**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019, policy review, medical record review, observation, and interview, the facility failed to provide skin and wound assessments, and wound treatments for residents' pressure ulcers for 2 of 4 residents (Resident #7 and #8) reviewed for pressure ulcers. The facility's failure to perform treatments and conduct assessments in accordance with facility policy contributed to the development and deterioration of pressure ulcers/injury for Resident #7 and #8 resulting in harm. The findings include: 1. Review of the Prevention and Treatment of Pressure Ulcers/Injuries Quick Reference Guide 2019, revealed .Stage 3 Pressure Injury .Full-Thickness loss [deep and beyond the first 2 layers of the skin and may reveal fatty tissue, muscle, tendon, or even bone] of skin, in which adipose (fat) is visible in the ulcer and granulation tissue [new tissue forming during healing] and epibole (rolled wound edges) are often present. Slough [form of dead tissue that appears tan or yellow] and/or eschar may be visible .Unstageable Pressure Injury .Obscured full-thickness skin and tissue loss .within the ulcer cannot be confirmed because it is obscured by slough or eschar [dead skin] .If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . 2. Review of the facility's policy titled, Skin Assessment, dated October 2022, revealed .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission and weekly .The assessment may also be performed after a change of condition .Documentation of skin assessment .Document observation ( .skin conditions .) .Document the type of wound .Describe wound (color, type of tissue in wound bed, drainage, odor, pain) . Review of the facility's policy titled, Documentation of Wound Treatment, dated October 2022, revealed .the facility completes accurate documentation of wound assessments .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates .The following elements are documented as part of a complete wound assessment .Type of wound .(pressure injury .) .Measurement .height, width, depth, undermining [erosion under the wound edges, resulting in a large wound with a small opening], tunneling [a wound that has progressed to form an opening underneath the surface of the skin] . Description of wound characteristics .Type of tissue in the wound bed ( .granulation, slough, eschar .) . Review of the facility's policy titled, Pressure Injury Prevention Guidelines, dated 2016, revealed .Interventions will be implemented in accordance with physician orders .When physician orders are present, the facility will follow the specific physician orders .Intervention will be documented in the care plan and communicated to all relevant staff . Review of the Treatment Nurse Job Description revealed .Major Duties and Responsibilities .Identifies, manages, and treats specific skin conditions, such as pressure injuries .Provide wound care on assigned residents, in accordance with physician orders .Completes a thorough and accurate wound assessment upon notification of wound. Completes the follow-up assessments weekly and as needed. Document all assessments in the medical record .Provides status reports to Director of Nursing weekly . 3. Review of medical record revealed Resident #7 was admitted to the facility on [DATE], with diagnoses of Diabetes, Dementia, Multiple Sclerosis, Paraplegia, Heart Failure, and Hypertension. Review of the Care Plan dated 12/21/2020, revealed .has the potential for skin breakdown r/t [related to] impaired mobility . Review of the physician's orders dated 2/14/2022 revealed .BARRIER CREAM TO SACRAL AREA AS PREVENTIVE MEASURES Order Date .FLOOR NURSE .TO APPLY BARRIER CREAM TO SACRAL AREA EVERY SHIFT AS PREVENTIVE MEASURES . Review of the WEEKLY SKIN ASSESSMENT [a full body skin assessment as part of our systematic approach to pressure injury prevention and management per facility policy] dated 2/18/2023, revealed .No new skin issues . There was no documentation the weekly skin assessment was completed for the week of 2/20/2023 Review of the Physician's Orders dated 2/22/2023, .Clean Wound to (R) ischial c [with] Wound Cleanser pat dry & [and] apply Santyl [medication to remove dead tissue and aid in wound healing] & Wound gel [gel used to hold sufficient moisture in the superficial layer of the wound site] .Cover . QOD [every other day] . Review of the Care Plan dated 2/22/23, revealed .wound tx [treatment] r [right] ischial area .Observe skin for reddened areas daily when providing care, notify nurse if present . There was no documentation the weekly skin assessment was completed for the week of 