**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interviews, staff interviews, and a clinical record review, the facility staff failed to ensure residents received two person assistance during care and bed mobility per care plan and the bed mobility assessment binder to prevent accidents for one (1) of six (6) residents in the survey sample, Resident #1 which resulted in a fall with major injuries. The findings included: Resident #1 was originally admitted to the facility [DATE] and readmitted [DATE] after an acute care hospital stay. The resident died in the facility on [DATE]. The diagnoses included metastatic cancer, heart failure, renal insufficiency and malnutrition. The quarterly Minimum Data Set (MD) assessment with an assessment reference date (ARD) of [DATE] coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated Resident #1's cognitive abilities for daily decision making were moderately impaired. A review of the Resident's care plan revealed an intervention dated [DATE] which indicated the resident required two-person assistance with bed mobility; also, the information in the bed mobility book included an intervention that stated the resident required two-person assistance with bed mobility. On [DATE] at approximately 9:26 AM an interview was conducted with the resident's Power-of-attorney (POA). The POA stated on [DATE] at approximately 10:45 PM she received a call from a nurse at the facility stating Resident #1 experienced a fall during care. The POA stated she requested the resident be transferred to the hospital for further evaluation. On [DATE] at 11:03 AM an interview was also conducted with Family Member (FM) #3. FM stated because the resident's condition was declining so he decided to stay with her at the facility as much as possible and sometimes almost 24 hours per day to monitor her care and do what he could. FM #3 stated after meeting with the administrative staff concerning the resident's care, he was informed that the resident should receive care every two hours by two persons. FM #3 stated most of the time when staff came to render care there was only one person and he would explain that he was informed care was to be rendered by two people and the staff would go out and return 30 minutes later or more with a second person. FM #3 further stated on [DATE] at approximately 10:00 PM, Certified Nursing Assistant (CNA) #4 entered the resident's room to render care and he reminded her that the administrative staff told him that the resident's care was to be provided by two persons. FM #3 stated he thought she would get another person as all others had done but she did not. FM #3 stated that CNA #4 told him it was time for her to get off and there was no one else available to help her, therefore she proceeded to render the resident's care alone. FM #3 stated CNA #4 was in a hurry and she snatched the sheet and the resident fell from the bed to the floor hitting the floor like a ton of bricks. FM #3 stated CNA #4 ran out the room to get help and returned with of 6 or 7 other people. He stated the 6 -7 staff members were unable to lift the resident off the floor therefore after approximately 30 minutes they used the lift to successfully get the resident off of the floor. FM #3 stated the resident complained of great pain and was transferred to the hospital. A review of the hospital's Discharge summary dated [DATE] at 12:37 PM read that Resident #1 was admitted to the hospital on [DATE] after a fall from the bed in the nursing facility resulting in a head contusion, a subdural hematoma and a displace or dislocated left knee joint prothesis was later identified. An interview was conducted with CNA #4 on [DATE] at 4:40 PM. CNA #4 stated she had worked with the resident before, but she was not working on her normal assignment for she normally worked a different unit. CNA #4 stated prior to assuming care for the Resident #1 she failed to review the bed mobility binder so she would know how much assistance was required during care/bed mobility. CNA #4 also stated that the CNA she received report from did not inform her that the resident was to have two people assistance with care/bed mobility. CNA #4 stated Family Member #3 called for assistance to change the resident and she went in alone to provide care. CNA #4 stated she positioned the resident on her right side and she placed one hand on the resident and was using the other hand to open the brief, when the resident rolled off the bed on to the floor. An interview was also conducted with the Director of Nursing (DON) on [DATE] at 11:30 AM. The DON stated after a review she identified the resident had experienced nine falls since admission to the facility and eight of the falls were a result of poor decision making (self transfers) by the resident and the ninth falls was a result of staff no utilizing two people when rendering care/bed mobility. The DON stated the Interdisciplinary team developed a four point Performance Improvement Plan on [DATE] when they identified the resident's fall was a result of not following the two person assistance plan. A review of the Resident's care plan revealed an intervention dated [DATE] which stated the resident required two person assistance with bed mobility. The Facility's Action Plan dated [DATE] indicated the following: 1. Staff failed to follow two persons bed mobility that was put in place. 2. Resident was sent to the emergency department for evaluation and treatment. CNA was re-educated on two persons bed mobility with another staff member. QAPI meeting. 3. Education of nursing staff as it relates to residents as it relates to two persons bed mobility. 4. Weekly audits conducted by Nurse Managers times four weeks the weekly thereafter. CNA education ongoing. An onsite review of the Facility's Performance Improvement Plan was validated through resident observations during bed mobility, staff interviews, and resident record reviews on [DATE] and [DATE]. Residents who were assessed and required two-person assistance with care were validated through assessments, care plans, and random observations. The survey sample was expanded to ensure no other resident that were assessed to require two person assistance experienced a fall secondary to not having two persons assistance with care/bed mobility. Four random residents were observed to received two person assistance as care planned. The random observations results were 100%. Three CNAs were interviewed to determine how they identified resident's who required two person assistance with bed mobility with 100% accurate responses. Four resident bed mobility status were reviewed in the binder for bed mobility status with 100% compliance validated by the care plan. The survey sample was expanded to ensure the Facility's Action Plan had been implemented. No new deficient practices in the area of F689 were identified during the onsite review, thus Past-Non Compliance (G) PNC was issued to the facility dated [DATE]. On [DATE] at approximately 5:47 PM a final interview was conducted with the Administrator, the DON and the Nurse Consultant. The above information was reviewed and the Facility's administration offered no further comments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.The facility staff failed to ensure the necessary treatment, care and services were provided to prevent development of a pressure ulcer that was initially identified at an advanced stage, resulting in harm. Resident #90 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has been discharged multiple times from the facility to the community. The admission, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/04/2021 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #90 cognitive abilities for daily decision making were intact. In sectionG(Physical functioning) of the admission MDS, the resident was coded as requiring extensive assistance of one person with bed mobility, transfers, dressing, toilet use and personal hygiene. Requires one person assist with locomotion on and off the unit and with eating. Requiring total dependence of one person with bathing. The admission MDS in section M (Skin Conditions) M0100 Determination of Pressure Ulcer/Injury Risk: Section A reads: Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. =Yes. Section B reads: Formal assessment instrument/tool (e.g., Braden, [NAME], or other) = Yes. Section C reads: Clinical assessment= Yes. M0150 Risk of Pressure Ulcers/Injuries. Is this resident at risk of developing pressure ulcers/injuries? =Yes. M0210. Unhealed Pressure Ulcers/Injuries. Does this resident have one or more unhealed pressure ulcers/injuries stage 1 or higher? = Yes. M0300 (Current number of unhealed pressure ulcers at each stage. G. unstageable deep tissue: Suspected deep tissue injury. Number of unstageable pressure ulcers suspected with deep tissue injury: 1. Number of unstageables present on admission: 1 M01030-Number of venous and arterial ulcers: 1 M1040-Other ulcers, wounds and skin problems: None M1200-Skin and Ulcer Treatments: Pressure reducing device for chair, Pressure reducing device for bed, Pressure ulcer care and application of dressings to feet. The MDS above only list Skin problems before the new unstageable ulcer on the left heel was identified. Braden Scale for Predicting Pressure Ulcers dated 11/02/16. Score is 16. SCORING: AT RISK 15-18. MODERATE RISK 13-14. HIGH RISK 10-12. VERY HIGH RISK 9 or below. The care plan dated 11/15/21 reads: Focus-The resident has an ADL self-care performance deficit r/t Activity Intolerance. Goals: The resident will improve current level of function in ADLs through the review date. Interventions: Staff to assist with ADL's (Activity of Daily Living) as needed. Provide sponge bath when a full bath or shower cannot be tolerated. A review of the MDS and Care Plan reveal no refusals for bed baths or bathing The Self Care assessment dated on 11/03/21 indicated that the Resident was dependent on staff to put on and take off footwear. The ability to put on and take off socks and shoes or other footwear that is appropriate for safe mobility; including fasteners, if applicable. The care plan dated 11/15/21 reads: Focus-Actual skin impairment r/t limited mobility, muscle weakness, and DM (Diabetes Mellitus) II, admitted with surgical incision to Right hip with staples, skin tears to Right lower leg, and Right Forearm, and skin breakdown to Right lateral ankle and Right buttock. Goals: Resident will have no evidence of skin impairment through next review. Keep skin clean and dry. Lotion to dry skin. Moisture barrier cream as needed for protection of skin. Pericare with incontinence episodes. Pressure reduction mattress. Treatments to all areas as ordered. Notify MD as needed. Weekly Skin Assessment. A review of the ADL (Activity of Daily Living) sheet note dated 12/13/21 reads: Resident prefers bed baths and is scheduled for baths/showers on Tuesday, Thursday and Saturday. The ADL sheets indicated that he took bed baths. There was no documentation to indicate that feet and legs were excluded during from bathing during bed baths. On 12/06-12/07/21, the resident took a bed bath and, according to facility documentation there was no indication of staff identifying a new unstageable ulcer to Resident's left ankle. A review of the CNA skin observations dated 12/04/21-12/07/21 was checked off showing none of the above were observed (scratches,red areas, discolorations and open areas) no check marks were placed. The Admissions Summary Note dated 11/02/21 at 16:42 (4:42 PM) reads: The Resident arrived from Hospital. The reason for the admission per the resident/POA (Power of Attorney) is UTI (Urinary Tract Infection)/ Dehydration. The Admissions note dated 11/2/2021 at 23:14 (3:14 AM) reads: Patient has a pressure area to sacrum. Open area also noted to Right outer ankle. Patient denies pain to either area. Patient able to make needs known. Chief Complaint: Comprehensive skin and wound evaluation for readmission to facility for DTI (Deep Tissue Injury) to sacrum, arterial ulcer to right lateral ankle. Patient has edema of bilateral lower extremities. There was no documentation about a left heel ulcer. A review of the Skin/Wound assessment note dated on 12/07/21 reveal that Resident #90 has a new unstageable ulcer to the left heel identified during the Comprehensive skin and wound evaluation by OSM (Other Staff Member)/Wound Care Nurse Practitioner #9. Wound plan of care reads: Recommend elevating patient's feet every couple hours and wearing compression stockings to decrease edema . Recommend frequent position changes to decrease pressure on sacrum. With a new unstageable found on left heel recommend patient not use his foot to propel himself around in his wheelchair as it is putting too much pressure on his foot. The POS (Physicians Order Summary) reads: Left Heel: Cleanse with NACL (Normal Saline) apply honey fiber and wrap with Kerlix every day shift Order date: 12/07/2021 Start date: 12/08/2021. A review of the TAR (Treatment Administration Record) show that Resident #90 received his wound care treatments to his left heel once identified. A review of progress note dated 12/9/2021 at 10:43 AM., reveal that wife was notified and asked about bringing resident in more clothing and slippers to help relieve pressure off heel when in w/c (wheel chair). Also confirmed that she updated about new wound to heel with her stating she was aware. Family member stated that she will bring him clothes and slippers as soon as she can because she has been sick herself. A review of progress notes dated 12/09/21 at 11:25 AM., reads: Spoke with Resident about using footrests on his WC (Wheel Chair) to aid in healing of his foot wounds and prevent further wounds. Therapy Director has educated him on avoiding crossing of his legs when he is sitting. He agreed that he will utilize the footrests and will allow staff to place pillows under his legs to elevate his feet when in bed. Advised to eat well and drink well and he stated that he does both. A review of progress notes dated 12/13/21 at 4:52 PM reads: Pt is suggested to float his heels while in bed which he did for 3 hours and requested me to take off pillows because he was uncomfortable. I did remove the pillows. Pt is in the bed now and call button with in reach. Weekly Skin Evaluation: 11/09/21 with a lock date of 11/14/21. Did not identify an unstageable wound to left ankle. 11/19/21 with a lock date of 11/19/21. Did not identify an unstageable wound to left ankle. 11/29/21 with a lock date of 11/29/21. Did not identify an unstageable wound to left ankle. 12/06/21 with a lock date of 12/13/21-left heel pressure unstageable (no notation in nurse's note that physician was made aware of this new area on 12/6/21). 12/13/21 (Weekly skin evaluation) with a lock date of 12/13/21 read: Left Heel Pressure Ulcer. On 12/08/21 at 5:40 PM during the initial visit buy this surveyor, Resident #90 was observed sitting in his wheel chair. No footrest were attached. Resident voiced that he prefers bed baths over showers. An interview was conducted on 12/09/21 at approximately 5:10 PM with LPN (Licensed Practical Nurse) #6 concerning Resident #90. She stated, The area on Resident #90's left heel is due to him digging his heels on the floor while propelling in the wheel chair. The area is blackened and swollen. We're floating his heels, providing foot pedals to his wheel chair and encouraging resident to wheel with his hands. We've asked his wife to bring in slippers. On 12/09/21 at approximately 8:40 PM., an interview was conducted with OSM (Other Staff Member/Wound Care Nurse Practitioner) #9 over the telephone concerning the new unstageable ulcer found on Resident #90's left ankle. She stated, I went to do my wound assessment on resident (12/7/21), I just happen to look at the right ankle when he told me 'my heel (Left Heel) hurts', that's when I saw it. It is currently unstageable with loose skin and black Skin. He has an arterial wound on his right ankle hard to heal. I recommend something on wheel chair so he won't propel himself around. I talked to him on Tuesday (12/07/21) about not putting pressure on his heel. The Wound Care Nurse Practicioner stated she was not made aware of the left heel by the nursing staff prior to her assessment. On 12/10/21 at approximately 9:15 AM, wound care observation was made with LPN (Licensed Practical Nurse) #7. The newly unstageable area on the left heel appeared to be blackened with eschar, large serosanguous drainage was noted. no odor was present. Resident tolerated wound care without difficulty. Wound care was conducted per wound care orders. On 12/10/21 at approximately 1:15 PM an interview was conducted with PA/OSM #4 (Physician Associates) concerning Resident #90 concerning his newly found unstageable on his left ankle. She stated, I was told through the nursing staff that he will walk in the wheel chair with heel toe push. OSM #9 had observed him on his heel. He need to keep his feet elevated. Normally the CNA's (Certified Nurses Assistants) will dress the patients. On 12/10/21 at approximately 1:30 PM an interview was conducted with CNA #3. She stated, I've worked with him twice. He was already dressed and bathed this morning. Normally when he's in bed he keeps his feet propped up. Whenever we see a new area we let the nurse know and we chart it in the kiosk. The nurses and CNA's do skin assessments together. After the shower we chart if there are any open areas. It's been a couple of weeks ago since I took care of him. Showers are given twice a week. Bed baths are given everyday. The facility's policy, Pressure Ulcer Monitoring and Documentation Dated: 11/01/2019. Reads: All Pressure Ulcers will be monitored. Procedure: 1. A licensed nurse will assess patients for the presence of pressure ulcers/injuries; if a pressure ulcer/injury is present, the nurse will evaluate for complications. 