture were not followed to promote healing. Findings include: 1. Review of the provider's 10/23/24 SD DOH FRI regarding resident 1 revealed: *On 10/21/24 resident 1 was being transferred with a sit-to-stand lift (mechanical lift used to assist from a seated to a standing position) and she was lowered to the floor. -CNA E assisted her up from the floor with a full body mechanical lift to the wheelchair. -Resident 1 complained of left leg pain that afternoon. -Orders were received for an x-ray and a doppler (ultrasound) for her left leg from her primary care provider. --The primary care provider did not feel these tests were urgent. -Radiology was not able to schedule the tests until 10/23/24. *On 10/23/24 the provider received a fax from x-ray that indicated resident 1 had a fracture of her left lower leg. -The primary care provider recommended emergency room (ER) consult for orthopedic care. -Resident 1 was transferred via ambulance to the ER. *On 10/24/24 resident 1 was discharged from the hospital with orders that no surgery was needed and a stabilizer was placed on her left leg. -She was non-weight bearing to her left leg and needed a full body mechanical lift (mechanical lift and sling used to lift a person's full body) for all transfers. *CNA E stated she had immediately reported the incident to registered nurse (RN) C. Observation and interview on 1/2/25 at 3:10 p.m. with resident 1 revealed: *She was seated in her recliner with her feet elevated. *A black knee immobilizer was present on her left leg from mid-thigh to mid-calf and was secured with Velcro. *When asked about her fall, she stated that she had broken her leg during the fall. *She indicated that she had been seeing a specialist and she was told that she was now able to do therapy on her leg. *She stated she didn't know how much to share, but her daughter could give more information. Phone interview on 1/2/24 at 4:12 p.m. with resident 1's daughter revealed: *Regarding resident 1's fall on 10/21/24, and she stated she Only knew what nursing home folks told me [what] mom told me, but she [resident 1] was confused at the time. *She was told by resident 1: -A certified nursing assistant (CNA) was transferring her. -She told the CNA that it [the lift] didn't feel right. -The CNA told her; it would be alright and continued the transfer. *Resident 1's daughter stated that she did not think that resident 1 had fallen, but when she talked to her mother on 10/21/24 it was unclear. *She was aware that the provider was notified, and an x-ray was ordered after the fall. *She stated the x-ray could not be scheduled for three days. *She talked to the nurse, and it didn't seem to her that the nurse thought it was serious. *She felt there was some minimization of the situation, and they should have taken her mother to the hospital right away. *On 10/22/24 she noticed that resident 1 was confused. *She stated, when she saw resident 1 on 10/23/24 at the hospital, she was concerned that resident 1 had been miserable in pain for three days. *A urine test at the hospital showed she had a urinary tract infection (UTI). *On 10/24/24 resident 1 was discharged from the hospital and returned to the facility. *Her discharge orders included resident 1 was to always wear the leg immobilizer and keep her leg elevated. *When the facility staff picked up resident 1 from the hospital the staff was given those instructions by the hospital staff. *She stated she felt the management staff understood the instructions but did not feel it was being followed by the CNAs. *At resident 1's two-week follow-up appointment she witnessed: -The knee immobilizer was below resident 1's knee, when it should have been placed mid-thigh. -Her pants were over-the-knee immobilizer. -Her knee was bent at a 90-degree angle and not elevated. *She stated, that after the appointment, it took another two weeks before the staff cared for her leg properly. *She and her sister had posted pictures on resident 1's wall regarding the care of her leg. *Her sister had come to the facility daily and educated the CNAs on the care of resident 1's leg. *At resident 1's second follow-up appointment with the orthopedic (bone specialist) surgeon resident 1's daughter was told that unless the leg was cared for as he instructed, the bone would not heal. *She indicated that resident 1 had told her that if she tried to tell the CNAs about the care of her leg the CNAs would dismiss her. *Resident 1 reported to her that a CNA had left the immobilizer off her leg when she was placed in bed. -She told the CNA that the immobilizer needed to be on, and the CNA stated she did not need it on in bed. *Resident 1 had told her daughter that she felt that the staff did not like her because she kept getting the staff in trouble. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her 10/18/24 Brief Interview of Mental Status assessment score was 15, which indicated her cognition was intact. *Her diagnoses included: fracture of shaft of tibia (10/23/24), urinary tract infection (10/23/24), Type 2 diabetes, macular degeneration, chronic kidney disease, arthritis, hearing loss, and folate deficiency (when the body does not have enough water-soluble B vitamin that is essential for cell growth and development, symptoms include fatigue and weakness). Review of resident 1's falls risk reports revealed: *On 10/7/24 she had slipped out of her wheelchair due to her wheelchair cushion. -Her fall risk assessment score was a 9, which indicated she was at a low risk of falls. *On 10/22/24 she had fallen from a mechanical lift and was referred to her medical provider. -Her fall risk assessment score was an 11, which indicated she was at a low risk for falls. Review of resident 1's nurses progress notes revealed: *On 10/21/24 she was lowered to the floor by a CNA while using a sit-to-stand mechanical lift. -An x-ray was ordered for her left lower leg. *On 10/23/24 Updated daughter in resident's increased confusion and requiring assistance with eating breakfast this morning. Daughter stated she noticed the confusion last night during her phone call. DON discussed with daughter about sending an order for UA [urinalysis] to rule out UTI as res [resident] has a hx [history] of UTI. Daughter thought this was a good idea and thanked DON for following up on this. -UA was obtained Resident tolerated well. Resident continues to be drowsy and has no remained in bed to rest. -The certified nurse practitioner notified the provider that the x-ray results indicated a fracture to resident 1's lower left leg, and to send her to the emergency room to be evaluated for increased confusion and diagnosis of urinary tract infection and to see the orthopedic specialist right away. -Her daughter was notified, and stated she would meet resident 1 at the hospital. -Resident left facility via gurney transport to the ER. -The ER notified the provider that there would be no surgery and they would be placing a stabilizer (brace) on resident 1's left leg. *On 10/24/24 resident returned .via facility van in facility w/c [wheelchair]. *On 10/28/24 she had been prescribed hydrocodone for left leg pain and she had increased confusion since starting this. -Her primary care provider (PCP) was notified. -On 10/29/24 her PCP stopped the order for hydrocodone related to her confusion. -He ordered to start tramadol 50 mg every 8 hours as needed for extreme pain. Review of resident 1's pain assessments revealed: *Between 9/16/24 and 10/17/24 her pain scores were a 0 on a 0 to 10 scale, which indicated she did not have pain. *On 10/21/24 her pain scores were six and four. *On 10/22/24 her pain score was a six. *On 10/23/24 her pain score was a nine. *Her physician orders included: -On 10/24/24 non-weight bearing to her left lower extremity (LLE). -On 11/5/24 when resident 1 was in her wheelchair her left foot pedal needed to be elevated in the highest position and immobilizer to LLE was to be always on, when she was in bed the brace could be open to help with skin integrity. --Make sure brace is over the knee and is put on over resident's pants per ortho [orthopedic specialist]. Review of resident 1's skin observations assessments revealed: *On 11/7/24 she had a brace to her left lower leg. -The brace may be open while she was in bed and was to be over her pants when she was up. -The leg needed to be elevated when she was sitting in her wheelchair, with a pillow on her leg for support. -A note that indicated a heel cushion and air mattress would be added. *On 12/16/24 and on 12/30/24 she had a brace to her left lower leg. -The brace may be open while she was in bed and was to be over her pants when she was up. -The leg needed to be elevated when she was sitting in her wheelchair, with a pillow on her leg for support. -A note that indicated her heel was to be floated on a pillow and she had an air mattress on her bed. Review of resident 1's orthopedic progress notes revealed: *On 10/24/24 she must be in straight leg brace at all times. -If resting in bed can have the brace open to help with skin integrity. *On 11/5/24 a note that included continue knee immobilizer at all times except skin care, and non-weight bearing left lower extremity. *On 12/12/24 a note that included non weight bearing to her left lower leg, continue knee immobilizer no standing. Interview on 1/2/25 at 5:02 p.m. with director of nursing B regarding resident 1 revealed: *Staff complete safe resident handling training and competencies during orientation and before they worked with residents. *Training is reinforced at staff stand-up huddles and staff meetings. *They had the provider come to the nursing home to see the resident. -The provider ordered an x-ray; the provider did not feel it was urgent. *Pain medication was given, and the resident's pain was managed. *The resident's cognition was intact and there were no cognitive changes at the nursing home. *Neither the resident nor the daughter demanded she be taken to the hospital. *The Nurse Practitioner gave orders to transport the patient to the emergency room after the X-ray results showed a fracture. * The facility transported her to the hospital. *The hospital tested and treated her for a UTI, they had felt the