2/20/2023 - 2/25/23 in accordance with the facility policy titled Skin Assessment. Review of the Wound Assessment Report [documentation per policy of a wound] dated on 2/27/2023, revealed .Pressure Ulcer . [right side] Ischial [near the ischium, which is the lower and back region of the hip bone] .Unstageable due to slough/eschar .Length-2.60 cm [centimeters] .Width - 2.20 cm .Depth - 0.00 cm .Physician notified . Review of the Physician's Progress Note, dated 2/27/2023, revealed .Patient with new right ischial pressure ulcer .Skin .Unstageable right ischial pressure ulcer with thick tan and dark slough noted which measures 2.6 [centimeters] by 2.2 cm [centimeters] .Plan .Will continue Santyl ointment and hydrogel . Review of the Wound Assessment Report, dated 3/6/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.60 cm [centimeters] .Width - 2.50 cm .Depth - 0.00 cm . Review of the Wound Assessment Report, dated 3/13/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.10 cm [centimeters] .Width - 1.80 cm .Depth - 0.00 cm . Review of the Physician's Progress Note, dated 3/13/2023, revealed .Patient with worsening of right ischial pressure ulcer .Unstageable right ischial pressure ulcer with thick tan and dark slough noted which measures 2.1 by 1.8 cm . Review of the Physician's Progress Note, dated 3/20/2023, revealed .Patient continues Santyl ointment mixed with wound gel for ischial pressure ulcer .Skin .Unstageable right ischial pressure ulcer with thick tan and dark slough noted . Review of the Wound Assessment Report, dated 3/20/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-2.80 cm [centimeters] .Width - 2.00 cm .Depth - 0.00 cm . Review of the Wound Assessment Report, dated 3/27/2023, revealed . Pressure Ulcer .Ischial .Unstageable due to slough/eschar . Length-3.10 cm [centimeters] .Width -2.50 cm .Depth - 0.00 cm . Review of the Physician's Progress Note, dated 3/27/2023, revealed .Patient with enlarged of right ischial pressure ulcer .unstageable .with dark slough .measures 3.1 by 2.5 cm . Review of the Weekly Skin Assessments revealed the facility failed to complete skin assessments for week of 3/26/2023 to 4/1/2023 in accordance with the facility policy. Review of the Wound Assessment Report, dated 4/3/2023, revealed .Pressure Ulcer .Ischial .Stage 4 .Length- 2.00 cm .Width - 3.50 cm .Depth - 1.00 cm .Granulation 50.00 % [percent] .Slough 50.00% . Review of the 4/3/2023 wound assessment showed the wound had deteriorated with an increase in size to 3.5 cm with a depth of 1.0 cm. There was no description of the wound bed tissue. Review of the Wound Assessment Report, dated 4/10/2023, revealed .Pressure Ulcer .Ischial .Stage 3 . Length- 3.70 cm .Width - 2.80 cm .Depth - 1.10 cm .Granulation Tissue 100.00% .Tunneling 0.50 .Undermining 2.0 .Wound Vac [Vacuum] . [Vacuum-assisted closure of a wound] . The wound deteriorated with an increase in length, developed tunneling and undermining. There was no documentation of the wound bed tissue description. The ischial wound was back staged by the wound care nurse from a stage 4 on 4/3/2023 to a stage 3 on 4/10/2023. Review of the Wound Assessment Report, dated 4/17/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 3.50 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 100.00% .Wound Vac . There was no documentation the weekly skin assessments were completed for the week of 4/24/2023 through 4/29/2023 in accordance with the facility policy. Review of the Wound Assessment Report, dated 5/1/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.30 cm .Width - 1.60 cm .Depth - 1.00 cm .Undermining 1 .Wound Vac . Review of the Wound Assessment Report, dated 5/15/2023, revealed .Pressure Ulcer .Ischial .Stage 3 . Length- 3.70 cm .Width - 2.60 cm .Depth - 1.20 cm .Granulation 95.00% .Slough 5.00% .Tunneling 2.00 .Undermining 10 . [Named Medical Director] visited on 05-15-23 [5/15/2023], the wound has deteriorated some, now has dark slough in the wound bed, and had foul odor . The wound measurements showed the wound deteriorated in size and developed a foul odor. Review of the Wound Assessment Report, dated 5/22/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.50 cm .Width - 2.40 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 5/29/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.00 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 6/12/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.00 cm .Width - 2.50 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.50 .Undermining 7 . Review of the Wound Assessment Report, dated 6/19/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 3.00 