2. Provide pain management prior to pressure ulcer/injury treatment as indicated. 3.The Skin Wound Evaluation will be completed weekly by a licensed nurse for any patient with pressure ulcers/injuries. 4. There will be a Wound Evaluation for each site. On 12/14/2021 at approximately 3:10 PM, the above findings were shared with the Administrator, Director of Nursing and Corporate Consultant. An opportunity was offered to the facility's staff to present additional information but no additional information was provided. 2. The facility staff failed to identify Resident #65's right lateral ankle pressure ulcer prior to it being found at an advanced stage resulting in harm. The pressure injury was found as a stage III with 40% granulation tissue and 60% slough/eschar. Resident #65 was originally admitted to the facility on [DATE]. Diagnosis for Resident #65 included but are not limited to Quadriplegia (paralysis of all four limbs), morbid (severe) obesity, Cerebral Infarction (stroke). Resident #65's Minimum Data Set (MDS-an assessment protocol) a quarterly assessment with an Assessment Reference Date of 10/22/21 coded Resident #65 a 06 out of a possible score of 15 indicating severe cognitive impairment. The MDS coded Resident #65 requiring total dependence of two with bathing, bed mobility, toilet use, hygiene and dressing, extensive assistance of one with transfer and eating for Activities of Daily Living care. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #65 with impairment on both sides to her upper and lower extremity. Resident #65 was coded as having no mood, rejection of care or behavioral problems. The MDS with an ARD of 10/22/21 under section M (Skin Condition - M0100) was coded for the using a Formal Assessment Instrument/tool (e.g., Braden, [NAME] or other) for the determination of Pressure Ulcer Risk. Under section (M0150) for Risk of Pressure Ulcers coded Resident #65 at risk for developing pressure ulcers and under section (M1200) for skin and treatments was coded for having pressure reducing device bed, turning/repositioning program and pressure ulcer care. Resident #65's care plan with a created date of 06/23/21 identified the resident with the potential for skin impairment and actual skin impairment to the left heel, left outer ankle, right lateral foot and left buttocks. The goal set for the resident by the staff was that the resident will have no evidence of skin impairment through next review date. Some of the interventions/approaches the staff would use to accomplish this goal is to keep skin clean and dry, lotion dry skin, moisture barrier cream as needed for protection of skin and weekly skin assessment. Resident #65's care plan with a revision date of 11/16/21 identified the resident with another pressure ulcer located to the right outer ankle. Some of the interventions/approaches the staff would use to accomplish this goal is for Healing Partners to provide skin/wound care as needed, turn and reposition, wedge foam, air loss mattress and wound care as ordered. A Braden Risk Assessment Report was completed on 10/20/21; resident scored a 10 indicating high risk for the development of pressure ulcers. Sensory perception is the ability to respond meaningfully to pressure-related discomfort. Resident #65 is very limited with sensory perception and only responds to painful stimuli and cannot communicate discomfort except by moaning or restlessness or has a sensory impairment which limits the ability to feel pain or discomfort over 1/2 of body. Activity (degree of physical activity) is chair fast, Mobility is completely immobile (does not make even slight changes in body or extremity position without assistance) and Friction & Shear with a problem requiring moderate to maximum assistance in moving, frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. Review of Resident #65's bi-weekly skin assessments were reviewed from 06/23/21 through 11/02/21 with no skin issues to the right lateral ankle until identified at an advance stage (stage III) by the Wound Specialist (NP) on 11/02/21. The Wound Care Specialist/Nurse Practitioner documented the following on a Tissue Analytics Form: -11/02/21 at 9:11 a.m., a new Stage III pressure ulcer was identified to right lateral ankle measuring 1.75 cm x 2.03 cm with 40% granulation tissue and 60% slough/eschar (dead) tissue with a moderate amount of serosanquinous drainage with unattached edges. The stage III pressure ulcer was documented as facility acquired. A treatment started to apply Honey Fiber to wound bed and wrap with kling/kerlix daily. -11/11/21 -stage III pressure ulcer to right lateral ankle measuring 1.91 cm x 1.94 cm with 10% granulation tissue and 90% slough/eschar with scant amount of serosanquinous drainage. Wound status documented as improving. A new treatment was started for Betadine three times daily, wrap with kling/kerlix. - 11/23/21 - Stage III pressure ulcer to right lateral ankle measuring 3.29 cm x 3.33 cm with 100% slough/eschar with scant amount of serosanquinous drainage with attached edges. Wound status documented as stable. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Offloading heels by wearing foot protectors and frequent positioning. Dressing is Betadine with Kling/Kerlix. -11/30/21 - Stage III pressure ulcer to right lateral ankle measuring 3.05 cm x 2.65 cm with 40% granulation and 60% slough/eschar with moderate amount of serosanquinous drainage and bleeding also present from wound bed with unattached edges. Wound status documented as worsening. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Treatment changed to Honey fiber - apply to wound bed daily and wrap with kling/kerlix. -12/14/21 - Stage III pressure ulcer to right lateral ankle measuring 3.68 cm x 2.88 cm with moderate amount of sersanquinous drainage and bleeding also present from wound bed with unattached edges. Wound status documented as worsening but without odor. Recommendation: offloading heels wearing foot protectors and frequently positioning. Ensure compliance with turning protocol, elevate legs regularly, wedge/foam cushion for offloading and specialty bed. Treatment changed to Collagen Ag daily. The current treatment as of 12/09/21 is to cleanse right lateral ankle with normal saline, pat dry, apply medihoney, cover with gauze and wrap with kerlix. On 12/09/21 at approximately 12:20 p.m., wound care observation was conducted with License Practical Nurse (LPN) #1. Resident #65 was lying in bed, positioned on her right side lying on an alternating low air loss pressure mattress. LPN #1 perform wound care with the assistance of another nurse. Prior to starting wound care to the Resident #65, LPN #1 washed her hands x 31 seconds, used hand sanitizer and donned a new pair of gloves. The LPN removed the dressing from the resident's right lateral ankle wound with a large amount of sersanquinous drainage present on dressing removed. The right lateral ankle wound bed noted with red granulation and yellow tissue present; no odor present. LPN #1 removed her gloves, applied hand sanitizer then applied a new pair of