**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to notify the physician of a pressure ulcer on admission and failed to notify the physician when a Stage 2 pressure ulcer on the coccyx deteriorated to an unstageable pressure ulcer for 1 of 6 (Resident #138) sampled residents reviewed with pressure ulcers which resulted in actual Harm. The findings include: 1. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with diagnoses of Hypertension, Dementia, Hypothyroidism, and Absence of a Kidney. A Hospital Wound Care note dated 7/9/19 documented, .stage 2 pressure injury to sacrum [a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis] . Review of the admission Observation performed by Licensed Practical Nurse (LPN) #1 dated 7/11/19 revealed a pressure ulcer on the coccyx (tailbone, a bony structure located at the bottom of the vertebral column) that was described as having zero length and depth. There was no documentation the physician was notified of the pressure ulcer on the coccyx. Review of the Weekly Skin Observations dated 7/17/19, 7/17/19, and 7/31/19 performed by LPN #1 revealed the presence of an open area to the coccyx and a nursing skin treatment/intervention of the application of a dressing (with or without topical medications) . There was no documentation the physician was notified of the open area on the coccyx and no documentation a treatment was ordered by the physician for the open area on the coccyx. Review of a General Order dated 7/18/19 and signed by Licensed Practical Nurse (LPN) #1 documented, .Apply cavilon protective stick (a fast-drying, non-sticky, alcohol free liquid barrier film) to coccyx area every 3 days .Nursing Order . There was no documentation the physician was notified. Review of the Wound Management Observation History dated 8/1/19 performed by LPN #2 documented, .Length .(centimeters) 4.5 .Width (centimeters) .3 .Tissue Type .Slough [the result of protein, fiber strands,and dead skin cells which can slow wound healing] .Wound edges .Irregular .Skin surrounding wound .Erythema (redness) . Review of the General Order dated 8/1/19 and signed by LPN #1 documented, .Clean with NS [Normal Saline]. Apply Medihoney [gel indicated for dry to moderately exuding wounds such as partial and full thickness pressure ulcers] to wound bed. Apply No Sting Barrier Spray to periwound [around wound] and cover with protective dressing daily until resolved .Nursing Order . There was no documentation the physician was notified that the pressure ulcer had deteriorated and the nursing order for the treatment was not signed by the physician. Review of the Wound Management Observation History dated 8/8/19 performed by LPN #2 documented, Length .(centimeters) .4.5 .Width .(centimeters) .3.3 .Exudate [drainage] .Moderate .Serous (clear, amber, thin and watery) .Tissue Type .Granulation [new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process] . There was no documentation the physician was notified of the pressure ulcer or that it had deteriorated. Review of the Wound Management Observation History dated 8/15/19 performed by LPN #2 documented, .Length .(centimeters) .4.9 .Width .(centimeters) .4.8 .Depth .(centimeters) .0.1 .Exudate .Moderate . Serous .Tissue Type .Slough . There was no documentation the physician was notified the pressure ulcer had deteriorated further. Interview with the Director of Nursing (DON) on 8/22/19 at 8:20 AM in the Private Dining Room, the DON was asked if a physician ordered the Medihoney treatment for the coccyx wound. The DON confirmed it was not ordered by a physician and stated, They should have been notified. I believe she put it in as a general nursing order. Observations in Resident #138's room on 8/21/19 at 10:40 AM, revealed Resident #138 was positioned on an air mattress (a mattress that reduces pressure on the bony prominences of the body). LPN #1 removed the dressing from the coccyx pressure ulcer. The dressing contained serosangious (blood and serous drainage) drainage. The wound measurements were 5.5 centimeters in length and 5.5 centimeters in width. The wound bed was covered with 40% black eschar (dead tissue that is leathery or thick, black, tan or brown) and 60% slough (dried inflammatory fluid that is