cm .Width - 2.20 cm .Depth - 1.00 cm .Granulation 95.00% .Slough 5.00% .Tunneling 1.00 .Undermining 10 .Wound Vac . The wound measurements sowed the wound to have deteriorated in length. There was no documentation the weekly skin assessments were completed for the weeks of 5/22/2023 - 5/27/2023, and 6/5/2023 - 6/18/2023 in accordance with the facility policy. Review of the 6/19/2023 skin assessment documented a dressing to the sacrum and a wound vac to ischial pressure ulcer. Review of the Care Plan dated 6/19/23, revealed .new sacral pressure ulcer . Review of Physician's Orders dated 6/19/2023 revealed .Sacral Pressure. There was no other information was included in the order. Review of the Physician's Progress Note dated 6/19/2023, revealed .Development of sacral pressure ulcer noted. Improvement of right ischial pressure ulcer appreciated .Skin .new unstageable sacral pressure ulcer with tan and dark slough noted which measure 7 by 4.2 cm. Moderated drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measure 3 by 2.2 cm by 1 cm deep. It undermines up to 1 cm at 10 o'clock .no drainage noted . Review of the Wound Assessment Report, dated 6/19/2023, revealed .Pressure Ulcer .Sacrum .Unstageable due to slough/eschar .length - 7.00 cm .Width - 4.20 cm .Depth - 0.00 cm . The sacral pressure ulcer was identified as unstageable with slough/eschar on 6/19/2023 and there was no physician's order for treatment until 7/28/2023. The only treatment in place was to apply barrier cream every shift as a preventative measure that was ordered on 2/14/2022. Review of the Treatment Administration Records (TAR) dated June 2023 and July 2023, revealed no pressure ulcer treatments were documented as being administered for the sacral pressure ulcer that was identified on 6/19/2023 for the following dates: 6/19/2023. 6/20/2023, 6/21/2023, 6/22/2023, 6/23/2023, 6/24/2023, 6/25/2023, 6/26/2023, 6/27/2023, 6/28/2023, 6/28/2023, 6/29/2023, 6/30/203, 7/1/2023, 7/2/2023, 7/3/2023, 7/4/2023, 7/5/2023, 7/6/2023, 7/7/2023, 7/8/2023, 7/9/2023, 7/10/2023, 7/11/2023, 7/12/2023, 7/13/2023, 7/14/2023, 7/15/2023, 7/16/2023, 7/17/2023, 7/18/2023, 7/19/2023, 7/20/2023, 7/21/2023, 7/22/2023, 7/23/2023, 7/24/2023, 7/25/2023, 7/26/2023, 7/27/2023, 7/28/2023, and 7/29/2023. Review of the Wound Assessment Report, dated 6/26/2023, revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 7.00 cm .Width - 4.20 .Depth - 0.00 . There was no documentation for the ischial pressure ulcer. Review of the Physician's Progress Note, dated 7/3/2023, revealed .Unstageable sacral pressure ulcer with tan and dark slough noted which measures 6.3 by 2.8 cm. Moderate drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.6 by 2 cm by 0.7 cm deep. It undermines up to 2.4 cm at 6 o'clock . Review of the Physician's Progress Note, dated 7/10/2023, revealed .Treatment of sacral pressure ulcer changed to Santyl ointment once a day .Unstageable sacral pressure ulcer with tan and dark slough and stage 3 right ischial pressure ulcer noted . Review of the Wound Assessment Report, dated 7/10/2023, revealed .Pressure Ulcer .Ischial .Stage 3 .Length- 2.60 cm .Width - 2.00 cm .Depth - 0.70 cm .Granulation Tissue - 1000.00% [percent] .Tunneling 2.40 .Undermining 6 . Review of the Wound Assessment Report, dated 7/10/2023, for the sacral pressure ulcer revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 6.30 cm .Width - 2.80 .Depth - 0.00 . Review of the Wound Assessment Report, dated 7/17/1012, revealed .Pressure Ulcer . Sacrum .Unstageable due to slough/eschar .measurements .Length - 5.30 cm .Width - 3.10 .Depth - 1.00 . Review of the Physician's Progress Note, dated 7/17/2023, revealed .Stage 3 sacral pressure ulcer with little tan slough noted which measures 5.3 by 3.1 cm by 1 cm deep Moderate drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.8 by 2.6 cm by 0.6 cm deep. It undermines up to 1.2 cm at 6 o'clock . Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated she was cognitively impaired, and was totally dependent for all activities of daily living (ADLs). Resident #7 had one unstageable and one stage 3 pressure ulcer. Review of the Physician's Orders, dated 7/28/2023, revealed .CLEAN SACRAL WOUND WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE [intended for the management of exudating [draining] wounds, COVER WITH DRY DRESSING .EVERY OTHER DAY .CLEAN WOUND TO RIGHT ISCHIAL WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE, COVER WITH DRY DRESSING. CHANGE EVERY OTHER DAY . The sacral pressure ulcer was identified on 6/19/2023 as unstageable pressure ulcer with slough/eschar. There was no physician's order for treatment of the sacral ulcer when it was identified on 6/19/2023, and no documented treatments to the sacral ulcer from 6/19/2023 - 7/29/2023. There was a previous entry for a physician order dated 6/19/2023, but it was not complete. There was an order dated 7/28/2023for treatment to the sacral pressure ulcer but was not started until 7/30/2023. Review of the July 2023 TAR revealed an order dated 7/28/2023 with a start date of 7/30/2023 .CLEAN SACRAL WOUND WITH WOUND CLEANSER, PAT DRY AND APPLY PROMAGRAN ALGINATE, COVER WITH DRY DRESSING, CHANGE EVERY OTHER DAY . Review of the Physician's Progress Note, dated 7/31/2023, revealed .Stage 3 sacral pressure ulcer with little tan slough noted which measures 6.2 by 3.2 cm by 0.6 cm deep. Moderated drainage noted .Stage 3 right ischial pressure ulcer with no slough noted which measures 2.8 by 2.5 cm by 1 cm deep. It undermines up to 1 cm at 12 o'clock . The progress note revealed the sacral pressure ulcer deteriorated in length, width, and depth from the 7/17/2023 measurements. Observation in the resident's room on 10/4/2023 at 9:28 AM, revealed Resident #7 had a pressure injury to the sacrum and right ischial. During an interview on 10/5/2023 at 12:34 PM, the Wound Care Nurse was asked should Resident #7's wound, identified on 2/22/2023, have a completed wound assessment. The Wound Care Nurse stated, .I was waiting for doctor [Named Medical Director] to get here .it had slough and eschar tissue .unstageable . In summary, Resident #7 developed a pressure ulcer to the right ischial/buttock area on 2/22/2023 and to the sacral pressure ulcer on 6/19/2023, both as unstageable when identified. The facility failed to perform weekly skin assessments in accordance with the facility policy, failed to ensure complete weekly wound assessments that included measurements, description in accordance with the facility policy, failed to consistently stage the pressure ulcer, and failed to perform wound care treatments. 4. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses of Diabetes, Depression, and Multiple Sclerosis. Review of the facility's Skin Assessments revealed Resident #8 had redness to the buttocks on 10/5/2021, 10/12/2021, 10/19/2021, and 10/24/2021 with no other description. Review of the Treatment Administration Record for 10/2021, revealed there was no interventions implemented for the redness to Resident #8's buttocks. Record review revealed there were no weekly skin assessments conducted for Resident #8 from 11/1/2021 through 11/22/2021. Review of the facility's Weekly Skin Assessments, dated 11/23/2021, revealed Resident #8 had ulcers to the buttocks, with no other description in the assessment. Review of the Care Plan with a revision date of 11/23/2021, revealed Resident #8 had .Stage IV [four] left buttock . The facility failed to conduct skin assessments from 11/1/2021 through 11/22/2021, prior to the identification of the Stage IV pressure ulcer to Resident #8's left buttock. Review of the facility's Wound Assessment Report, dated 11/24/2021, conducted by the Wound Nurse revealed .Pressure Ulcer .Left Buttock .Date Wound Identified 11/23/2021 .Stage 3 [the care plan dated 11/23/2021 documented the pressure ulcer was a Stage 4] . Review of the Physician Orders dated 11/23/2021, Clean open area to left buttocks with wound cleanser, apply AG [Alginate] to wound bed, and cover with foam dressing every other day. Review of the Physician's Progress Note dated 11/29/2021, 6 days after the stage 4 pressure ulcer was identified, revealed .initial wound assessment . developed a pressure ulcer .left ischium .unstageable .thick tan and dark slough noted which measures 4.5 by 3.1 cm . heavy drainage noted . Review of the facility's Wound Assessment Report, dated 11/29/2021, revealed .Pressure Ulcer .Left Buttock; left ischial .Date Wound Identified 11/23/2021 .unstageable due to slough, eschar .Length 4.5cm . Width 3.1 cm . Depth 0 cm . Review of the Physician Order dated 11/29/2021, revealed Clean left ischial wound with wound cleanser, apply Santyl to open, then apply Calcium Alginate over Santyl, and cover with foam dressing QOD [every other day] Review of the Physician Order dated 11/30/2021, revealed Juven one packet by mouth twice per day X[times] 60 days. There was no documentation the Weekly Wound Assessment Report was completed the week of 12/6/2021. Review of the Physician's Progress Note, dated 12/13/2021, revealed .A lot of slough is gone from the left ischial pressure ulcer .unstageable .7.5 by 4.4 cm . heavy drainage noted . Review of the facility's Wound Assessment Report, dated 12/13/2021, revealed .Pressure Ulcer .Left Buttock .left ischial .unstageable .7.50 cm .4.40 cm . The resident's wound to the left ischial/buttock increased in size from 11/29/2021 to 12/13/2021. There was no documentation the Weekly Wound Assessment Report was completed on 12/20/2021 and 12/27/2021. Review of the Physician Order dated 12/22/2022, revealed Clean wound to left ischial with wound cleanser, apply Santyl and Alginate and cover with foam dressing daily. Review of the Physician Order dated 12/29/2021, revealed Prostat 30 cc [cubic centimeter] by mouth daily. Review of the facility's Wound Assessment Report, dated 1/3/2022, revealed .Pressure Ulcer .Left Buttock .left ischial .Stage 4 .7.9 cm .3.9 cm .3 cm . undermining .2 [o'clock] . The resident's wound increased in height and had undermining from 12/13/2021 to 1/3/2022. Review of the Physician Order dated 1/3/2022, revealed Clean left ischial with wound cleanser, lightly pack are of depth with Silver Alginate and cover with foam dressing daily. Review of the Physician's Progress Note, dated 1/3/2022, revealed .Slough is gone from the left ischial pressure ulcer .Stage 4 .palpable bone noted .6.9 by 3.9 by 3 cm with up to 1 cm undermining at 2 o'clock .heavy drainage . Review of the facility's Wound Assessment Report, dated 1/17/2022, revealed .Pressure Ulcer .Left Buttock .left ischial .Stage 4 .6.8 cm .4.6 cm .1.40 cm . tunneling 2.5 .undermining . There was no documentation the Weekly Wound Assessment Report was completed the week of 1/10/2022. The width of the resident's wound increased in size from 1/3/2022 to 1/17/2022. There was no documentation the Weekly Wound Assessment Report was completed the week of 1/24/2022. Observation in the resident's room on 10/5/2023 at 7:43 AM, revealed Resident #8 had a pressure ulcer to the left ischial. In summary, Resident #8 had redness to the buttocks on 10/5/2021, 10/12/2021, 10/19/2021, and 10/24/2021. The facility failed to conduct skin assessments from 11/1/2021 through 11/22/2021 in accordance with facility policy for a systematic approach to pressure injury prevention and management. On 11/23/2021, the facility documented Resident #8 had Stage 4 pressure ulcer to the left buttock. 5. During a Telephone interview on 10/5/2023 at 2:15 PM, the Medical Director was asked who was responsible for monitoring, assessing, and providing wound care treatments in the facility. The Medical Director stated, .I thought it was [Named Wound Care Nurse] .not sure if the nurses [floor nurses] are signing off on the treatment administration records .I don't know why that is happening [the charge nurses are completing the wound care and not the wound care nurse] . The Medical Director was asked if the Wound Care Nurse was certified, should she document the measurement and stage the wound when identified. The Medical Director stated, Yes .she can .I'm not sure what the policy says .they should document the assessment at the time it [wound] is found .there should be no delay . The Medical Director was asked if a wound is identified as a stage 4 can you backstage a wound to a stage 3 and would that be an accurate assessment. The Medical Director stated .No . The Medical Director was asked at what stage should the wounds be identified. The Medical Director stated, .Preferably at a stage 1 . The Medical Director was asked if it was acceptable to identify a wound that's unstageable with slough and eschar. The Medical Director stated No . The Medical Director was asked should there be missed skin assessments, wound assessments, and missed treatments. The Medical Director stated, .No . staff should follow the orders for treatments . During an interview on 10/5/2023 at 3:25 PM, the Director of Nursing (DON) confirmed there should not be any missed weekly skin assessments or wound assessments. The DON stated, The Unit Manager and myself make sure they are being done. The DON was asked at what stage should a pressure injury be identified. The DON stated, .At a stage one . The DON was asked who stages the wounds when identified. The DON stated, . [Named Medical Director] comes in and does the assessments and the measurements . [Named Wound Care Nurse] does not stage the wounds .she should describe the wound in a nurse note when identified . The DON confirmed that a Registered Nurse and the DON could stage and measure the wounds. The DON was asked when she attended the Quality Assurance (QA) meeting was she informed Resident #7's wounds (sacrum and ischial) were identified as unstageable. The DON stated, No . she just said they were unstageable [did not specify they were identified as unstageable] .