gloves. The wound was cleansed with normal saline in a circular motion x 2, gloves removed, hand sanitizer applied, new gloves applied, Manuk-ahd honey coated dressing applied to wound bed, covered with gauze and wrapped with kling. A phone interview was conducted with the Wound Specialist/Nurse Practitioner (NP) on 12/10/21 at approximately 1:16 p.m. When asked if the staff had informed her prior to performing wound care to Resident #65 on 11/02/21 that the resident had a stage III to her right lateral ankle, she replied, No. The NP stated, While providing routine wound care with the assistance of a nurse on 11/02/21, I observed a new stage III pressure ulcer to the right lateral ankle. The NP said the wound had been there then for a while due to the fact that the wound bed had some granulation tissue present as well as slough and eschar. Review of Resident #65's clinical record revealed a weekly skin evaluation entered by LPN #1 on 11/02/21 at approximately 3:03 p.m. The document included the following: wound to right outer ankle. An interview was conducted with LPN #1 on 12/13/21 at approximately 10:14 a.m. When asked if she identified the pressure ulcer on Resident #65 on 11/02/21, she replied, It was found on 11/02/21 by the NP. She said the NP need assistance with positioning Resident #65 and while positioning the resident, the NP found the pressure ulcer to the resident's right outer ankle. LPN stated, I do the resident's wounds often and to be perfectly honest, I never say the wound the right outer ankle until it was identified by the NP on 11/02/21. A debriefing was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m. When asked, At what stage do you expect for the nurses to first identify a pressure ulcer she replied, They should be found when there is a difference in the color of their skin; at a stage I. Definitions *Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). * Stage 3 Pressure Injury: Full-thickness skin loss - Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages). *Low air loss mattress is an alternating pressure mattress systems are designed to heal and prevent bedsores (http://www.medicalairmattress.com/deluxe.html). *MANUK-Ahd is a honey impregnated super absorbent gelling fiber dressing that maintains a balanced moist environment conducive to wound healing. Dressing properties cause honey to gel with wound fluid and allows for easy removal. Benefits from using Manuk-ahd honey gel include the following: easily conforms to any wound type, gels with exudate, high strength and integrity, super absorbent for moderate to heavy exuding wounds, high sugar levels in the honey results in osmotic pressure, promoting autolytic debridement and wound odor reduction (https://www.woundsource.com/product/manukahd-lite). Based on observations, resident interviews, staff interviews, clinical record reviews, and review of facility documents, the facility staff failed to provide necessary care and service to prevent deterioration for 1 of 58 resident's (Resident #92) who had stage IV pressure ulcer to the coccyx. The coccyx pressure ulcer on admission to the facility measured length 9.96 centimeters by width 3.89 centimeters by depth 0.30 centimeters and on 12/2/21 the coccyx pressure ulcer measured 16.00 centimeters by 7.66 centimeters by 2.0 centimeters with a tunneling at six o'clock measuring 5.50 centimeters, and it presented malodorous with heavy drainage which constituted harm. For 2 of 11 residents with facility acquired pressure ulcers in a survey sample of 58 residents, the facility staff failed to initially identify them prior to an advanced stage. Resident #65's right lateral ankle pressure ulcer was initially identified by the facility staff as a stage III with 40% granulation tissue and 60% slough/eschar. For Resident #90, the facility staff initially identified a left heel pressure ulcer as unstageable on 12/7/21, which constituted harm. The findings included: 1. Resident #92 was originally admitted to the facility 11/1/21 after an acute care hospital stay and has never been discharged from the facility. The current diagnoses included; neurofibromatosis, neurosarcoidosis, diabetes and a neurogenic bladder with a right urethral stone. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 11/7/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #92's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of two people with bed mobility, transfers, and toileting, extensive assistance of one person with personal hygiene, bathing, and dressing, limited assistance of one person with locomotion, and supervision after set-up with eating. On 12/7/21 at approximately 3:45 p.m., an interview was conducted with Resident #92. The resident stated the wound care Nurse Practitioner (NP) was disappointed with the condition of the coccyx pressure ulcer because it showed significant deterioration during the 12/2/21 assessment but it was worse on 12/7/21, even with the ordered change in the treatment on 12/2/21. The resident also stated the wound care NP instructed him on 12/2/21 to ensure the staff repositioned him frequently and provided incontinence care timely to prevent further wound deterioration. The resident further stated the suprapubic catheter eliminated most moisture but as a result of anal cancer he was unaware of when or if he had a bowel movement. The resident also stated he is able to assist the staff when he is positioned and can hold on to the bed rail while care is rendered. Review of the Braden Scale for Predicting Pressure Sore Risk revealed the resident had a potential for pressure ulcer development secondary to sensory loss, for he was unable to feel pain or discomfort in 1 to 2 extremities, chairfastness; for his ability to walk was severely limited or non-existent, unable to bear weight and/or must be assisted into a chair or wheelchair, limitations in mobility; makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently and friction and shear; requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. The resident score 15 on the Braden Predictor which classified him as At Risk. A moderate risk was 13-14, high risk 10-21 and a very high risk was 9 or below. Review of Resident #92's current care plan dated 11/16/21 read; the resident has pressure ulcers (Coccyx, heels) or potential for pressure ulcer development related to decreased functional mobility. The goal read; the resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions included; monitor nutritional status. Provide supplements as ordered, monitor intake and record and position resident as needed. The clinical record revealed Resident #92 had no weekly skin assessments or wound care evaluation between 11/9/21 and 11/24/21, recommendation offered by the wound care NP were not instituted from 11/4/21 through 12/2/21 and there was no evidence the the facility staff informed the NP of the not carrying out the recommendation, and wound care treatments were not documented as completed on the Treatment Administration Record for the following days; 11/2/21, 11/3/21, 11/21/21, 11/23/21, 12/3/21 and 12/8/21 and a Certified Nursing Assistant was given the responsibility to round with the wound care NP and write verbal orders to be transcribed into nurse documentation and recommendations for orders to treat wounds. The wound care NP Wound Tissue Analytics document of the coccyx pressure ulcer recommended a Specialty bed, ensure compliance with turning and elevate the legs regularly. Observations were make of the Resident #92 in bed 12/7/21 at approximately 3:45 p.m., 12/8/21 at approximately 11:55 a.m., 12/9/21 at approximately 1:35 p.m., 12/10/21 at approximately 2:40 p.m. and 12/13/21 at approximately 5:15 p.m. During each of the observations the resident's legs were not elevated as recommended. Review of the Clinical Record revealed the following documentation: The nurse's weekly skin evaluation dated 11/1/21 listed a stage IV sacral pressure ulcer present on admission to the facility without measurements or description. A Wound Tissue Analytics document dated 11/2/21, which stated Resident #92 was admitted to the facility with a stage IV coccyx pressure ulcer measuring length 9.96 centimeters by width 3.89 centimeters by depth 0.30 centimeters and presented with 20 percent granulation tissue and 80 percent eschar, no odor and