**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to timely notify the physician of a change in a resident's condition related to a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to timely notify the physician of a heel wound and obtain orders for treatment resulted in actual Harm for resident #50 when the wound deteriorated from a reddened area to a deep tissue injury/pressure ulcer. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries .If a new skin alteration is noted .Notify attending MD [physician] .notify family, guardian . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Chronic Obstructive Pyelonephritis, Dysarthria following Cerebrovascular Disease, Atrial Fibrillation, Diabetes, Chronic Kidney Disease, Insomnia, Parkinson's Disease, Generalized Edema, and Adjustment Disorder with Depressed Mood. The Departmental Notes written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. [approximately] 1 in. [inch] diameter . Observation in Resident #50's room on 6/26/18 at 4:46 PM revealed Licensed Practical Nurse (LPN) #1 removed the heel protector and the dressing from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. Interview with the Wound Nurse on 6/26/18 at 5:40 PM, in the Administrator's office, the Wound Nurse was asked when she completed the last skin inspection for Resident #50, and what were the findings. The Wound Nurse stated, .June 19 .the right heel was just red and bubbly and still blanchable .the MD was notified yesterday [6/25/18] .got an order today for the wound . The Wound Nurse was asked when she identified a wound, how were her findings communicated to the staff. The Wound Nurse stated, .sometimes I don't write it down, I just keep it in my head . The Wound Nurse was asked why the skin inspection sheets documented that the skin was intact if Resident #50 had a wound on her right heel. The Wound Nurse stated, .there was nowhere to document. The Wound Nurse was asked if the physician had been notified on 5/28/18 when the wound was identified. The Wound Nurse stated, .no I just notified him today [6/26/18] . There were inconsistencies by the Wound Nurse of the description of the wound and when she notifed the MD. The facility failed to notify the physician of a new pressure ulcer for Resident #50 for 29 days after identification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview the facility failed to revise the care plan to identify the development of a pressure ulcer for 1 of 2 (Resident #50) sampled residents reviewed with pressure ulcers. The failure of the facility to accurately perform skin assessments and revise Resident #50's care plan with updated interventions to address a reddened area when it was identified resulted in actual Harm to Resident #50. The findings included: The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .Steps in the Procedure .develop the resident centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the residents overall critical condition .Once inspection of skin is completed document the findings on a facility-approved skin assessment tool .If new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin .The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Chronic Obstructive Pyelonephritis, Cerebrovascular Disease, Atrial Fibrillation, Diabetes, Chronic Kidney Disease, Parkinson's Disease, Generalized Edema, and Adjustment Disorder with Depressed Mood. Review of Resident #50's care plan last updated on 5/10/18 did not reflect the current status of Resident #50's skin integrity related to a Deep Tissue Injury that was identified 5/28/18. There was no documentation on the care plan that the wound was identified 5/28/18 or any interventions were implemented. Review of a Departmental Note written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. [approximately] 1 in. [inch] in diameter. no open areas noted. no c/o [complaint of] pain . Observations in Resident #50's room on 6/26/18 at 11:05 AM revealed Resident #50 sitting up in a wheelchair with heel protectors on. Interview with LPN #1 on 6/26/18 at 3:08 PM, at the North Nurses' Station, LPN #1 was asked if Resident #50 had any skin issues. LPN #1 stated, .yes . Observations in Resident #50's room on 6/26/18 at 4:46 PM revealed LPN #1 removed the heel protector and the dressing from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. The Departmental Notes written by the Wound Nurse dated 6/26/18 documented, .This am [morning] resident noted with dti to right heel measuring 1.0 cm. [centimeters] x [by] 1.4 cm. Area previously noted with redness . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if newly identified pressure ulcers should be reflected on the care plan. The DON confirmed care plans should be updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on National Pressure Ulcer Advisory Panel (NPUAP) reference guide, facility policy review, medical record review, observation, and interview, the facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer, failed to obtain new treatment orders, and failed to accurately assess a wound before it deteriorated to a Deep Tissue Injury (DTI) for 1 of 2 (Resident #50) sampled residents reviewed for pressure ulcers. The failure of the facility to accurately assess, implement interventions and document the findings before the pressure ulcer progressed into a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50. The facility failed to notify the physician, failed to obtain physician's orders for treatment of the pressure ulcer, and initiated treatment of the pressure ulcer without a physician's order. The findings included: Review of the NPUAP quick reference guide defined a Suspected Deep Tissue Injury (DTI): with unknown depth as a .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue .evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue . The facility's Pressure Ulcer/Injury Risk Assessment policy dated 7/17, documented, .The purpose of this procedure is to provide guidelines for the structured assessment and identification of residents at risk of developing pressure ulcers/injuries .Steps in the procedure .Once inspection of skin is completed document the findings on a facility-approved skin assessment tool .If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration of skin .Documentation .The following should be recorded in the resident's medical records .the condition of the resident's skin .Initiation of a (pressure or non-pressure) form related to the type of alteration in the skin if any new skin alterations noted .Document in medical record addressing MD [Medical Doctor] notification if new skin alteration noted with change of plan of care .Documentation in medical record addressing family, guardian or resident notification if new skin alteration noted with change on plan of care .Reporting .Notify attending MD if new skin alteration noted .notify family, guardian .if new skin alteration noted . The facility's Pressure Ulcer/Skin Breakdown-Clinical Protocol policy dated 3/14, documented, .The nurse shall describe and document/report the following .full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or a necrotic tissue .The physician will authorize prudent orders related to wound treatments, including wound cleansing and debridement approaches, dressings .and application of topical agents . Medical record review revealed Resident #50 was admitted to the facility on [DATE] with diagnoses of Hemiplegia, Chronic Obstructive Pyelonephritis, Cerebrovascular Disease, Atrial Fibrillation, Diabetes, Chronic Kidney Disease, Parkinson's Disease, Generalized Edema, and Adjustment Disorder with Depressed Mood. Review of the quarterly Minimum Data Set (MDS) with an assessment reference date of 5/11/18 documented a Brief Interview for Mental Status (BIMS) score of 15 which indicated Resident #50 was cognitively intact. Resident #50 required extensive assistance with bed mobility and transfers and was at risk of developing pressure ulcers. The Departmental Notes written by Licensed Practical Nurse (LPN) #1 dated 5/28/18 documented, .noted blister to right heel approx. [approximately] 1 in. (inch) diameter . The Departmental Notes written by the Wound Nurse dated 6/26/18 documented, .This am [morning] resident noted with dti to right heel measuring 1.0 cm. [centimeters] x [by] 1.4 cm. Area previously noted with redness . The care plan updated 5/10/18 documented, .At risk for altered skin integrity .Approaches .Weekly skin audits .6/1/18 .Bilateral heel protectors as resident tolerates . Review of physician progress note dated 6/9/18 documented, .Special care to avoid heel decubitus . Review of the facility's weekly Skin Inspection Report revealed documentation that Resident #50's skin was intact from 5/1/18 through 6/26/18. Review of a handwritten statement signed by Resident #50 when asked how long the nurse had been treating her right heel documented, .the Nurse had been treating it she [Resident #50] stated for some time . Review of a signed statement by the Wound Nurse dated 6/27/18 documented, I [Named Wound Nurse] as the wound nurse have been treating [Named Resident #50] Right Heel for DTI without order and Dr. notification . The facility was unable to provide documentation of any wound assessments for the right heel pressure ulcer from the time of wound identification on 5/28/18 until 6/26/18. The failure of the facility to accurately access and document findings before the reddened pressure area deteriorated into a DTI on Resident #50's right heel resulted in actual Harm to Resident #50. Observations in Resident #50's room on 6/26/18 at 11:05 AM revealed