cognitive changes were related to her pain. *She was at the hospital for one night on observation and then discharged and transported back to the facility with the orthopedic physician's discharge orders for the non-weight bearing of the left leg, immobilizer brace, and to elevate her left leg. *The charge nurse received the orders and relayed them to the staff during shift change. *The only time she was aware of the immobilizer not being used correctly was when the daughter called her from the follow-up orthopedic appointment. *When the daughter and resident 1 voiced concerns to DON B regarding the care of resident 1's LLE fracture, DON B educated the staff. -She intermittently observed the placement of the brace and the elevation of resident 1's LLE to ensure proper care. *The resident was very good at expressing how her immobilizer should be placed and maintained on her leg. -DON B stated she felt the staff listened to resident 1. Review of the provider's 11/13/24 Abuse and Neglect Reporting policy revealed: *Definitions: -Neglect: Failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness. *Policy: -The agency will comply will all applicable federal, state or local laws regarding abuse or neglect. Review of the provider's 7/22/24 Abuse and Neglect policy revealed: *Policy -The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to initiate preventative interventions for one of one sampled resident (1) who was at risk for and developed a pressure ulcer to her left heel after fracturing her left lower leg during a fall. Findings include: 1. Observation on 1/2/25 at 2:45 p.m. of resident 1's room revealed: *Two light blue padded heel protector boots were on the bed. *An air mattress was present and inflated on the bed frame. *Resident 1 was seated in her wheelchair listening to an audiobook with her back towards the door. *There was a gait belt, pillow, and hangers on the recliner seat. Observation and interview on 1/2/25 at 3:02 p.m. with certified nursing assistant (CNA) F revealed: *She exited resident 1's room with a full-body lift. *She stated resident 1 had needed to be transferred with a full-body lift since she started working at the facility. *She was a travel CNA who had been working at the facility since the end of October. *She stated resident 1 had needed to be transferred with a full-body lift (a mechanical lift and sling used to lift a person's full body) since she started working at the facility. Observation and interview on 1/2/25 at 3:10 p.m. with resident 1 revealed: *She was seated in the recliner with her feet elevated. *A black knee immobilizer (splint) was present on her left leg. -The splint extended from her lower calf to her mid-thigh and was secured in place with Velcro. *When asked about her fall, she stated that she had broken her leg during the fall. *She indicated that she had been seeing a specialist and she was told that she was now able to do therapy on her leg. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her 10/18/24 Brief Interview of Mental Status assessment score was 15, which indicated her cognition was intact. *Her diagnoses included: fracture of her left lower leg on 10/23/24, Type 2 diabetes, macular degeneration, and folate deficiency. *Her physician orders included: -A 10/24/24 non-weight bearing to her left lower extremity (LLE). -An 11/5/24 when resident 1 was in her wheelchair her left foot pedal needed to be elevated in the highest position and immobilizer to LLE was to be on at all times, when she was in bed the brace could be open to help with skin integrity. *Her 1/2/25 care plan included: -A 6/1/22 focus that she had the potential for pressure ulcer development R/T [related to] impaired mobility. --Interventions imitated on 6/1/22 and revised on 12/10/24 included provide pressure relief cushion in wheelchair and recliner. Pressure reducing mattress on bed. -A 10/24/24 focus that she was at risk for falls related to weakness, poor activity tolerance and impaired mobility evidenced by a history of falls with the most recent fall being 10/21/24. --Interventions for this focus included remind resident to call for assistance to reposition in wheelchair and lock brakes prior to attempting to rise from wheelchair and Reminded resident if feeling tired to call staff to sit in recliner to nap. -A 11/11/24 focus that she had a deep pressure injury to her left heel. --The goal for this focus included Resident will have no complications R/T [related to] non-pressure wound to L foot through the review date. --Interventions initiated on 11/7/24 included to elevate her heels off bed, to use heel protectors, and provide an air mattress. Review of resident 1's 10/16/24 Braden Scale (an assessment used to predict pressure sore risk) score was a 15.0 which indicated she was at mild risk for developing a pressure ulcer. Review of resident 1's skin observations assessments revealed: *On 11/7/24 she had a Stage 1 (red non-blanchable skin area) pressure ulcer (PU) on her left heel that measured 1.5 cm (centimeters) by 1.3 cm. -Her left leg was to be elevated as she had a brace on her left lower leg due to a fracture. -A note that indicated a heel cushion and air mattress would be added to her care interventions. *On 12/16/24 her left heel was a scabbed area and classified as a Stage I PU. -Her left leg was to be elevated as she had a brace to her left lower leg due to a fracture. -A note that indicated to Float heel on pillow and she had an air mattress on her bed. *12/30/24 the PU on her left heel was noted to be a Stage I. --A note that indicated Float heel on pillow and she had an air mattress on her bed. Interview on 1/2/25 at 5:02 p.m. with DON B regarding resident 1 revealed a Braden Scale assessment should have been done when she returned from the hospital, but it was not done. Interview on 1/2/25 at 6:05 p.m. with RN/WCN D and DON B regarding resident 1 revealed: *A significant change assessment was not completed when she returned from the hospital. -She was not reassessed for a potential change in pressure ulcer risk when returned from the hospital. *Preventative measures in place to prevent pressure ulcers prior to the development of resident 1's documented pressure ulcer were a daily multivitamin with zinc, and nutritional supplements. *The provider's process for completing skin assessments was that was to be completed weekly by a nurse or the wound nurse on bath day. *On 11/7/24 when resident 1's skin wound was found, the wound was measured, documented, and the provider was notified. -At that time the air mattress and heel protectors were added as pressure relieving interventions. * The expectation after a skin wound was identified was: -The dietician was to be notified. -The area was to be measured and documented weekly until the wound was healed. *The skin assessment on 12/16/24 and 12/30/24 identified a stage I PU to resident 1's left heel. -RN/WCN D stated she had never identified the wound as a stage I PU, she had always documented it as a suspected deep tissue injury (SDTI). --A SDTI wound indicates damage to deep tissue under the skin and may appear purple or maroon. Skin can be firmer or soft (boggy), and warmer or cooler than surrounding tissue. A blood-filled blister with a dark wound bed may also be present. --After reviewing the documentation on both assessments she stated she felt the documentation was probably copied and pasted. *RN/WCN D stated that the SDTI wound was documented as healed on 12/26/24. *DON B stated her expectation would be that the skin be assessed rather than copied from the previous assessment. -She confirmed copying information from a previous assessments was not an acceptable form of documentation of an assessment. Observation and interview on 1/2/24 at 6:16 p.m. with resident 1, RN/WCN D and administrator A revealed: *Resident 1's posterior left heel had an approximate one-half cm (centimeter) by one cm reddened non-blanchable area. -RN/WCN D stated that the current reddened area appeared to be in a different area than the original wound. *She stated the first wound had started as a flat area, red in color with some purplish areas. -She stated that the first wound was a SDTI. -She stated that the SDTI had progressed to look like a scab, that was dry and loose around edged. *Then one day she could not find it. *RN/WCN D stated she thought at first the wound may have been caused by her brace but the brace was higher up and could not have caused the wound. Review of the provider's 4/26/24 Skin Assessment Pressure Ulcer Prevention and Documentation Requirements policy revealed: *Purpose -To systematically assess residents regarding risk of skin breakdown -To accurately document observations and assessments of residents -To appropriately use prevention techniques and pressure redistribution surfaces on those resident at risk for pressure ulcers. Residents who are unable to reposition themselves independently, as indicated on the Sit-Stand-Walk Data Collection Tool UDA (user defined assessment), should be repositioned as often as directed by the care plan approaches. Developing an individualized repositioning schedule is required for those residents unable to position themselves and is based on nutrition, hydration, incontinence, diagnoses, mobility and observation of the resident's skin over a period of time. Notify the physician/practitioner of the ulcer and resident's condition to obtain orders for a treatment. -Inquire whether physician/practitioner believes it is clinically necessary to see resident. *Notify resident and/or family representative of the pressure ulcer, orders and planned interventions. *When a pressure ulcer is present, complete the Wound Data Collection UDA daily, documentation should include the following: -An evaluation of the ulcer, if no dressing is present -An evaluation of the status of the dressing; if present (whether it is intact and whether draining, if present, is or is not leaking) -The status of the area surrounding the ulcer (that can be observed without removing the dressing) -The presence of possible complications, such as signs of increasing area of ulceration or soft tissue infection -Whether pain, if present, is being adequately controlled.