moderate serosanguious drainage. The treatment was cleanse with normal saline and Medihoney and silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. The weekly skin evaluation dated 11/8/21 listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. There wasn't a wound care NP note until 11/9/21. A Wound Tissue Analytics document dated 11/9/21, revealed the coccyx pressure ulcer had stalled. It measured 7.51 centimeters by 9.43 centimeters by depth 0.20 centimeters and presented with 50% granulation tissue and 50% eschar, no odor and moderate serosanguious drainage. The treatment was cleanse with Dakins and Dakins moist to dry and silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. There was no further weekly skin evaluations between 11/8/21 and 11/19/21. There was no weekly wound assessments between 11/9/21 and 11/24/21. The weekly skin evaluation dated 11/19/21 listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. There wasn't a new wound care NP note until 11/24/21. A Wound Tissue Analytics document dated 11/24/21, revealed the coccyx pressure ulcer was worsening. It measured 15.23 centimeters by 7.79 centimeters by depth 0.30 centimeters and presented with 30% granulation tissue and 70% eschar, no odor and moderate serosanguious drainage. The treatment remained cleanse with Dakins and Dakins moist to dry and a silicone dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. The weekly skin evaluation dated 11/27/21, listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. A Wound Tissue Analytics document dated 12/2/21, revealed the coccyx pressure ulcer was worsening. It measured 16.00 centimeters by 7.66 centimeters by depth 2.00 centimeters, and a tunneling at six o'clock measuring 5.50 centimeters and the coccyx pressure ulcer presented with 30% granulation tissue and 70% eschar, malodorous, and with heavy serosanguious drainage. The treatment remained cleanse with Dakins and Santyl and a super- absorbent dressing. Specialty bed, ensure compliance with turning and elevate the legs regularly. A Wound assessment dated [DATE], revealed the coccyx pressure ulcer was worsening. It measured 16.16 centimeters by 7.71 centimeters by depth 2.00 centimeters, and a tunneling at six o'clock measuring 5.50 centimeters and the coccyx pressure ulcer presented with 10% granulation tissue and 90% eschar, malodorous, and with heavy purulent drainage. The treatment remained cleanse with Dakins and Santyl and a super-absorbent dressing. An amended note written by the wound care NP dated 12/8/21 read; discussed possible debridement of the sacral wound as well as needing to send the resident out to have surgical debridement done. This was tried by me (NP) on Tuesday but the eschar was too adherent to the wound bed. Will look at attempting debridement when rounding on 12/14/21 if the eschar is loosen enough by the Santyl. The next weekly skin evaluation was dated 12/12/21, and listed the coccyx pressure ulcer and referred the reader to the wound care NP notes. Review of the Treatment Administration Record revealed the following orders for the coccyx pressure ulcer: 11/1/21 - 11/2/21;cleanse sacral area with dermal wound cleanser, pat dry. Apply hydrogel and cover with a dry dressing daily and as needed if soiled, [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility's documentation, the facility staff failed to provide the necessary care and services to 1 of 58 residents (Resident #170) for the prevention and complication of a Urinary Tract Infection (UTI) and sepsis. The facility staff failed to notify the physician or Physician Assistant (PA) when orders were given for a UA with C&S, and that they were never obtained, over five days. The resident became unresponsive, with oxygen saturation levels of 83% (normal=95-100%), and was transferred via 911 (emergent) to the local hospital and admitted on [DATE] with a diagnosis of severe sepsis, hypothermia at 88 degrees, complicated UTI and Acute Kidney Injury (AKI); which constitutes harm. The findings included: Resident #170 was originally admitted the nursing facility on 12/13/17. The resident was discharged to the local hospital on [DATE] and did not return to the nursing facility. Diagnoses for Resident #170 included but not limited to Hematuria (blood in the urine) and Urinary Tract Infection (UTI). The most recent Minimum Data Set (MDS) was a significant change assessment with an Assessment Reference Date (ARD) of 07/22/21 coded the resident on the Brief Interview for Mental Status (BIMS) a 13 of 15 indicating no cognitive impairment. Resident #170 was coded total dependence of two with dressing, total dependence of one with bathing and toilet use, extensive assistance of two with bed mobility and supervision with one assist with hygiene for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for always incontinent of bladder and bowel. The care plan with a created date on 05/11/18 and a revision date of 10/17/21 identified Resident #170 at risk for UTI related to has history of UTI's. The goal set for the resident by the staff was that the resident's UTI will resolve without complications by the review date. One of the interventions/approaches the staff would use to accomplish this goal is monitor/document/report to MD as needed for signs and symptoms of UTI: frequency urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status and behavioral changes. On 10/11/21, Physician Assistant (PA) progress revealed the following information: Resident #170 is being seen today possible UTI symptoms per nursing staff. Per nursing, there are concerns that the resident may have a UTI and states his catheter was recently removed by urology. Resident was recently sent to the emergency room (ER) for hematuria and treated for UTI. Under general information revealed the following: incontinent of bowel and bladder, penile discharge present and with no visible hematuria in his brief. The PA wrote to obtain UA with C&S if symptoms develop. On 10/13/21, PA progress note dated 10/13/21 revealed the following information: Resident #170 is being seen today for evaluation of hematuria and confusion per nursing staff. Resident has a significant history of recurring UTI's and recently had catheter removed per urology order. Under general information revealed the following: report hematuria with confusion; change from baseline. The PA wrote an order for UA with C&S and to continue monitoring and supportive care. During the review of Resident #170's clinical record did not reveal lab results for UA with C&S after being ordered on 10/13/21. On 12/09/21 at approximately 5:29 p.m., an interview was conducted with the Regional Director of Clinical Services. The Regional Director said if the nurse was not able to obtain the urine specimen as ordered by the physician, PA or Nurse Practitioner (NP) then the nurse should have communicated to oncoming shift that Resident #170 still needed to have urine obtain for a UA with C&S. She said if the nurses were still not able to obtain the urine then the physician, PA or NP should have been notified and to possibly get an order for a straight Cath to obtain the urine sample. She said the nurse's should have been monitoring the resident for s/s of UTI and a change in condition and to notify the physician, NP or PA right away if such symptoms occurred and to document in the information in the resident's clinical record. On 12/09/21 at approximately 5:40 p.m., an interview was conducted with the Medical Director. He said if the nurses were not able to obtain the labs as ordered for UA with C&S, myself the NP or PA should have been notified. The Medical Director was informed by the surveyor that the resident was having signs of UTI to include confusion and hematuria. He stated, If the resident was having signs of UTI and the staff were not able to obtain the labs as ordered, an order would have been given to straight Cath to obtain the urine specimen. He said the resident could have been treated prophylactically with antibiotics until the C&S was received. License Practical Nurse (LPN) #9 documented in the resident's nurses note on 10/13/21 at approximately 3:13 p.m., that the resident was informed several times during the shift a urine sample has been ordered. The resident replied several times I don't have to go yet. The urine sample was not collected