Resident #50 sitting up in wheelchair with heel protectors on. Interview with LPN #1 on 6/26/18 at 3:08 PM, at the North Nurses' Station, LPN #1 was asked if Resident #50 had any skin issues. LPN #1 stated, .yes . Observations in Resident #50's room on 6/26/18 at 4:46 PM revealed Licensed Practical Nurse (LPN) #1 removed the heel protector and the dressing (no date or initials when applied) from Resident #50's right heel revealing a dark dry area to the bottom of the heel. The wound was not identified as a DTI by the staff until the surveyor requested to look at Resident #50's heels. Interview with Wound Nurse on 6/26/18 at 5:05 PM, in the hall by the dining room, the Wound Nurse stated, .Yesterday it was real red, I put betadine [an antiseptic used for skin disinfection] and optifoam [an adhesive dressing] on the wound to try to contain it .measured it today . The Wound Nurse was then asked what you would stage the wound at today. The Wound Nurse stated, A DTI . The Wound Nurse was asked what is the facility's policy regarding newly identified wounds. The Wound Nurse stated, .It was just red not open. The Doctor was notified and he said continue the heel protectors . The Wound Nurse was asked how information about wounds is relayed to the other staff involved in a resident's care. The Wound Nurse stated, .I chart in the wound notes. The nurses have access to them . Interview with the Wound Nurse on 6/26/18 at 5:40 PM, in the Administrator's office, the Wound Nurse was asked when she completed the last skin inspection for Resident #50, and what were the findings. The Wound Nurse stated, .June 19 .the right heel was just red and bubbly and still blanchable .the MD was notified yesterday [6/25/18] .got an order today for the wound . The Wound Nurse was asked when she identified a wound, how were her findings communicated to the staff. The Wound Nurse stated, .sometimes I don't write it down, I just keep it in my head . The Wound Nurse was asked why the skin inspection sheets documented that the skin was intact if Resident #50 had a wound on her right heel. The Wound Nurse stated, .there was nowhere to document. The Wound Nurse was asked if the physician had been notified on 5/28/18 when the wound was identified. The Wound Nurse stated, .no I just notified him today [6/26/18] . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's order. The DON stated, .I spoke with the CNA [Certified Nursing Assistant] last night, and she said there had been a dressing on it for quite some time, and [named Resident #50] said she [Wound Nurse] has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware [of the pressure ulcer] . The DON was asked if any of the administrative staff ever made rounds with the wound nurse. The DON stated, No .we used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable. There were inconsistencies of the description of the wound and when the physician was notifed by the Wound Nurse. The facility failed to perform an accurate skin assessment to identify a pressure ulcer, failed to notify the physician of the development of a new pressure ulcer for treatment orders and failed to accurately assess a reddened area before it deteriorated to a Deep Tissue Injury (DTI) resulted in actual Harm for Resident #50.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement effective fall prevention interventions for 1 of 8 (Resident #60) sampled residents. The failure of the facility to implement effective fall interventions resulted in actual Harm when Resident #60 fell after the malfunction of a chair alarm, and sustained a hip fracture which required surgical repair. The findings included: The facility's undated PERSONAL SAFETY ALARMS policy documented, .Personal safety alarms are used to alert that a resident who is at risk for falls .attempting to stand .get out of bed .or leave a desired area .All personal alarms and alert devices must be maintained in good working order at all times .The intent of personal safety alarms is immediate response to the sounding of an alarm to minimize the potential for a fall or injury .SPECIFIC PROCEDURE .Check the alarm to ensure it is in working order. If it is not working properly, check/replace the batteries. If still not working, lockout/tag out the device per facility policy and procure a working device immediately .Test the alarm to determine that the device chosen can be heard . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Vascular Dementia, Hypertension, Adjustment Disorder with Depressed Mood, Chronic Obstructive Pulmonary Disease, Rheumatoid Arthritis, Hyperlipidemia, Insomnia, Vitamin D Deficiency, and Palliative Care. Review of the quarterly Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment, and Resident #60 had 2 or more falls with no injury since admission and required assistance with transfers. The care plan dated 11/23/17 documented, .at risk for falls r/t [related to] impaired balance during transitions and poor safety awareness .Approaches .5/21/2018 .chair alarm added to alert staff of resident getting up unassisted . A FALL RISK EVALUATION (an assessment completed by nursing staff to assess the resident's potential to fall) revealed Resident #60 was at high risk for falls on 5/11/18. High risk for falls was a score of 10 or higher. A facility Resident Incident Report dated 5/21/18 documented, .Incident type .Fall .Immediate Actions Taken .apply bed/chair alarm . A physician's telephone order dated 5/21/18 documented, .Bed/chair alarm applied to alert staff of resident attempting to get up unassisted . A facility Resident Incident Report dated 5/24/18 at 7:30 AM, documented, .Incident type .Fall .RECOMMENDATIONS/INTERVENTIONS .Evaluation of foot wear, alarm replaced . A facility Teachable Moment dated 5/24/18 at 11:00 AM, documented, .Make sure .alarm working properly . A facility Resident Incident Report dated 5/24/18 at 11:30 AM, documented, .Incident type .Fall .Type of Injury .Fracture .Witness .[named Witness #1] . A physician's telephone order dated 5/24/18 at 12:00 PM, documented, .Send to [named hospital] ER [emergency room] .d/t [due to] fall w/ [with] c/o [complaint of] pain to (R) [right] hip/leg, arm [and] head . A hospital radiology report dated 5/24/18 at 12:47 PM, documented, .Right intertrochanteric fracture . A physician's telephone order dated 5/24/18 at 2:30 PM, documented, .Transfer to [named hospital] for admission d/t (R) hip fracture . Observations in Resident #60's room on 6/25/18 at 10:17 AM, 11:47 AM, and 3:25 PM, on 6/26/18 at 2:26 PM and 4:49 PM, and on 6/27/18 at 8:02 AM, revealed Resident #60 lying in bed, was non-ambulatory, and required staff assistance for activities of daily living. Resident #60 fell on 5/21/18, and the new intervention was to use of bed/chair alarm. The resident fell on 5/24/18, at 7:30 AM, and a new intervention was to replace the chair alarm due to alarm malfunction. Resident #60 fell again 4 hours later on 5/24/18 at 11:30 AM. The chair alarm did not sound, and the fall resulted in a right hip fracture which required surgical repair for Resident #50. Telephone interview with Witness #1 (Not facility staff) on 6/27/18 at 8:55 AM, Witness #1 was asked if she remembered the incident when Resident #60 fell on 5/24/18. Witness #1 stated, Yes .She [Resident #60] was in her wheelchair, and she got up and walked toward the nurses' desk. When she got to the corner, she started to stumble. She reached out to the med [medication] cart, the med cart rolled, and she went down to the ground . Witness #1 was asked if the alarm sounded when Resident #60 got up from her wheelchair. Witness #1 stated, I didn't hear anything. Telephone interview with Witness #2 (Not facility staff) on 6/27/18 at 9:02 AM, Witness #2 was asked if she remembered the incident when Resident #60 fell on 5/24/18. Witness #2 stated, Yes .She [Resident #60] was walking toward the nurses' station, and she lost her balance, stumbled backward and tried to grab onto the med cart. The med cart wheels weren't locked, and she just kind of went down as it rolled. Witness #2 was asked if any kind of alarm sounded. Witness #2 stated, No. Interview with Registered Nurse (RN) #1 on 6/27/18 at 3:25 PM in the lobby, RN #1 was asked what happened when Resident #60 fell on 5/24/18 and fractured her hip. RN #1 stated, I wasn't on the hall when she fell, and by the time I got back there, she was already on the floor right in front of the nurses' station. RN #1 was asked if the chair alarm was sounding when he got to the hall. RN #1 stated, No. RN #1 was asked if the chair alarm was in place. RN #1 stated, Yes. The pad was in the chair and hooked up .I looked at the alarm, took it out of the chair, pressed on it and let go. Half the time the alarm would go off, and half the time it wouldn't .as far as we could tell the pad was faulty . Interview with the DON on 6/27/18 at 8:17 AM in the Administrator's office, the DON was asked if the facility has Patients at Risk meetings. The DON stated, .We have at risk meetings every Thursday. We go over falls, wounds and everything . Interview with the Director of Nursing (DON) on 6/27/18 at 9:50 AM, in the Administrator's office, the DON was asked who replaced the faulty chair alarm after Resident #60's fall on 5/24/18 at 7:30 AM. The DON stated, I think [named Central Supply Employee] checked it that morning, and it was working appropriately then . Interview with the Central Supply Employee on 6/27/18 at 9:21 AM, in the Administrator's office, the Central Supply Employee was asked how often she checked alarms. The Central Supply Employee stated, Daily .first thing in the mornings . The Central Supply Employee was asked if she had replaced the chair alarm for Resident #60 after the fall on 5/24/18 at 7:30 AM. The Central Supply Employee confirmed she did not replace it. Interview with the DON on 6/27/18 at 6:35 PM, in the Administrator's office, the DON was asked if she was aware that the chair alarm that was placed on 5/21/18 for Resident #60 was not working on 5/24/18. The DON stated, Isn't that the one in the recliner? The DON was asked if Resident #60 would have 3 alarms, one for the bed, one for the wheelchair, and one for the recliner. The DON stated, They usually can have one for the bed and one for the chair. The DON was asked if the staff would have used the same alarm for the recliner and the wheelchair. The DON stated, Yes . The DON was asked what staff should do if the alarm is not working. The DON stated, Go to the supply room and get them . The DON was asked what happens after hours for Central Supply needs. The DON stated, They can still go in and get them, and they leave her a note. Interview with the Central Supply Employee on 6/27/18 at 6:38 PM, in the Administrator's office, the Central Supply Employee was asked if the nursing staff had left her a note about a faulty chair alarm, or that they had taken one for Resident #60 that morning. The Central Supply Employee stated, No. The facility failed to implement effective fall interventions, which resulted in actual Harm to Resident #60.

Based on review of the Administrator's Job Description and the Director of Nursing's (DON) Job Description, and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of the residents, when they failed to recognize an ongoing concern with pressure ulcers and falls. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 2 (Residents #50) sampled residents with pressure ulcers. The failure of the facility to be effectively and efficiently administered resulted in actual Harm to 1 of 8 (Residents #60) sampled residents reviewed for falls. The administration failed to ensure skin assessments were ongoing and accurate, failed to ensure pressure ulcers were identified timely, failed to ensure the physician was notified timely of a pressure ulcer, and failed to ensure wound treatments were ordered by the physician prior to treatment initiation. Administration failed to ensure an effective fall prevention program, when an implemented fall intervention for use of a chair alarm was not functioning properly, and resulted in a fall with a hip fracture, which required surgical repair. The findings included: Review of the Administrator's Job Description documented, .The primary purpose of your job position is to direct the day-to-day functions of the facility .Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies .Review and check competence of work force and make necessary adjustments/corrections as required or that may become necessary .Assist the Medical Director in the development and implementation of medical and nursing services and procedures and professional standards of practice .Ensure that the facility is maintained in a clean and safe manner for resident comfort and convenience by assuring that necessary equipment and supplies are maintained to perform such duties/services . Review of the DON's Job Description documented, .The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department .Develop a written plan of care .for each resident that identifies the problem and needs of the resident .Ensure that all personnel involved in providing care to the resident is aware of the resident's care plan .Ensure that nursing personnel refer to the resident's care plan prior to administering daily care to the resident .Review nurses' notes to determine that the care plan is being followed .Ensure that resident assessment information is transmitted on a timely basis .Review and revise care plans and assessments as necessary but at least quarterly . Interview with the DON on 6/27/18 at 7:51 AM, in the Administrator's office, the DON was asked how many falls had she investigated. The DON stated there had been 47 falls in the past 3 months. The DON was asked if the number of falls in the past 3 months was a concern. The DON stated, Yes ma ' am .47 is pretty low for 3 months . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's order. The DON stated, .I spoke with the CNA [Certified Nursing Assistant that was assigned to Resdient #50] last night, and she said there had been a dressing on it for quite some time, and [named Resident #50] said she [Wound Nurse] has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware [of the pressure ulcer] . The DON was asked if any of the administrative staff ever made rounds with the wound nurse. The DON stated, No .We used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable that Resident #50's pressure ulcer was not assessed or that the physician was not notified timely. Interview with the DON on 6/27/18 at 6:35 PM, in the Administrator's office, the DON was asked if she was aware the chair alarm that was placed as a fall intervention on 5/24/18 was not functioning when Resident #60 fell again on 5/24/18. The DON confirmed she was not aware. The DON was asked whether she expected previous fall interventions to be documented as effective or not in use on subsequent fall investigations. The DON stated, Yes, but I was not aware it was not working . Interview with the Administrator on 6/27/18 at 7:43 PM, in the Administrator's office, the Administrator was asked who was responsible to ensure the wound assessments were completed. The Administrator was unable to answer, and stated, That is something they discuss in their nursing meetings, not in our stand-up meetings. The Administrator was asked if the DON was responsible for ensuring the physician was notified of wounds, and that wound assessments were completed. The Administrator stated, Well, we both are, I guess. The Administrator was asked how she became informed of new wounds in the building. The Administrator stated, That would be clinical. They have their nurse meeting here, and sometimes I listen in if I'm not on a call .Also I attend their at-risk meetings held on Thursdays. The Administrator was asked if the physician had been notified of the missed wound assessments. The Administrator stated, I didn't talk to him. I don't know . The Administrator was asked who notified the Medical Director. The Administrator stated, I'm not sure. I'll have to ask [named the DON]. Administration failed to ensure nurses provided and documented wound assessments for pressure ulcers, failed to revise the care plans to reflect the residents' current status for pressure ulcers, and failed to notify the physician of pressure ulcers, resulting in actual Harm to Resident #50. Refer to F580, F659, and F686. Administration failed to ensure an effective fall prevention program, which resulted in actual Harm to Resident #60 when an implemented fall intervention for use of a chair alarm was not functioning properly, and resulted in a fall with a hip fracture, which required surgical repair. Refer to F689. Administration failed to ensure the Quality Assessment and Assurance (QAA) Committee identified the system failures related to pressure ulcers and falls and implemented corrective actions with ongoing monitoring. Refer to F867.

Based on facility policy review, medical record review, observation and interview, the facility's Quality Assessment and Assurance (QAA) Committee failed to have an effective, ongoing quality program that identified, developed, implemented and monitored appropriate plans of action for pressure ulcers and falls. The QAA Committee failure to ensure an effective pressure ulcer prevention and treatment system resulted in actual Harm for Resident #50 when she developed a pressure ulcer to the right heel on 5/28/18, and the facility's Wound Nurse failed to assess the wound, failed to notify the physician, failed to revise the care plan related to the pressure ulcer, and initiated wound treatments without a physician's order. The QAA committee's failure to ensure an effective fall prevention system (an effective process to reduce patient falls) resulted in actual Harm for Resident #60. The chair alarm intervention implemented for Resident #60 was not functioning properly, and resulted in a fall with a hip fracture, which required surgical repair. The findings included: The facility's Quality Assurance and Performance Improvement (QAPI) Committee policy dated 7/16, documented, .The facility shall establish and maintain a Quality Assurance and Performance Improvement (QAPI) Committee that oversees the implementation of the QAPI Program .The Administrator shall delegate the necessary authority for the QAPI Committee to establish, maintain and oversee the QAPI program .The committee shall be a standing committee of the facility, and shall provide reports to the Administrator and governing board .The primary goals of the QAPI Committee are to .Establish, maintain and oversee facility systems and processes to support the delivery of quality of care and services .Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately . The facility's Quality Assurance and Performance Improvement (QAPI) Program policy dated 4/14, documented, .The facility shall develop, implement, and maintain an ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) program that builds on the Quality Assessment and Assurance Program to actively pursue quality of care and quality of life goals .The primary purpose of the Quality Assurance and Performance Improvement Program is to establish data-driven, facility-wide processes that improve the quality of care, quality of life and clinical outcomes of our residents .The program is ongoing and comprehensive .Systems are in place to monitor care and services .Adverse events are tracked, monitored, and investigated as they occur .Actions plans are implemented to prevent recurrence or adverse events .Gathering and using QAPI data in an organized and meaningful way .Areas that may be appropriate to monitor and evaluate include .Clinical outcomes .pressure ulcers .falls .Taking systematic action targeted at the root causes of identified problems .This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing . The QAA Committee failed to ensure the facility's pressure ulcer program was effective. The QAA committee failed to effectively track, trend and monitor the effectiveness of the pressure ulcer prevention program, failed to ensure care plans were revised to reflect residents current wound status, and failed to ensure the physician was notified timely of changes in resident status related to pressure ulcers. Refer to F580 F659, and F686 Interview with the DON on 6/27/18 at 7:51 AM, in the Administrator's office, the DON was asked who was ultimately responsible for ensuring nurses do the wound assessments. The DON stated, That would be me . The DON was asked what role the Administrator played in the clinical oversight of the facility. The DON stated, She is involved in all of our meetings . The DON was asked how the Medical Director was involved in management of wounds in the facility. The DON stated, We fax him, and we pick up the phone and call him. The DON was asked how the Medical Director was involved with fall management at the facility. The DON stated, I go over the trends and interventions at the QA [Quality Assurance] meeting. The DON confirmed the Medical Director reviewed and signed all incident reports. The DON was asked if she felt the facility's 47 falls documented for the past 3 months were a concern. The DON stated, Yes ma'am. I see every fall as a concern. But I also want to give all my patients as much as independence as possible .47 [falls] is pretty low for 3 months . Interview with the Director of Nursing (DON) on 6/27/18 at 8:17 AM, in the Administrator's office, the DON was asked if it was acceptable that Resident #50's pressure ulcer was not assessed, or that the physician was not notified of the pressure wound from 5/28/18 until 6/26/18. The DON confirmed the Wound Nurse was aware of the pressure ulcer on Resident #50's right heel, and failed to notify the physician, and that the Wound Nurse initiated treatments without a physician's order. The DON stated, .I spoke with the CNA [Certified Nursing Assistant] last night, and she said there had been a dressing on it for quite some time, and [named Resident #50] said she [Wound Nurse] has been treating it for quite some time .I'm not sure why the weekly skin assessment didn't show it, because it was there when the skin assessment said it was intact .none of the rest of us were aware [of the pressure ulcer] . The DON was asked if any of the administrative staff ever make rounds with the wound nurse. The DON stated, No .we used to make rounds, and that just fell by the way . The DON confirmed it was not acceptable. Interview with the Administrator on 6/27/18 at 7:43 PM, in the Administrator's office, the Administrator was asked who was responsible to ensure the wound assessments were completed. The Administrator was unable to answer, and stated, That is something they discuss in their nursing meetings, not in our stand-up meetings. The Administrator was asked if the DON was responsible for ensuring the physician was notified of wounds, and that wound assessments were completed. The Administrator stated, Well, we both are, I guess. The Administrator was asked how she became informed of new wounds in the building. The Administrator stated, That would be clinical. They have their nurse meeting here, and sometimes I listen in if I'm not on a call .Also I attend their at-risk meetings held on Thursdays. The Administrator was asked if the physician had been notified of the missed wound assessments. The Administrator stated, I didn't talk to him. I don't know . The Administrator was asked who notified the Medical Director. The Administrator stated, I'm not sure. I'll have to ask [named the DON]. The QAA Committee failed to ensure the facility's fall prevention program was effective. The QAA committee failed to effectively track, trend and monitor the effectiveness of the fall prevention program. Refer to F689. The failure of the QAA to ensure an effective fall prevention program for a resident with severe cognitive abilities resulted in actual Harm to Resident #60 when she fell and sustained a hip fracture that required surgical repair.