moist, stringy, yellow, tan, green, or brown). The surrounding tissue was bright red with areas of maceration (skin appears lighter in color and wrinkly). The depth could not be determined due to the slough and eschar in the wound bed. Interview with Licensed Practical Nurse (LPN) #3 on 8/21/19 at 5:51 PM in the Private Dining Room, LPN #3 was asked when he first saw Resident #138's coccyx pressure ulcer. LPN #3 stated, August 1 [2019] .it was unstageable [full thickness skin or tissue loss with unknown depth of the wound] due to slough . LPN #3 was asked if the pressure ulcer had improved. The LPN #3 stated, No. I don't see that. LPN #3 was asked if a physician had been notified of the pressure ulcer on the coccyx. The Unit Manager stated, I don't know. LPN #3 was asked if he should have notified the physician. LPN #3 stated, Yes, Ma'am. Interview with the DON on 8/22/19 at 8:05 AM in the Private Dining Room, the DON was asked if a physician was notified about the pressure ulcer on Resident #138's coccyx. The DON stated, I don't see documentation that reflects that . The DON was asked if she notified the physician after she observed the pressure ulcer on 8/21/19. The DON stated, .did not . Telephone interview with Physician #1 (Resident #138's physician) on 8/22/19 at 9:58 AM, Physician #1 was asked if he should have been notified that Resident #138 had a pressure ulcer on the coccyx. Physician #1 stated, I suspect so .you want a full team approach .with a worsening wound the nurse should raise the flag . Telephone interview with the Nurse Practitioner on 8/22/19 at 11:27 AM, the Nurse Practitioner was asked if she had seen Resident #138's pressure ulcer. She stated, I have not . The Nurse Practitioner was asked if she expected staff to notify her if a pressure ulcer had deteriorated. The Nurse Practitioner stated, Yes. The Nurse Practitioner was asked when she was notified about Resident #138's coccyx pressure ulcer. The Nurse Practitioner stated, I can't recall .I didn't know about it being worse . The facility failed to notify the physician of a Stage 2 pressure ulcer on the coccyx which deteriorated to an unstageable pressure ulcer and resulted in Harm to Resident #138. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on The National Pressure Ulcer Advisory Panel (NPUAP) Quick Reference Guide, facility policy review, medical record review, observation, and interview, the facility failed to provide the necessary treatment for the prevention and healing of pressure ulcers for 2 of 6 (Resident #53 and #138) sampled residents reviewed with pressure ulcers. The facility's failure to stage or obtain measurements of the pressure ulcer on admission, failure to notify the physician of the pressure ulcer on admission, and failure to identify the stage of the the pressure ulcer until it became unstageable resulted in actual Harm to Resident #138. The findings include: 1. The NPUAP Prevention and Treatment of Pressure Ulcers: Quick Reference Guide dated 2014 documented, .Comprehensive assessment of the individual and his or her pressure ulcer informs development of the most appropriate management plan and ongoing monitoring of wound healing. Effective assessment and monitoring of wound healing is based on scientific principles, as described in this section of the guideline .1. Complete a comprehensive initial assessment of the individual with a pressure ulcer .Reassess the individual, the pressure ulcer and the plan of care if the ulcer does not show signs of healing .Assess the pressure ulcer initially and re-assess it at least weekly .Document the results of all wound assessments .weekly assessments provide an opportunity for the health professional to assess the ulcer more regularly, detect complications as early as possible, and adjust the treatment plan accordingly .Address signs of deterioration immediately .Assess and document physical characteristics including: location .Stage .size .tissue type .color .periwound [area around the wound] condition .wound edges .sinus tracts [a narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formation] undermining [occurs when the tissue under the wound edges becomes eroded, resulting in a a pocket beneath the skin at the wound's edge] .tunneling [channels that extend from a wound into and through subcutaneous tissue or muscle] .exudate [drainage] .odor .Select a uniform, consistent method for measuring wound length and width or wound area to facilitate meaningful comparisons of wound measurements across time .Select a consistent, uniform method for measuring depth .Stage II: Partial Thickness Skin Loss .presenting as a shallow open ulcer with a red pink wound bed .May also present as an intact or open/ruptured serum-filled blister .Unstageable: Depth unknown, Full thickness tissue loss in which the base of the ulcer is covered by a slough (yellow, tan, gray, green, or brown) and or eschar (tan, brown, or black) in the wound bed . 2. The facility's Skin Integrity Manual revised 3/1/10 documented, .ASSESSMENT .Risk Factors .Example of these risk factors include but are not limited to .Impaired/decreased mobility and decreased functional ability .Co-morbid conditions .Under nutrition, malnutrition, and hydration deficits .Wound assessment includes type, stage, location, and measurement of site .length, width and depth .Exudate .type, odor, amount, color .Wound bed to include .necrotic tissue, slough .Periwound .wound edge appearance to include description and measurement .Weekly Skin and Wound Assessments . 3. Medical record review revealed Resident #138 was admitted to the facility on [DATE] with diagnoses of Hypertension, Dementia, Hypothyroidism, Absence of a Kidney, and Malnutrition. A Hospital Wound Care note dated 7/9/19 documented, .stage 2 pressure injury to sacrum [a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis] . The Hospital Discharge summary dated [DATE] documented, .[Resident #138] has developed a decubitus wound . Review of the admission Observation report dated 7/11/19 revealed Resident #138 had a pressure ulcer on his coccyx (tailbone, a bony structure located at the bottom of the vertebral column). The admission observation did not identify the stage of the coccyx pressure ulcer and there was no documentation the physician was notified the resident had a pressure ulcer. Interview with Licensed Practical Nurse (LPN) #1 on 8/21/19 at 5:17 PM, in the Private Dining Room, LPN #1 confirmed that she was the admitting nurse for Resident #138 on 7/11/19. LPN #1 was asked to describe Resident #138's coccyx area when he was admitted to the facility. LPN #1 stated, .It was just reddened .top layer of skin removed, denuded skin [loss of the epidermis, caused by exposure to urine, feces, body fluids, wound exudate, or friction] . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #138 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderately impaired cognition, required extensive assistance for bed mobility, was at risk for developing pressure ulcers/injury, and had a stage 2 pressure ulcer on admission. This was the first entry in the medical record that identified the pressure ulcer on Resident #138's coccyx. The Care Plan revised 8/21/19 documented, .Risk for loss or alteration in skin integrity related to presence of Stage 2 sacrum wound .Approach .air mattress maintained at all times .Administer medications and treatments as ordered .Evaluation Notes: 08/21/2019 .wounds assessed this am [morning] with coccyx noted to have slough to 75% of wound and eschar to 25% of wound .air mattress applied and turnq2 [turn every 2 hours] . There were appropriate nutritional approaches were in place. Review of the Weekly Skin Observations dated 7/17/19, 7/24/19, and 7/31/19 by LPN #1 revealed the presence of a pressure ulcer on the coccyx. The Weekly Skin Observations did not identify the stage or measurements of the pressure ulcer. The General Order dated 7/18/19 documented and signed by LPN #1 documented, .Apply cavilon protective stick [a fast-drying, non-sticky, alcohol free liquid barrier film] to coccyx area every 3 days .Nursing Order . There was no documentation the physician was notified about the new treatment. The Weekly Skin Observation dated 7/31/19 performed by LPN #1 documented, .redness open area to coccyx . The stage of the pressure ulcer was not identified and there were no measurements. There was no documentation the physician was notified about the change in the pressure ulcer. Review of a Wound Management Observation History performed by LPN #3 dated 8/1/19 revealed Resident #138's pressure ulcer had a length of 4.5 centimeters and a width of 3 centimeters with slough in the wound bed and erythema (redness) around the pressure ulcer. There was no documentation that identified the stage of the pressure ulcer. Observations on 8/19/19 at 4:35 PM, 8/20/19 at 10:19 AM, 1:59 PM, and 4:38 PM, in Resident #138's room, revealed Resident #138 did not have an air mattress on his bed. Interview with the LPN #3 on 8/21/19 at 2:44 PM in the Unit Manager office, LPN #3 was asked when he saw Resident #138's pressure ulcer. LPN #3 stated, This is when they brought me in on it .on 8/1 [8/1/19] was my first assessment and I started measuring it. LPN #3 was asked why the stage of the pressure ulcer was not identified on the assessments. LPN #3 stated, You know what? I don't know why I didn't do that. Interview with the Director of Nursing (DON) on 8/21/19 at 4:34 PM, in the Private Dining Room, the DON was asked if a physician had seen Resident #138's pressure ulcer on the coccyx. The DON stated, I don't know. Interview with the DON on 8/22/19 at 8:05 AM in the Private Dining Room, the DON confirmed the pressure ulcer on the coccyx had not been measured until 8/1/19. The DON confirmed the stage of the pressure ulcer on the coccyx had not been identified on the Wound Management Observations between 8/1/19 and 8/21/19. The DON was asked if the nurses should document and report any changes in a pressure ulcer to the physician. The DON stated, Yes, Ma'am. The DON was asked if a physician was notified about the deteriorating coccyx pressure ulcer. The DON stated, I don't see documentation that reflects that . The DON confirmed she had not seen Resident #138's coccyx wound until 8/21/19. The DON was asked if she had notified the physician after she saw the pressure ulcer on 8/21/19. The DON stated, .did not . The General Order dated 8/1/19 documented and signed by LPN #1 documented, .Clean with NS [Normal Saline]. Apply Medihoney [gel indicated for dry to moderately exuding wounds such as partial and full thickness pressure ulcers] to wound bed. Apply No Sting Barrier Spray to periwound and cover with protective dressing daily until resolved .Nursing Order . There was no documentation the physician was notified about the change in the wound or the change in the treatment. Interview with the DON on 8/22/19 at 8:20 AM in the Private Dining Room, the DON was asked if a physician had ordered the Medihoney treatment for the coccyx pressure ulcer. The DON confirmed it was not ordered by a physician and stated, They should have been notified. I believe she put it in as a general nursing order. Review of a Wound Management Observation History dated 8/8/19 by LPN #3 revealed the wound had increased in size to a length of 4.5 centimeters and width of 3.3 centimeters with a moderate amount of drainage. This assessment did not identify the stage of the pressure ulcer on the coccyx. There was no documentation the physician was notified the pressure ulcer had deteriorated. A General Order dated 8/14/19 received by LPN #1 documented, .Clean with NS. Apply Santyl nickel thick to wound bed. Apply No Sting Barrier Spray to periwound and cover with protective dressing daily until resolved . Telephone interview with the Nurse Practitioner on 8/22/19 at 11:27 AM, the Nurse Practitioner confirmed she was notified about the pressure ulcer and gave a telephone order for Santyl treatment (a medication that removes dead tissue) on 8/14/19. The Nurse Practitioner was asked if she had seen Resident #138's pressure ulcer. She stated, I have not. Review of the Wound Management Observation History report dated 8/15/19 performed by LPN #3 revealed the wound had progressed to a length of 4.9 centimeters, a width of 4.8 centimeters and a depth of 0.1 centimeters, with slough in the wound bed. This assessment did not identify the stage of the pressure ulcer to the coccyx. Observation in Resident #138's room on 8/21/19 at 10:40 AM, revealed Resident #138 lying on an air mattress. LPN #1 removed the dressing and it was soaked with serosanguinous (blood and serous drainage) drainage. The wound measurements were 5.5 centimeters in length and 5.5 centimeters in width. The wound bed was covered in 40% black eschar and 60% slough. The surrounding tissue was bright red with areas of maceration (skin breakdown). The depth could not be determined due to the slough and eschar in the wound bed. Interview with Certified Nursing Assistant (CNA) #1 on 8/21/19 at 11:05 AM in Resident #138's room, CNA #1 was asked when Resident #138 was placed on the air mattress. CNA #1 stated, Today. Interview with CNA #1 on 8/21/19 at 5:48 PM, in the Second Floor Nurses' Station office, CNA #1 was asked when she first took care of Resident #138. CNA #1 stated, I had him the 18th [7/18/19]. CNA #1 was asked if she remembered what his coccyx looked like. CNA #1 stated, It was pretty bad. There was a black spot on it. It was above or on his coccyx, the same place it was now. He came here with it. CNA #1 was asked to describe it. She stated, A little smaller than a tennis ball. CNA #1 was asked what color the wound was. She stated, Black. Interview with Unit Manager #1 on 8/21/19 at 5:51 PM in the Private Dining Room, Unit Manager #1 was asked if the pressure ulcer was improving. Unit Manager #1 stated, No. I don't see that. Telephone interview with Physician #1 on 8/22/19 at 9:58 AM, Physician #1 was asked if he should have been notified about Resident #138's pressure ulcer on the coccyx. Physician #1 stated, I suspect so .you want a full team approach .with a worsening wound the nurse should raise the flag . Interview with the DON on 8/22/19 at 11:45 AM in the Private Dining Room, the DON was asked if LPN #1 or LPN #3 had wound care training. The DON confirmed they had attended wound care inservices in the facility and stated, They are not wound certified. The facility failed to stage and obtain measurements, report to the physician, and treat a pressure ulcer which resulted in actual Harm to Resident #138 when the Stage 2 pressure ulcer on the coccyx deteriorated to an unstageable pressure ulcer. 4. Medical record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Alzheimer's Disease, and Hypertension. Review of the quarterly MDS dated [DATE] revealed Resident #53 had a BIMS score of 10, which indicated moderately impaired cognition, and required extensive assistance from staff for bed mobility. The Care Plan dated 8/15/19 documented, .Problem .pressure ulcer .Assess the pressure ulcer for stage, size (length, width, and depth), presence/absence of granulation tissue .systematic skin inspection .Keep clean and dry . The Wound Management Observation History dated 8/15/19 performed by by LPN #3 documented, .Pressure Ulcer .Left bottom of foot . This assessment did not include measurements or stage of the pressure ulcer. The physician was not notified about this pressure ulcer until 8/16/19. The Physician's Order dated 8/16/19 signed by the physician 8/19/19 documented, .clean bottom of left foot with ns [normal saline], pat dry, apply calcium alginate [a highly absorbent, biodegradable alginate dressing derived from seaweed] .cover with 4x4 [a gauze dressing] and wrap with kerlix [sterile and non-sterile gauze rolls used for both primary and secondary dressings], change every three days . Review of the August 2019 Treatment Administration Records (TARS) revealed there was no documentation the treatments were administered since ordered on 8/16/19. A Physician's order dated 8/20/19 documented, .apply cavilon wand every three days until healed . Observations in Resident #53's room on 8/21/19 at 8:15 AM, revealed Resident #53 had a clear cavilon dressing that was dry and intact with a healing stage 2 pressure ulcer on the ball of the left foot. Interview with Registered Nurse (RN) #2 on 8/20/19 at 5:06 PM, in the Second Floor Nurses' Station office, RN #2 was asked what Resident #53's pressure ulcer on the ball of his left foot looked like when she first found it. RN #2 stated, It was a fluid filled pressure ulcer. Interview with the DON on 8/21/19 at 9:23 AM in the Private Dining Room, the DON was asked if treatments were ordered when the wound was identified on the bottom of the left foot on 8/15/19. The DON stated, No, Ma'am. It was on the 16th. The DON confirmed there was no documentation the treatments were administered as ordered.