on the 7-3 shift. The nurses note did not indicate the NP/PA or physician were made aware the UA with C&S was not obtained as ordered. An interview was conducted with the LPN #9 on 12/10/21 at approximately 11:17 a.m. The LPN stated, The 11-7 shift reported off to me that Resident #170 need a UA with C&S. The nurse said she was not able to obtain the urine specimen so it was passed on the oncoming nurse for the 3-11 shift on 10/13/21. On 12/10/21 at approximately 11:25 a.m., a phone interview was conducted with LPN #10. The LPN was assigned to provide care and services to Resident #170 on 10/13/21 (3-11 shift). The LPN stated, I don't recall ever being told in report that Resident #170 need a urine sample but I know for sure, I did not obtain a urine specimen from Resident #170. Review of Resident #170's clinical record revealed the following documentation entered on 10/17/21 at approximately 3:22 p.m. Resident #170 noted with altered mental status, unresponsiveness with oxygen saturation at 83% on room air. A new order was obtained to send to the ER for evaluation and treatment. Resident #170 was admitted to the hospital and placed in Intensive Care Unit (ICU), the resident did not return to the nursing facility. Review of the hospital records revealed the following: Resident #170 presented in the emergency room (ER) on 10/17/21 from (name of nursing facility) for further evaluation due to Altered Mental Status (AMS). The 911 transport revealed the following: Resident #170 was transferred from (name of nursing home) where he was found unresponsive and hypoxic. The resident was placed on non-breather mask and transported to the ER. On the evaluation work-up at (name of hospital), in the ER Resident #170 was awake but sluggish and continues on non-breather mask. Upon arrival to the hospital, the ER records indicated Resident #170's body temperature @ 88 degrees F (hypothermia - low body temperature) with a Bair Hugger and warming lights. The white blood count was 16,000, urinalysis with large leukocyte esterase, positive nitrites and WBC too numerous to count with 4+ bacteria. The ER records indicated the resident was admitted to Intensive Care Unit (ICU). Intravenous Fluids (IV), IV antibiotic (Vancomycin and Aztreonam) was started. The resident was diagnosis but not limited to severe sepsis, complicated UTI, Acute Kidney Injury (AKI), hypothermia and Acute Metabolic Encephalopathy. A debriefing was conducted with the Administrator, Director of Nursing and Regional Director of Clinical Services on 12/14/21 at approximately 12:35 p.m., Resident #170's issues was presented again. The facility did not present any further information about the findings. Definitions -Urinary tract infection occurs when there is compromise of host defense mechanisms and a virulent microbe adheres, multiplies, and persists in a portion of the urinary tract. Most commonly, UTI is caused by bacteria, but fungi and viruses are possible. Urine culture and sensitivity are the gold standards for diagnosis of bacterial UTI (https://www.ncbi.nlm.nih.gov). -Sepsis is a serious medical condition. It's caused by an overwhelming immune response to infection. The body releases immune chemicals into the blood to combat the infection. Those chemicals trigger widespread inflammation, which leads to blood clots and leaky blood vessels. As a result, blood flow is impaired, and that deprives organs of nutrients and oxygen and leads to organ damage. In severe cases, one or more organs fail. In the worst cases, blood pressure drops, the heart weakens, and the patient spirals toward septic shock (https://www.nigms.nih.gov/education/Documents/Sepsis.pdf). -Severe sepsis symptoms may include but not limited to organ failure, such as kidney (renal dysfunction resulting in less urine) low platelet count and change in mental status, pain in the lower abdomen and blood in the urine. Systolic pressure is equal to or less than 100 millimeters of mercury (mmhg) and abnormal white blood cell count (either too high or too low). In some cases, sepsis may turn into septic shock, which is a drastic drop in blood pressure that can increase the risk of death. Signs of septic shock include but not limited to: needing medication to maintain systolic blood pressure equal to or greater than 64 mmHG and high levels of lactic acid in your blood, which means your cells aren't using oxygen in the right way. To prevent urosepsis, get treated as soon as possible. The longer you delay treating UTI, the more likely to develop urosepsis, septic shock, renal failure and death (https://webmd.com). -Acute Kidney Injury occurs when your kidneys suddenly become unable to filter waste products from your blood. When your kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood's chemical makeup may get out of balance. Acute kidney failure - also called acute renal failure or acute kidney injury - develops rapidly, usually in less than a few days (https://www.mayoclinic.org/diseases-conditions/kidney-failure/symptoms-causes). -Urine Analysis (UA) is a test to find germs (such as bacteria) in the urine that can cause an infection. Urine in the bladder. This means it does not contain any bacteria or other organisms (such as fungi) but bacteria can enter the urethra and cause a UTI (http://www.webmd.com/a-to-z-guides/urine-culture). -Culture and Sensitivity (C&S) is sample of urine is added to a substance that promotes the growth of germs. If no germs grow, the culture is negative. If germs grow, the culture is positive. The type of germ may be identified using a microscope or chemical tests. Sometimes other tests are done to find the right medicine for treating the infection. This is called sensitivity testing (http://www.webmd.com/a-to-z-guides/urine-culture). -[NAME] system is a temperature management system used in a hospital or survey center to maintain a patient's core body temperature (https://www.bairhugger.com). -Hypothermia is a medical emergency that occurs when your body loses heat faster than can produce heat, causing a dangerously low body temperature. Normal body temperature is around 98.6. Hypothermia occurs as your body temperature falls below 95 degrees Fahrenheit (https://www.mayoclinic.org). -Oxygen saturation levels are considered normal between 95-100%. Levels that fall to 88% or lower, seek immediate attention (medlineplus.gov).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #122 was admitted on [DATE]. Diagnosis included but were not limited to, right tibial and fibular fracture and Muscle Weakness. Resident #122's Minimum Data Set (an assessment protocol) with an Assessment Reference Date of 05/03/2019 coded Resident #122 with a BIMS (Brief Interview for Mental Status) score of 15 indicating no cognitive impairment. In addition, the Minimum Data Set coded Resident #122 as requiring limited assistance of 1 for bed mobility, toilet use and personal hygiene, extensive assistance of 1 for transfer and dressing, physical help of 1 in part of bathing activity and independent with set up help only for eating. On 06/05/2019 at approximately 12:00 p.m., review of Resident #122's clinical record revealed the following: Discharge Summary from the hospital revealed Discharge Diagnosis which included but was not limited to, Right Tibia fracture S/P (Status Post) Right Tibial ORIF (Open Reduction Internal Fixation) on 03/31. Skin and Wound Evaluation for Resident #122 dated 04/05/2019 revealed that the resident had a Surgical Incision on the Right Shin closed with Steri-Strips, present on admission. Wound Measurements: Area: 4.9 cm2., Length: 20.8 cm., Width: 0.4 cm. The Braden Scale For Predicting Pressure Sore Risk dated 04/05/2019 revealed a score of 15. Physician Orders dated 04/05/2019 revealed treatment order for: Xeroform Petrolat Patch 4 x 4 Pad (Bismuth Tribromoph - Petrolatum) Apply to right foot surgical area topically every evening shift for surgical incision. Cleanse area with NACL (Sodium Chloride) apply Xeroform and dry dressing. Review of the Nurse Practitioner Progress Note dated 04/30/2019 revealed a note under the History of Present Illness with a date of 04/17/2019, it was documented in part, as follows: Nursing also states that he is having some redness to his incision area. This writer observed his incision where it is very slightly erythematous but with out any signs and symptoms of infection. Review of the Nurse Practitioner Progress note dated 05/01/2019 revealed the following, it was documented in part, as follows: [AGE] year old white male who is a skilled resident of the facility for right tibial and fibular fracture was reporting pain to therapist for approximately 2 days. Therapist uncover his boot to find out patient had increased erythema to right lower extremity linear open wounds directly from stabilization boot. Patient stabilization boot will be discontinuing, Ortho will be contacted. Patient reports increased pain. Again he is noted with erythema and sloughing to the area where he will be started on Santyl and Keflex. Skin and Wound Evaluation for Resident #122 dated 05/01/2019 revealed information identifying a new Pressure Ulcer-Medical Device Related Pressure Ulcer, *Stage 3: Full-thickness skin loss located on the Right Shin with 100% slough in wound bed It was documented that the Pressure Ulcer was acquired in - house. The question on the form asked, How long has the wound been present? It was answered, New. Wound Measurements were documented as follows: Area: 4.2 cm2., Length: 3.1 cm., Width: 1.9 cm. Wound Pain was documented in part, as follows, Pain Frequency: Intermittent. Medication Administration Record for May 2019 had an order dated 05/01/2019 and is documented in part, as follows: Hold camboot usage and call ortho to make them aware and if they want to order something else for stability of right ankle fracture one time only for open skin wound / right ankle fracture for 1 day. Treatment Administration Record revealed that Xeroform Petrolat Patch had a D/C (Discontinue) date of 05/01/2019. Treatment Administration Record revealed an order dated 05/02/2019 and is documented in part, as follows: Santyl Ointment 250 Unit/GM (Collagenase) Apply to Right shin topically every evening for wound healing. Clean right shin wound with NS. Apply Santyl and dressing daily. D/C Date 05/07/2019. Review of Nurse Practitioner Progress Note dated 05/07/2019 revealed the following, and is documented in part, as follows, Orthopedic office states that it is okay to keep the boot off at this time. In reassessment of patient's wounds, erythema has lessened and his wounds are not draining but scabbed over. At this time Santyl will be discontinued. Patient did complete Keflex on today. Patient will start Bacitracin to linear leg wound. Treatment Administration Record revealed an order dated 05/07/2019 and is documented in part, as follows, Bacitracin Zinc Ointment 500 Unit/GM Apply to right leg topically every evening shift for leg wound for 10 days clean with DWC (Dakins Wound Cleanser) and apply Bacitracin to right leg wound, kerlix and the ace wrap. Last date treatment documented on [NAME] dated 05/17/2019. Skin and Wound Evaluation dated 05/08/2019 revealed Pressure Ulcer, Stage 3 on Right Shin had improved. It is documented, Wound Bed - Epithelial - 100% of wound covered, surface intact. Wound Measurements: Area: 1.0 cm2., Length: 1.8 cm., Width: 0.8 cm. Skin and Wound Evaluation dated 05/14/2019 revealed Pressure Ulcer, Stage 3 on Right Shin had improved. It is documented, Wound Bed - Epithelial - 100% of wound covered, surface intact. Wound Measurements: Area: 0.5 cm2., Length: 1.2 cm., Width: 0.6 cm. Review of Care Plan focus created on 05/17/2019 revealed and is documented in part, as follows: The resident has pressure ulcer (R Shin) R/T (Related To) use of fracture boot. Review of Nurse Progress Note dated 05/21/2019 revealed and is documented in part, as follows: Surgical and mechanical device related pressure wound to right shin healed over at time of wound assessment. Tx (Treatment) ordered discontinued. On 06/07/2019 at approximately 9:15 a.m., the unit nurse was asked to show Resident #122's right shin to the surveyor. The surveyor observed a dry, scabbed linear area on the right shin that was the incision site. The nurse pointed to a tan circular area next to the incision site where the pressure ulcer had been before it healed. The Surveyor observed a boot with velcro straps in the residents room. On 06/07/2019 at 9:45 a.m., an interview was conducted with Registered Nurse (RN) #2 Unit Manager concerning the Pressure Ulcer identified on Resident #122's right shin and she was asked, Has Resident #122 had the same boot since admission? RN #2 stated, Yes. RN #2 was asked, Could the boot be removed? RN #2 stated, Yes. RN #2 was asked, When did the staff remove the boot? RN #2 stated, Resident #122 has a surgical incision on the right leg. The staff removed the boot daily, it was taken off for his treatment on 3-11 shift and he did not sleep in it at night. RN #2 was asked, What can you tell me about the Stage 3 pressure ulcer on the right shin? Did he have 1 or 2 areas on the right shin? RN #2 stated, He had 2 areas. He had a incision site and a pressure ulcer from the boot. The boot rubbed a superficial area with slough on his leg. The Nurse Practitioner saw the wound and ordered antibiotics to include Keflex and Santyl and within a week it was healed. RN #2 was asked, Why wasn't the wound identified before it became a Stage 3? RN #2 stated, The nurse may have not cleansed the wound before staging the area. On 06/07/2019 at 11:20 a.m., an interview was conducted with the Nurse Practitioner and she was asked, What can you tell me about the wound on Resident #122's right shin? The Nurse Practitioner stated, Next to the incision line the skin was red, warm to touch. The incision line had scabbed and in the breaks of the incision line it was draining yellow slough. I ordered Santyl and Keflex, monitored a couple times, asked therapy about the boot not being worn for a bit because they thought the wound was from the boot. I diagnosed it as Cellulitis. On 06/10/2019 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) and the Nurse Consultant. The DON was asked, What caused the wound next to the incision line? The DON stated, Thinking it was Cellulitis, coming from infection. I don't think the nurse assessed it correctly. The DON was asked. Are your nurses trained to assess? The DON stated, Yes. The DON was asked, Do your nurses know how to assess wounds? The DON stated, Yes. The Surveyor stated, The wound was assessed at a Stage 3 when it was identified. The DON was asked, Who assessed the wound? The DON stated, The nurse. The DON was asked, At what stage would you expect the nurses to identify a wound? The DON stated, At a Stage 1. The DON was asked, Do you think the boot caused the wound? The DON stated,Not sure, some of the staff thought so, not sure. Staff documented that the boot caused the wound. On 06/10/2019 at approximately 8:30 p.m. at pre-exit meeting the Administrator, Director of Nursing and Nurse Consultant was informed of the findings. The facility did not present any further information about the finding. *Guidance from www.npuap.org The National Pressure Ulcer Advisory Panel (NPUAP) includes: Stage 3 Pressure Injury (ulcer): Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury Based on staff interviews, clinical record review and facility documentation review the facility staff failed to ensure 2 residents (Residents #99 & Resident #122) of 63 residents in the survey sample received care, consistent with professional standards of practice, to identify a pressure ulcer prior to an advanced stage constituting harm for Resident #99; and inaccurately assessed and documented a pressure ulcer to the shin for Resident #122. 1. The facility staff failed to identify Resident #99's left heel pressure ulcer prior to it being found at an advanced stage resulting in harm. The pressure ulcer was first identified found as an unstageable with 100% eschar (hard black dead tissue). 