**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 7 residents (Resident #1) reviewed for care provided. The facility failed to ensure Resident #1's surgical incision on his ankle was properly assessed and received physician ordered daily dressing changes. The facility failed to ensure a physician ordered wound vac, gently pulls fluid from a wound over time, was placed on Resident #1's surgical incision to help with healing. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/19/23 at 2:24 p.m. While the IJ was lowered on 10/20/23 at 10:42 a.m., the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. This facility failure led to Resident #1 being sent to the hospital with his left leg red, swollen and warm to touch which resulted in the resident being admitted to ICU for sepsis and left ankle wound with tendons exposed and mild swelling of the entire area with redness up to the knee. Findings Included: Record review of Resident #1's face sheet in his clinical record revealed the resident admitted to the facility on [DATE], was [AGE] years old with the following diagnoses: cellulitis of left lower limb (bacterial skin infection), dementia without behaviors, psychotic and mood disturbances, anxiety, atrial fibrillation (irregular, often fast heart rate), peripheral vascular disease (narrow blood vessels reduce blood flow to the limbs), COPD (airflow limitation), MRSA (severe staph infection), depressed mood, varicose veins (twisted, rough, enlarged veins), Chronic Kidney disease, cardiac pacemaker (prevents the heart from beating too slow), angina pectoris (chest pain), glaucoma (can cause vision loss), hypothyroidism (deficiency of thyroid hormones), diabetes (too much sugar in the blood), hearing loss, reflux, hypertension (high blood pressure), osteoporosis (weak and brittle bones), history of prostate cancer. Record review of Resident #1's face sheet indicated that his family member was his responsible party and medical power of attorney. Record Review of Resident #1's care plan, dated 9/8/23, documented the resident had cellulitis infection and was being treated with antibiotics and the facility should have monitored the incision/wound for increased signs of infection: swelling, drainage, redness, pain and warmth. The care plan documented the resident was resistive to care and did not want to change clothes when visibly soiled despite education, call family member if resident continues to refuse, educate resident/family /caregivers of the possible outcome(s) of not complying with treatment or care. Record review of Resident #1's quarterly/Medicare 5-day MDS resident assessment, dated 9/13/23, documented the resident had a BIMS score of 4 of 15, indicating severe cognitive impairment. The MDS assessment indicated that Resident #1 required limited assistance from staff for ADLs and had limited range of motion of one lower extremity. Record review of Resident #1's clinical record revealed that on 10/5/23, Resident #1 had surgery at Hospital A to remove a cancerous lesion on his left ankle. The surgical incision was left open and packed. Resident #1 returned to the facility with wound care orders for daily dressing changes. The orders sent to the facility with Resident #1 stated: daily dressing change left ankle: flush with NS or wound cleanser, lightly pack with iodoform gauze covered with gauze secured with kerlex and ace bandage as tolerated; keep left lower extremity elevated as much as possible. Record review of Resident #1's clinical record revealed the following physician orders for wound care: 10/5/23 -left ankle - clean with wound cleaner/normal saline, lightly pack with iodoform gauze then cover with gauze then wrap with Kerlex and ace bandage/coban as tolerated. Change daily. Keep left foot elevated as much as possible. 10/10/23 - continue with current orders until wound vac arrives then begin wound vac to lower left medial aspect. Cleanse with wound cleanser, apply wound vac at 125 mmhg continuous. Record review of Resident #1's clinical record revealed the following weekly skin assessments: 9/15/23 - completed by RN I - Resident's lower legs are wrapped. He did not want them messed with at this time. 9/21/23 - completed by RN I - Resident said he just went to the wound care doctor and did not need his dressing changed at this time so I could not unwrap his legs. 9/28/23 - no skin assessment documentation was found in Resident #1's clinical record for this date 10/5/23 - completed by WCN - wounds to bilateral feet 10/11/23 - Left lower dressing clean, dry and intact, bilateral lower extremities multiple scabs dry Record review of nurses notes in Resident #1's clinical record documented the following: 10/12/23 at 2:17 p.m. - Resident stated that the VA just did it (dressing change), left messaged {sic}for physician to be notified about Veteran's refusal of wound care at facility. Awaiting return call for new orders. Documented by WCN. 10/13/23 at 11:08 a.m. - tramadol oral tablet 50 mg - give one tablet by mouth every 8 hours as needed for pain. Resident complaining of pain in foot, nurse is aware - documented by WCN 10/13/23 at 4:07 p.m. - After getting Veteran to his room and agreeing to place wound vac, Veteran then changed his mind and would not let this nurse even removed old bandages. Attempted three times, will reapproach tomorrow.- documented by WCN 10/13/23 at 4:09 p.m. - would not let this nurse remove old bandages after agreeing and getting to his room. Attempted three times. Will reapproach tomorrow. - documented by WCN 10/13/23 at 6:19 p.m. - resident complained of pain to left foot, when asked it foot could be assessed, resident refused and stated. It's all bandaged up and we will have to take everything off and rewrap it again and it will just be a hassle. This nurse told resident we would need to make sure there was not an infection. Resident refused again on letting this nurse remove and assess wound. Pain medication was administered and follow up was assessed. - documented by LVN A 10/14/23 at 4:20 p.m. - refused three times - documented by the WCN 10/15/23 at 7:51 a.m. - resident was discovered on the floor. This nurse assessed resident, no injury noted and vital signs are within normal limits. Resident denies any pain, resident stated the he lost his balance from the recliner to the wheelchair. This nurse assessed resident to the wheelchair, This nurse informed the ADON, NP and POA. Documented by LVN B 10/15 23 at 8:41 a.m. - Resident #1 was transferred to a hospital on [DATE] at 8:43 a.m. related to per {family member's} request since resident #1 does not have a wound vac and has increased confusion. Documented by LVN B Record review of Hospital records concerning Resident #1's History and Physical dated 10/15/23 revealed the resident came to the emergency room as a transfer from the Hospital A due to elevated troponin levels (a protein that's released into the bloodstream during a heart attack). The resident presented to Hospital A with lethargy and weakness. The resident has dementia and was unable to provide a history. The family member was present to help provide the history. The family member states that the resident was recently found to have an ankle wound of his left lower extremity that was discovered to have squamous cell cancer. The resident had excision of the cancer and has been at the skilled nursing home for treatment. The resident was supposed to have a wound vac in place and it was ordered for the resident but the family member says that the staff lost it and the resident has been without the wound vac or treatment of the ankle wound. The family member saw the resident on Thursday (12th) and he was doing fine but upon seeing him today, she noticed that there was some redness around the ankle extending all the way up to the knee that she did not see before. While at Hospital A, the resident was found to have a troponin of 1900 (considered elevated level about 40 ng/L). A PICC line was placed and patient sent to Hospital B. Prior to this evaluation, his blood pressure dropped as low as 64/51. Physical Examination: Extremities: left ankle wound with tendons exposed. Mild swelling of the entire area with redness changes spreading up to the knee. During a confidential interview on 10/17/23 at 12:19 p.m., CI stated the facility had orders to change the dressings on Resident #1's left foot every day and to have a wound vac placed on his foot. CI stated Resident #1 was in ICU at that time with severe dehydration and a bad urinary tract infection. CI stated she went to the facility on Sunday (10/15/23) and as soon as she saw Resident #1, she knew something was not right. CI stated Resident #1's leg was swollen, puffy and it was warm to touch. CI stated his eyes were glassed over and he was not talking correctly. In addition, CI noticed the dressing on Resident #1's leg was dated 10/10/23 when the podiatrist changed the dressing. CI stated the nurse that was working on Sunday called her on Sunday after Resident #1 fell and the nurse told her that he had not seen a wound vac and there was not one on Resident #1's leg. CI stated, if Resident #1 was refusing care, why in the world did staff not call Resident #1's POA so the POA could talk to Resident #1 so he would get the care he needed? During an interview on 10/17/23 at 2:05 p.m., the DON stated the Wound Care Nurse who was out of the building right now but would be back shortly. The DON stated she knew that the nurses were doing really good documentation on Resident #1 refusing care and Resident #1 did not let the girls touch his leg at all. The DON stated Resident #1 was very non-compliant with receiving care. During an interview on 10/17/23 at 4:40 p.m., LVN C stated Resident #1 was his own person and if he told you he was not going to something, he was not going to do it. LVN C stated Resident #1 had been seeing a wound care doctor at Hospital A once a week, and he had a reaction to the antibiotic so they had to change the antibiotic. LVN C stated Resident #1 had poor circulation in his legs and always hasdtrouble with wounds on his legs but the wound care orders were daily but he always refused care. During an interview on 10/18/23 at 8:35 a.m., ADON D stated she took care of Resident #1. ADON D stated Resident #1 was a very sweet man but if he did not want to do something, he was not going to do it. ADON D stated she had not taken care of Resident #1 during the day but one night, she did and his bandages were clean, dry and intact. During an interview on 10/18/23 at 9:30 a.m., MA E stated Resident #1 was on her hall and always refused showers but they did their best to get him in the shower. MA E stated she has never helped with Resident #1's wound care. MA E stated if Resident #1 refused dressing changes, she would have reported that to the DON and put it in the computer. MA E stated if Resident #1 refused to do something, the nurse should have called his family member so she could talk to him and they also should be reporting it in the computer. During an interview on 10/18/23 at 9:45 a.m., RN F stated she had taken care of Resident #1 and he was in his 90's and he followed commands but he really did not want anyone to help him. RN F stated she had not done any wound care for Resident #1 after he had the procedure. RN F stated they had a wound care nurse and she was supposed to be changing his dressing and on the weekends, the nurse was responsible to do dressing changes. RN F stated she remembered seeing an order for a wound vac but after that she had not taken care of him. During an interview on 10/18/23 at 10:00 a.m., CS G stated Hospital A ordered the wound vac for Resident #1 and it came in last Thursday 10-12-23. CS G stated she told the WCN later that day that the wound vac came in and it was kept in her office. CS G stated she felt WCN tried to put the wound vac on Resident #1 that day and she brought it back in her office because she did not want to leave it at the nurses station. During an interview on 10/18/23 at 10:15 a.m., the DON stated Resident #1 was one of the projects that she took on and COVID did a number on his mental capacity. The DON stated Resident #1 got even more standoffish and he did not like to come out of his room. The DON stated Resident #1 was allergic to several medications and they had to send him to the hospital due to a reaction. The DON stated a new order came from the VA on the 10th for a wound vac and the WCN went down to Resident #1's room to put his wound vac on and he refused. The DON stated she thought the WCN went down to Resident #1's room four times wanting to look at his legs and Resident #1 refused and he fell on Sunday and was sent out to the hospital. The DON stated Resident #1 was always refusing dressing changes but he gets his dressing changed at the VA every week. The DON stated if a resident refused dressing changes for a few days, they would send the resident to the hospital. The DON stated the family should have been called and notified of Resident #1 refusing the wound vac and dressing changes. During an interview on 10/18/23 at 3:25 p.m., the WCN stated she had taken care of Resident #1. The WCN stated Resident #1 refused care because his ankle hurt him too bad. The WCN stated she had changed Resident #1's dressing two or three times after his procedure on the 5th. The WCN stated Resident #1's wound care order was changed to daily dressing changes on 10/5/23. The WCN stated she would call the doctor if there was a change of condition but Resident #1 did not have a change of condition. The WCN stated she called the VA and left a message for the doctor because Resident #1 was refusing dressing changes but she never received a call back. The WCN stated she looked back in the record and he had refused dressing changes frequently. The WCN stated she was Resident #1's wound care nurse on Friday and Saturday, she was Resident #1's actual nurse that day. The WCN stated Resident #1 was not complaining about any pain on Friday or Saturday. The WCN stated it was Resident #1's right to refuse care and dressing changes and she could not force Resident #1 to have his dressing changed. During an interview on 10/18/23 at 4:00 p.m. LVN H stated if she had a resident that kept refusing dressing changes, she would call the doctor and the family member and tell them about the resident's refusal. LVN H stated, How can you do a good skin assessment if you don't look under the dressing and see what was going on with the wound. LVN H stated if she had a resident with a bandage, she was going to look under it to see what the wound was doing. During an interview on 10/18/23 at 4:35 p.m., LVN A stated she attempted to change Resident #1's dressing on Friday (13th) because his foot was hurting and she needed to check on the wound but he refused. LVN A stated Resident #1 said changing his bandage would be a hassle. LVN A stated she remembered calling Resident #1's family member when he refused a shower but she finally got him to take a shower. LVN A stated if she had a resident who was refusing to have dressings changed, she would notify the ADON of the refusal. LVN A stated she did give Resident #1 a PRN pain medication for the pain he was having in his foot. An observation on 10/19/23 at 8:20 a.m. at Hospital B revealed Resident #1 lying in bed. Resident #1 was sitting up in bed, eyes blinking but seemed blurry, wearing glasses, wound vac on left foot and it was covered with a grippy sock and his left foot was twice the size of his other foot and there was a lot of yellowish fluid in the container on the wound vac and he had and IV fluids running continuously. During an interview on 10/19/23 at 11:25 a.m., when asked what her expectations when a resident refused dressing changes, the DON stated the nurse should have contacted the physician and family about the refusal and the sent the resident to the hospital. During an interview on 10/19/23 at 11:52 a.m., the Administrator stated the facility did not have a specific policy for when a resident refuses care or if they have a low BIMs score or are incompetent , they just follow the Resident Rights. During an interview on 10/19/23 at 12:15 p.m., Resident #1's primary physician stated apparently Resident #1 was refusing his dressing changes. Resident #1's primary physician stated the last time he saw Resident #1, he had some edema so he started him on Lasix (diuretic). When asked if he should have been notified of Resident #1 refusing dressing changes, the physician stated his expectation would be for the nurse to contact him if a resident was refusing dressing changes. During a call back on 10/19/23 at 12:25 p.m., Resident #1's primary physician stated he had just reviewed Resident #1's nurses notes and found where they had attempted to contact the doctor at Hospital A but they never reached out to him. During an interview on 10/19/23 at 12:35 p.m., Hospital A NP stated she honestly only assisted when Resident #1 has surgery on his ankle. Hospital A NP stated they should have called someone when Resident #1 was refusing dressing changes. During a follow-up interview on 10/19/23 at 12:45 p.m., Hospital A NP called back and stated she found documentation on 10/10/23 when Resident #1 came to Hospital A for a dressing change, the doctor had ordered a wound vac and documented the wound was worse. During an interview on 10/19/23 at 1:20 p.m., LVN B stated he did not usually take care of Resident #1 but the aide that morning (Sunday) informed him that Resident #1 was not eating and not feeling well and said his chest was hurting. LVN B stated Resident #1 had fallen that morning and he assessed him and notified Resident #1's family member of the fall. LVN B stated when Resident #1's family member arrived at the facility, she immediately asked about dressing changes and wanted to know where the wound vac was because it was not on his ankle. LVN B stated he checked the medication room and the main lobby and the mail room and he could not find a wound vac anywhere. LVN B stated Resident #1's leg was very red, swollen and warm to touch and he was very confused. LVN B stated he called the NP and informed her that Resident #1 did not have a wound vac in place and his ankle was very painful. LVN B stated Resident #1's family member said to send him to the hospital but he called the NP back and informed her of the need and the NP said to send Resident #1 out so he sent him to the hospital. LVN B stated he did not know that Resident #1 was refusing dressing changes. LVN B stated if a resident refused dressing changes, he would notify the family and the physician to see what needs to be done next. LVN B stated the resident does have the right to refuse but there was a risk when they do that and usually when staff or family talk to the resident, the resident will comply. Record review of Wound Treatment Management Policy, copyright 2021, documented the following: Policy: To promote wound [NAME] of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 5. Treatment decisions will be based on: a. Etiology of the wound: i. pressure injuries will be differentiated from non-pressure ulcers, such as arterial, venous, diabetic, moisture or incontinence related skin damage. ii. Surgical iii. Incidental (i.e. skin tear, medical adhesive related skin injury). iv. Atypical (i.e. dermatological or cancerous lesion, pyoderma calciphylaxis). b. Characteristics of the wound: i. Pressure injury stage (or level of tissue destruction if not a pressure injury). ii. Size - including shape, depth and presence of tunneling and /or undermining. iii. Volume and characteristics of exudate. iv. Presence of pain. v. Presence of infection or need to address bacterial bioburden. vi. Condition of the tissue in the wound bed. vii. Condition of peri-wound skin. c. Location of the wound. d. Goals and preferences of he resident/representative. 6.c. The facility will follow specific physician orders for providing wound care. 7. Treatments will be documented on the Treatment Administration Record. 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound On 10/19/23 at 2:24 p.m., the Administrator was notified that an Immediate Jeopardy (IJ) had been identified. IJ templates were provided and a Plan of Removal was requested. The Facility's Plan of Removal (as follows) was accepted on 10/19/23 at 5:14 p.m. Plan of Removal Problem: Failed to Provide dressing changes Interventions: - 100 % skin rounds completed by 5 pm today on 10/19/23 by Administrative Nurses and Corporate Compliance Nurses. No additional skin issues noted. - The following in-services were initiated by Regional Compliance Nurse on 10/19/23: Any nurse not present or in-serviced on 10/19/23 will not be allowed to assume their duties until in-serviced. All newly hired staff will be in-serviced prior to taking an assignment. Licensed Nurse: - Wound prevention and treatment including providing treatment as ordered (wound vac) and initialing/dating dressing. - Documentation and accurate assessment of wounds. Including wound vac use and functioning. - Notification of Physician with change of condition or refusal of care immediately and if physician does not respond timely, notify Medical Director. - Refusal of care for residents who have decreased BIMs score or continued refusal of care. - Negotiated risk assessment and family notification - SBAR completion for physician and family notification of refusals - Social services will be notified of residents with continual refusal of care to address any psychosocial or cognitive issues. NA/CNA - Who to notify for refusal of care - Where to document refusal and notification of charge nurse The Medical Director was notified of the potential immediate jeopardy situation on 10/19/23 at 10:53 a.m. and off cycle QAPI was completed. Monitoring -The DON/designee will conduct wound rounds each wound weekly x 4 weeks. Monitoring will start 10/19/23. -The DON/designee will audit 10 skin assessments weekly to ensure all assessments match the resident's currently condition weekly x 4 weeks. Monitoring will start 10/19/23. -DON/designee will validate all wounds have treatment orders in place weekly x 4 weeks. Monitoring will start 10/19/23. -DON/designee will monitor for refusals of care using SBAR and follow up with family and physician 5 x weekly x 4 weeks. Monitoring will start 10/19/23. -Regional Compliance Nurse will monitor DON/Designee for monitoring compliance weekly x 4 weeks. Monitoring will start 10/19/23. -The QA committee will review the findings and make changes as needed monthly. Monitoring of the Plan of Removal included: On 10/20/23 at 8:10 a.m., the Administrator and DON were at the front door in-servicing staff who were not contacted prior to that day. The Administrator stated all staff who were working on the floor were in-serviced before starting their day. During interviews with facility staff conducted on 10/20/23 from 8:10 a.m. to 10:05 a.m., 42 of 52 nursing staff members verified that they had received in-service training covering change of condition, refusing care and reporting findings. All staff interviewed acknowledged and demonstrated understanding of the topics covered in the inservice training. The following staff were interviewed: DON, 6 LVNs, 2 ADONs, 2 Medication Aides, 1 Regional Nurse, 1 VP of the company, 3 Hospitality Aides, 2 CNAs, 1 RN, 1 SW and 1 COTA. An observation on 10/20/23 at 8:20 a.m., on a laptop on the 200 hallway had documented; Refusal of care of Change of condition: Did you notify the provider, did you receive a response, did you notify family and did you start an SBAR. An observation on 10/20/23 at 9:20 a.m., revealed on each hallway by the CNAs station and on every lap top, there was a posting that documented the following: Refusal of Care or Change in Condition: 1. Did you notify the Provider? 2. Did you receive a response? 3. Did you notify family? 4. Did you start a SBAR? Record review and an interview with the administrator on 10/20/23 at 10:15 a.m. Reviewed the binder the Administrator provided with all the in-serviced conducted so far. The Administrator stated staff that come into work at 2:00 p.m. and 11:00 p.m. today will be in-serviced as the arrive for work and will not clock in until they have been in-serviced. 1. The first section was labeled Plan of Removal and contained the accepted POR and the IJ Templets. 2. The second section was labeled In-Services which covered the following areas: a. Negotiated risk agreement - education a resident/family would be provided for refusals or negative behavior. 40 staff signatures b. Wound Prevention Strategies - 39 staff signatures c. Physician and family communication of condition change - 32 staff signatures d. Abuse/Neglect - 41 staff signatures 3. Follow up questions for staff concerning the in-serviced - 42 staff signatures 4. Skin assessments - 73 resident assessments 5. Posted notification - refusal of care or change in condition Monitoring sheets - will be used for monitoring by the facility On 10/20/23 at 10:42 a.m., the Administrator was informed the IJ was lifted as of 10:42 a.m. While the IJ was lowered, the facility remained out of compliance at a level of actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems.