**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure unnecessary pressure wasn't caused by Resident #1's knee immobilizer to Resident #1's left posterior ankle/calf and left lateral leg which caused an unstageable pressure injury and left lateral leg unstageable pressure injury from a medical device. An Immediate Jeopardy (IJ) situation was identified on 2/22/2023 at 5:21 PM. While the IJ was removed on 2/23/2023 at 4:07 PM, the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems. This failure placed residents at risk for improper wound management, the development of new pressure ulcers, deterioration, infection, pain, loss of limb, or death. Findings include: Record review of Resident #1's electronic face sheet, dated 12/29/2023, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included: displaced supracondylar fracture without intercondylar extension of lower end of right femur (Supracondylar femoral fracture (also called a distal fracture) is when the thigh bone, or femur, is broken at the knee), hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), muscle weakness and lack of coordination. Record review of Resident #1's Initial MDS assessment, dated 1/2/2023, revealed a BIMS score was not obtained. Section G revealed Resident #1 required extensive assistance from two persons for bed mobility and toilet use; extensive assistance from two staff for locomotion on and off the unit, dressing, personal hygiene, and bathing; Limited assistance of two staff members for transfers. Section M revealed Resident #1 was at risk for pressure ulcers/injuries but did not have any. Record review of Resident #1's care plan, dated 12/24/2023, revealed resident has the potential for pressure ulcer development Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. Date Initiated: 12/24/2022. Ensure heels are floated with the use of pillows. Resident has a surgical site observe for s/s of infection (increased redness, increased pain, drainage, etc). Report to physician if noted. Record review of the hospital progress notes dated 12/16/2022 revealed Resident #1 was admitted to hospital on [DATE] due to a fall sustained at home which resulted in both femurs being fractured. Record review of the hospital progress notes, dated 12/18/2022, revealed Resident #1's skin assessment which indicated no wounds on the resident. The skin was normal appearing in texture and temperature, no rash, petechiae (are pinpoint, round spots that appear on the skin because of bleeding), or lesions noted. Record review of the hospital progress notes, dated 12/21/2022, revealed Resident #1 had Bilateral Supracondylar Fractures of the femur, operation completed, a long-leg compression bandages were applied in both lower extremities and knee immobilizers. Record review of the hospital progress notes, dated 12/23/2022, revealed Resident #1's was transferred from the hospital to Facility A on 12/24/23. Record Review of Resident #1 DR-C orders, dated 12/21/2023, did not indicate any removal or non-removal of knee immobilizers. Did not indicate anything with skin care. Orders were not clear. Record review of Resident #1's initial skin assessment, dated 12/24/2023, completed by LVN-D, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no. During an interview on 2/16/2023 at 3:15 PM, LVN-D stated she really couldn't remember about Resident #1 knee immobilizers. She stated she couldn't remember if the residents' braces were ever taken off. She stated she couldn't remember ever taking the residents braces off personally. She stated she could not remember removing or opening immobilizers to do the initial skin assessment. She stated that any device that is on a resident when they enter the facility should be removed to do an initial skin assessment, unless doctor orders specify to not remove the device. She stated this is done to know if the resident had any skin injury before being accepted into the facility. Record review of Resident #1's skin assessment, dated 12/31/2023, completed by RN-B, indicated skin color normal, skin temperature warm, bruising: no, skin tear: no, moisture associated skin damage: no, and does the resident have a pressure, venous, arterial, or diabetic ulcer: no. Attempted interview with RN-B on 2/16/2023 at 4:30 PM, 2/17/2023 at 10:25 AM, 2/21/2023 at 3:15 PM and 2/22/2023 at 11:45 AM were unsuccessful. No call back was received prior to exit on 2/23/2023. Record review of Resident #1 transfer order, dated 1/2/2023, indicated per family request resident was sent back to the hospital due to being confused and not acting like herself. Record review of the hospital progress notes, indicated on 1/3/23, ICU-E nurse notes that bilateral knee immobilizers and pressure prevention boots removed. ACE wrap/kerlex and Inconel original dressing removed. Multiple wound/skin abnormalities/pressure injuries noted; too numerous to count. Called for unit camera for detailed admission documentation, but one was not available. Upon my assessment I see: Left lateral foot deep tissue injury left posterior ankle/calf unstageable pressure injury, left lateral leg unstageable PI, left heel DTI with blood blister, Right heel Stage 1 PI, R posterior Upper thigh intact blood blister, posterior bilateral thighs DTI's, sacral and coccyx DTI's, L hip stage 2/open blister, multiple mid-back DTI's/Bruises. All present on admission. Family reports she had surgery on 12/21/22 and was discharged on 12/23/22 Attempted interview with ICU-E on 2/21/2023 at 3:45 PM, 2/22/2023 at 10:45 AM, and 2/23/2023 at 9:45 AM was unsuccessful. No call back was received prior to exit on 2/23/2023. Record review of the hospitals wound care notes, with pictures, dated 1/4/23, indicated 4 wounds total on left leg. Left posterior ankle/calf unstageable PI Measuring 9x2.5x0 (LxWxD in cm), Left lateral leg unstageable PI measuring 2.5x1.5x0.1, R posterior upper thigh intact blood blister, and posterior bilateral thigh DTI's. Record review of transfer orders dated 1/9/2023 revealed Resident #1 was transferred to Facility B on 1/10/2023 due to wounds. Record review of Resident #1 transfer order dated 1/25/2023, revealed Resident #1 was transferred back to the hospital on 1/25/2023 due to wounds. Record review of Resident #1's wound care notes, dated 1/25/2023, indicated: Left posterior Achilles/calf, wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 23x5x0.1 (previously it was 9x2.5x0), S/S of infection-Yes Assessment Notes: Under the care of DR-C in the nursing home. Wounds originally caused from knee immobilizer, worse than last admission. Record review of Resident #1 transfer order dated 1/27/2023 revealed Resident #1 was transferred back to Facility B on 1/27/2023 due to wounds. Record review of Resident #1 transfer order dated 2/13/2023 revealed Resident #1 was transferred back to the hospital on 2/13/2023 due to wounds. Record review of wound care notes, dated 2/13/2023, indicated: Left posterior Achilles/calf, wound condition-chronic, odor-yes, Unstageable pressure injury obscured full thickness skin and tissue loss, Measurement- 30x9x0.2 (originally it was 9x2.5x0) S/S of infection-Yes, Pain-4/10, Assessment Notes: DR-C consulted and per note no further surgical intervention. Need consult for wound care doctor to see patient. During an interview on 2/16/2023 at 11:15 AM, MR-A stated if the only wound care notes in her system were of the initial assessment on 12/19/2023 and there was nothing by the date of Resident #1's transfer on 12/24/2023 this indicated no wounds were formed/found on the resident by the time of discharge from the hospital. During an interview on 2/15/23 at 3:30 PM, the DON stated Resident #1 was only at the facility for 8 days. She stated the only thing she remembered about the resident was the resident was in double braces for both legs due to having a double hip fracture. She stated the resident had two leg braces on. She stated she never removed the leg devices while she was at the facility, to assess the skin. She stated she remembered because the two scheduled shower days while she was at the facility, she was due for showers and the braces were not removed. She stated the braces were not removed to do the shower, Resident #1 was wrapped in plastic from the waist to the lower legs to transfer to shower and give the resident her shower. She stated facility staff should have called the physician for the directions on if the braces should be removed or not, but we did not contact the physician. During a phone interview on 2/17/2023 at 4:45 PM, DR-C stated his expectation was Resident #1's braces should have been at least opened or removed for a skin assessment at the facility. He stated when Resident #1 left the hospital her skin was in good condition. He stated he was unaware the resident had skin wounds even when she got back to the hospital. During an interview on 2/16/2023 at 4:15 PM, the ADON stated if any resident came into the facility with a brace around any part of the body and a skin assessment was to be done, the brace should be removed. She stated she didn't remember Resident #1 directly but, in her case, if she came into the facility with braces on around both legs, they should have been removed to access the skin for the initial skin assessment when she was transferred from the hospital to their facility. She stated the first thing that should be followed was the doctors' orders. She stated if there were no doctors' orders the facility should reach out to the physician for the orders. Record review of the facility's policy, dated 2003, titled Immobilization Devices, Splints/Slings/Collars/Straps indicated: Goals 1. The resident will achieve safe and effective application of supportive immobilization devices. 2. The resident will maintain baseline neurovascular and skin integrity status. 3. The resident will be free from injury associated with immobilization devices. Procedure 1. Review physician's order. 1. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 2. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet. 3. Skin integrity should be assessed periodically when the device is removed. This was determined to be an Immediate Jeopardy on 2/22/2023 at 5:21 PM. The Administrator was notified. The Administrator was provided with the IJ template on 2/22/2023 at 5:21 PM. The following Plan of Removal was submitted by the facility was accepted on 2/23/2023 at 11:00 AM: Identified Concern: The facility failed to prevent the development of multiple avoidable pressure sores for one resident. [Resident #1] who was ordered bilateral knee immobilizers on 12/21/2022 related to fracture's resulting from a fall. From 12/24/2022 to 1/2/2023 both knee immobilizers were never removed to assess skin. On 1/2/2023 [Resident #1] was identified with multiple wounds to an area covered by the knee immobilizer on both legs . The following plan of action outlines immediate interventions employed by the facility to remove any further concerns surrounding the issues: Problem: Failure to prevent pressure injury Interventions: 100% skin rounds initiated 2/22/23 by DON, ADON, Treatment Nurse LVN-D. With RCN oversight. Assessment done for Resident #2, Resident #3 and Resident #4 (only other residents in house with braces of any kind. No immobilizers in house. Issues founded during skin rounds will be addressed, treatment orders will be obtained, ulcer assessment will be completed, and care plans updated. Families and physicians will be notified if any skin issues are found. Residents with immobilizers or braces have the potential to be affected by alleged deficient practice. The following in-services were initiated by the RCN 2/22/23: Any nurse not present or in-serviced on 2/22/23, will not be allowed to assume their duties until in-serviced. Ongoing In-service will be completed by DON/ADON/TREATMENT NURSE/OR RN Supervisor, until all staff, weekend, PRN, and agency staff in completed. The following in-services were initiated by the RCN 2/22/23 o Licensed Nurses: Pressure ulcer prevention and treatment. What to do when a resident is admitted with an immobilizer without orders to remove, when to remove and assess skin and check pulses. Licensed Nurses will have competency for performing skin assessments starting 2/22/23 by DON/RCN, and will continue until all staff is competent including, PRN, agency, and weekend staff is complete. The medical director [DR-F] (acting medical director while [DR-G] is unavailable due to being out of the country) was notified of the immediate jeopardy situation on 2/22/23 at 6:23 pm. Monitoring The DON/designee will monitor all new residents with immobilizers/braces to ensure orders are in place for removal of immobilizer per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. The DON / designee will view each pressure ulcer weekly X's 6 weeks suing available monitoring tool. The DON / designee will audit all skin assessments weekly to ensure all assessment match the resident's current condition for 6 weeks using current monitoring tool. DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks. DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks The QA committee will review findings at the monthly QA meeting and makes changes as needed. Monitoring of the POR included the following: During an interview on 2/23/2023 at 11:15 AM, RN-H (day shift) stated he did receive in-service that morning over immobilizers and devices on residents. He stated the in-service in detail was what to look for on the resident in skin assessments around a device and above and below the device if physician orders indicated to not remove the device, make sure there were physician orders in for every single device, if no there were no physician orders, do not make any assumptions about devices, make sure everything was spelled out in the doctor's orders on the details of removal or non-removal of the device, call physician if anything is no clear about the device and if it is allowed to be removed or not. During a phone interview on 2/23/2023 at 2:00 PM, CNA-I (night shift) stated she was part of both in-services last night, dated 2/22/2023. She stated it was over how to reposition a resident, which is every 2 hours, the signs and symptoms of infection such as tenderness, redness, warm, and smell/drainage. She stated if there was anything on a resident that was observed to inform the charge nurse immediately. She stated they were to make sure from the charge nurse or DON that orders were in the system from the physician on what was allowed to be removed or not removed before taking a resident to the shower. She stated if no orders were in the system she is to wait until DON or charge nurse reaches out to the physician for exact orders. Observation of LVN-D and the ADON revealed them completing skin assessment of Resident #2. The removable soft brace around the right knee was removed and skin was assessed by both nurses. The skin looked good, there was no breakdown, bruising or indentions within the skin where the brace was placed. Resident #2 did not complain in any way towards pain, tightness, or sensitivity. The braces were replaced back around the right knee and the resident went back to sleep. During an interview on 2/23/2023 at 2:15 PM DON stated that she is doing all the checks that are indicated in the PoR. She stated she is going around every 2 hours to ensure residents are being repositioned and that the staff understands everything in the two in-services given on 2/22/2023 at 8:15 PM. She stated she will be working with LVN-D who is the new wound care nurse to do all assessments which she would review on ever new resident. She stated she would be the one doing all checks in the facility from this point on especially new resident with devices. She stated that care plans were being reviewed for all residents with devices. During an interview on 2/23/2023 at 2:45 PM, CNA-J (day shift) stated she did get in-serviced the second she came into the facility. She stated it was over repositioning, skin checks, and wheelchair moving for residents. She stated she never messed with any devices unless it came to giving the resident a shower. She stated if this was a question, we go to our charge nurse or the DON for clarification on if the device needed to be removed or not before showering. She stated overall the in-service was on making sure the residents were being repositioned correct, in a timely manner. She stated that residents that need to be repositioned every 2 hours and if indicated as a 2 person assist, she should get help to do so. She stated that the in-service covered who to report if they saw anything unusual with the residents' skin, which includes tenderness, redness, heat, drainage, pain, etc. During a phone interview on 2/23/2023 at 3:45 PM, LVN-K (night shift) stated the in-services covered skin and devices. She stated the first thing nurses needed to look at if they had a resident with a device/immobilizer was if there were physician orders in the system that specifically stated if the devices were allowed to be removed or not. She stated if there were orders, and the device was allowed to be removed then it should be removed every couple of hours to access the skin to make sure everything looked good. She stated if the physician order stated do not remove the device the skin still needed to be accessed above and below the device for any infection, swelling, or signs of wounds. She stated if anything was found during any of these assessments this was to be reported to the charge nurse or the DON immediately. She stated residents should be checked every two hours for repositioning. Record review of in-services dated 2/22/2023 at 8:15 PM, titled what to do when resident is admitted with an immobilizer, led by the DON revealed the Topic covered: 1. When a resident is admitted to the facility with an immobilizer you must make sure that you have written orders from the physician stating whether you can remove the immobilizer. If there is no order, contact the physician to obtain orders for removal of immobilizer daily to assess skin and pulses under the immobilizer and notify the DON that a resident was admitted with an immobilizer without an order to remove for skin assessment. 2. If there was an order to leave the immobilizer in place you must assess the residents' skin around the top and bottom of the immobilizer for redness, swelling or any signs/symptoms of infection, check pulses and document it accurately. 3. If there is an order that you may remove the immobilizer, you must remove it to assess the skin and pulses under the immobilizer and document it accurately. 4. If there are any skin issues found under the immobilizer you need to notify the physician to obtain treatment orders, notify the DON, and document the finding accurately by completing an ulcer assessment. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. Record review of in-services dated 2/22/2023 at 8:15 PM, titled pressure ulcer prevention and treatment, led by DON revealed the topic covered: 1. Resident must be changed every time they had an incontinent episode or at the very least, every 2 hours, even when up out of bed. 2. Residents must be turned and repositioned at least every 2 hours. This included when they were up in their wheelchairs. 3. If you find they don't need incontinent care, they still need to be turned and repositioned a minimum of every 2 hours. 4. Residents that are difficult to turn must be repositioned and changed by 2 people. 5. Heels must be floated. 6. If a resident sits up in a chair, make sure they have a cushion in place. 7. It does not take long to develop a pressure ulcer and poor incontinent care and lack of turning and repositioning increases a resident's risk. 8. Nurses-you must do treatments as ordered. You are responsible for making sure the treatments are done when the treatment nurse is not here. If you have any concerns about a wound, report it to the treatment nurse or the DON/ADON immediately. A signature page included which did have all staff that had worked the night before 2/22/2023 signatures and all employees in the building at currant time on 2/23/2023. The Administrator was informed that the Immediate Jeopardy was removed on 2/23/2023 at 4:07 PM. the facility remained out of compliance at a scope of isolated with actual harm that is not immediate jeopardy, due to the facility's need to continue to monitor the implementation and effectiveness of their corrective systems.