2. For Resident #122, the facility staff failed to accurately assess and document an area of cellulitis at a surgical incision wound on the right shin. The facility staff inaccurately assessed and documented the area as a stage 3 pressure ulcer. The findings included: 1. Resident #99 was admitted to the facility on [DATE]. Diagnosis for Resident #99 included but not limited to *Type II Diabetes and *Congestive Heart Failure Resident #99's Minimum Data Set (MDS-an assessment protocol) with an Assessment Reference Date of 04/24/19 coded the resident with a 15 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS), indicating no cognitive impairment. In addition, the MDS coded Resident #99 total dependent of one with toilet use, dressing, personal hygiene and transfer, extensive assistance of two with bed mobility and extensive assistance of one with bathing. Under section M Under section (M0150) at risk for developing pressure ulcers was coded yes. Under section (M1200) for skin and treatments was coded for having pressure reducing device for bed. Resident #99's person-centered comprehensive care plan revised on 06/06/19 documented Resident #99 with pressure ulcer and at risk for further skin impairment due to decreased mobility and incontinence. The goal: will have not further skin impairment through the next review. Some of the intervention/approaches to manage the goal included to provide *keep skin clean and dry, moisture barrier cream as needed for protection of skin, pressure reduction mattress and pressure reduction surface to wheelchair. A Braden Risk Assessment Report was completed on 03/29/19; resident scored a 16 indicating at risk for the development of pressure ulcers. Mobility is very limited; makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. Review of Resident #99's Medication Administration Record (MAR) for June 2019 included the following order written on 05/31/19: *Santyl ointment-apply to left heel topically every night shift for wound healing. Cleanse with dermal wound cleanser, apply Santyl, cover with dry dressing. On 06/05/19 at approximately 10:35 a.m., a wound care observation was conducted with License Practical Nurse (LPN) #13. Resident #99 was lying in bed, positioned in a supine position (on her back). Prior to starting wound care, LPN #13 washed her hands and donned a pair of gloves. The LPN removed the old dressing from the left heel wound, removed her gloves, used hand sanitizer, and then applied a new pair of gloves. The left heel wound dressing observed with small amount of yellow drainage with no odor. The left heel wound bed observed with yellow slough; no odor present. The wound was cleansed with wound cleanser in a circular motion x 2; gloves removed, hand sanitizer applied, a new pair of gloves applied, Santyl ointment applied to wound bed with a q-tip, covered with 2 x 2 gauze, covered with coversite, gloves removed, hands washed x 32 seconds. Weekly skin and wound-Total Body Skin Assessment was completed on on 05/30/19 by LPN #12. Under the section for number of new wounds was coded for no new wounds. Review of Resident #99's the clinical record written by LPN #5 revealed the following: - 05/31/19 Resident seen by the Podiatrist with LPN #5; Deep Tissue Injury (DTI), to left heel, cleanse with DWC, apply Santyl, cover with dry dressing. -Clinical note dated 6/3/19 included the following: Left heel wound originally found by podiatry and charge nurse on 05/31/19. Left heel originally a DTI but debrided that day on 05/31/19. Orders received on 05/31/19 for Santyl treatment. Wound assessed by unit manager. Wound bed with minimal slough, and predominant granulated tissue, EP and moist. Wound measurement at time of assessment 3.0 cm x 2.0 cm x 0.1 cm, with moderate drainage noted. The clinical note was written by the RN-Clinical Manager on Unit 3. An interview was conducted with the RN-Clinical Manager on Unit 3 on 06/10/19 at approximately 2:09 p.m., who stated, I did not see Resident #99's pressure ulcer to his heel on 05/31/19. The area was found by the podiatrist and LPN #5; you will need to speak with LPN #5 for further details. She stated, I only documented what was told to me by LPN #5. The review of progress note written by the podiatrist on 05/31/19 at 1:06 p.m., revealed the following information: -Black eschar has formed to the left heel (3 cm x 3 cm (centimeter) and necrotic). -Plan: Debride ulcer to left heel with number 10 blade, apply santyl-treated with santyl and dry dressing applied. Skin & Wound Evaluation completed on 06/05/19 included the following: -Type (Pressure) -Stage (Unstageable: Obsured (sic) full-thickness skin and tissue loss). -Due to (Slough and/or eschar) -Location (Left Heel) -Acquired (In-House Acquired) -How long has the wound been present (05/31/19) -Wound Measurements (0.9 cm x 0.8 cm) -Wound bed (Slough) -% Slough (90% of wound filled) An interview was conducted with LPN #5 on 06/10/19 at approximately 2:42 p.m., who assisted the podiatrist with Resident #99 on 05/31/19. The LPN stated, I was holding Resident #99's foot for the podiatrist when I felt something hard to his left heel. She said the podiatrist looked at the area to his heel. The surveyor asked, When did you first realize that Resident #99 had an unstageable wound to his left heel she replied, I did not know Resident #99 had an area to his left heel until I found it on that day (05-31-19) while assisting the podiatrist. A phone interview was conducted with the *podiatrist on 06/07/19 at approximately at 3:45 p.m. The surveyor asked, On 05/31/19, an area was noted on Resident #99's left heel; can you tell me what you observed? The podiatrist said he was doing a follow up assessment on Resident #99 current wounds (arterial) to his left foot with LPN #5 assisting. He said the nurse was holding the resident's left foot in her hand when she asked me to look because she felt something hard on his heel. The podiatry stated, I observed a hard black pressure ulcer to the heel. The surveyor asked, What stage was the pressure ulcer he replied, The pressure ulcer was an unstageable wound because it was covered with hard black eschar that required debridement. He stated, The wound was debrided, the hard covering was removed with a scalpel blade and after the debridement was done, there was still some eschar present. The podiatrist said he started Santyl ointment to continue with the chemical treatment of the left heel wound. A phone interview was conducted with LPN #12 on 06/10/19 at approximately 5:10 p.m The LPN completed the weekly skin and wound assessment on 05/30/19 that read no new wounds. The LPN stated, I did the resident's skin assessment that day and I did not notice any new areas. The surveyor asked, How long does it take for eschar to develop she replied, It takes a while but it was not there on 05/30/19; that's all I can tell you. An interview was conducted with the Director of Nursing (DON) and Cooperate Nurse on 06/10/19 at approximately 5:35 p.m. The surveyor asked, At what stage do you expect for your nurses to first identify a pressure ulcer she replied, When the skin is red and blanchable but at least by a stage I. A pre-exit meeting was held with the Administrator, Director of Nursing and Cooperate Nurse on 06/10/19 at approximately 8:25 p.m. The facility did not present any further information about the findings at the time of exit. A pressure ulcer prevention policy was requested from the DON and Cooperate Nurse on 06/10/19 at approximately 11:12 a.m. The Cooperate Nurse said the facility does not have a policy on pressure ulcer prevention but did provide a policy on General Wound care/Dressing Changes. The policy was reviewed but did not contain any information on preventing pressure ulcers. Definitions: -Podiatrist is a health professional who diagnoses and treats disorders of the feet (Mosby's Dictionary of Medicine, Nursing & Health Professions). *Diabetes Mellitus Type II is a lifelong (chronic) disease in which there is a high level of sugar (glucose) in the blood (https://medlineplus.gov/ency/article/007365.htm). *Heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. Heart failure does not mean that your heart has stopped or is about to stop working. It means that your heart is not able to pump blood the way it should. It can affect one or both sides of the heart. The weakening of the heart's pumping ability causes blood and fluid to back up into the lungs, the buildup of fluid in the feet, ankles and legs - called edema (mayoclinic.org). *A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). *Santyl is used to help the healing of burns and ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (antibiotics <http://www.webmd.com/cold-and-flu/rm-quiz-antibiotics-myths-facts. *Pressure Injury-Deep Tissue (Persistent non-blanchable deep red, maroon or purple discoloration) Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages).