**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to ensure two of 28 residents did not develop pressure ulcers, and failed to ensure one of 28 residents had prevalon boots in place as ordered by the physician. 1. Resident #24 developed full thickness skin loss to her first (thumb) and fourth finger on her left hand. This was identified as harm by the survey team. 2. Resident #5 did not have weekly skin assessments completed by the nursing staff. On 02/01/2019 a Stage III pressure ulcer was discovered on her left heel. This was identified as harm by the survey team. 3. Resident #2 was not wearing physician ordered prevalon boots. Findings include: 1. Resident #24 was originally admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Hypertension, anxiety, diabetes mellitus, congestive heart failure, and chronic Atrial fibrillation. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24 as having problems with short term memory and daily decision making skills. Initial tour of the facility was conducted on 05/28/2019 at approximately 11:30 a.m. Resident #24 was observed lying in bed. Her left hand was wrapped in gauze. LPN (licensed practical nurse) #4 was in the hallway and was asked about the dressing. She stated, She had an injury .there was some exposed bone. We are doing dressing changes on it .I'm pretty sure we did an X-ray and nothing was broken. The clinical record was reviewed from 05/28/2019 through 05/30/2019. Observed on the POS (physician order sheet) was an order dated 04/12/2019, Cover left thumb with hydrofera blue foam and pad between fingers and palm-Change Q [every] 3 days. A wound team progress note dated 04/12/2019 contained the following information: Visit Information: Called to ck [check] for breakdown of fingers Pain: Patient response screams out when touch [sic] either hand and fights nurse attempting care. Left thumb-thumb may be broken-bone protruding at middle joint-soft-no tone to upper thumb area-all fingers thin and contracted-Some light bleeding at area shown above [referring to picture of injury] and also finger crossing has open tissue. Will need to talk with Dr. about possible X-ray of area and develop plan of care. Cleaned and covered with hydrofera foam and secured . The care plan for Resident #24 included: LTC Skin Intergrity Outcomes included but were not limited to: Skin Integrity Maintained; [Name] will not have further issues from moisture; Minimize risk for skin breakdown r/t [related to] pressure or moisture thru next review'; Interventions included but were not limited to: Apply moisture as needed for dryness; Change dressing to 1st and 4th finger each shift as ordered (Discontinued); Hydrofera blue dsg [dressing] to 1st finger wound on Rt [hand] (Discontinued); Hydrofera blue dsg to Lt [left thumb] every 3 days. On 05/29/2019 at approximately 10:00 a.m., the DON [director of nursing] was in the conference room to speak with the survey team. She was asked to let the wound nurse know that this surveyor needed to see the dressing change to Resident #24's left hand when it was done. The DON left the room and returned a few minutes later. She stated, The dressing was done early this morning .it is only done every three days and is very painful for the resident, if you want to see it we will do it again. The DON was asked if the dressing could be done the following morning [05/30/2019]. She stated she would let the wound nurse know. On 05/29/2019 at approximately 2:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 came to the conference room to discuss the wound on Resident #24's left thumb. She was accompanied by the DON. LPN #6 stated that occupational therapy had been working with Resident #24 in her room doing range of motion to her hand and had informed her that there was a wound present. She stated that she looked at the wound and initiated dressing changes. It was requested that the occupational therapist that had worked with Resident #24 be brought into the conversation. The COTA (certified occupational therapy assistant) that worked with Resident #24 came to the conference room. She stated, We [occupational therapy] picked her up around the end of March for contracture management. At that time her hand was stuck in a fisting position .I first saw her on April 2nd .the skin of her thumb and fingers had fused together .I was working with her and she pulled away .her fingers became unstuck and were open at the knuckle of her thumb .it looked like bone .nursing was informed and they started the dressing changes then. The COTA was asked about an order on the POS dated 01/07/2019 for RNP [restorative nursing] -PROM [passive range of motion] in BUE [bilateral upper extremities] in all planes as tolerated by patient. The COTA stated, She had been getting that, but it stopped when therapy came back in. It was requested that the Restorative aide be brought into the conversation. The CNA (certified nursing assistant) #4 who provided restorative nursing care to Resident #24 came to the room. She was asked about Resident #24's left hand. She stated, We got her back in restorative around the end of December or the first part of January .I did Passive range of motion to her uppers, her arms and hands .when I was working with her there wasn't nothing wrong with her left hand like open areas or anything .her hand was contracted but I could get it open by rubbing it and putting lotion on it to loosen it up .I could move her thumb out and get to her palm, it wasn't stuck in a fist CNA #4 was asked when she stopped providing services. She left the room and returned with documentation. She stated, Here is the referral .we got that on January 7 .I saw her three times a week starting January 10 .my last visit with her was March 21 .therapy was coming in and we can't do restorative if the resident is getting therapy. The COTA was asked when Occupational therapy started. She stated, The evaluation was done on March 28 .it looks like the request was made on March 20 for her to be evaluated for an orthotic for that hand .usually after we get the request it's done in the next day or two .It must have gotten overlooked. The therapist that did the evaluation was a traveler and she is not here any more. The COTA and the Restorative CNA were asked what services Resident #24 received to treat her left hand contractures from 03/21/2019, the day of the last restorative visit until the date of the evaluation, 03/28/2019. Neither could provide an answer. The evaluation completed on 03/28/2019 was presented by the COTA. Per the evaluation: Range of Motion .UE ROM [Upper extremities range of motion]: RUE ROM = Impaired (contractures and deformities present at all joints, able to grasp items); LUE ROM = Impaired (contractures and joint deformities present at all joints of hand, with flexion. Patient's hand contracted in flexion) .Joints: Shoulder = WFL [within functional limits]; Elbow/Forearm = WFL, Wrist = WFL; Hand = Impaired; Shoulder = WFL; Elbow/Forearm = Impaired (contracted in elbow flexion); Wrist = Impaired (contracted in extension); Hand = Impaired (all digits and joints contracted and deformities present, in flexed position). The COTA was asked what a flexed position meant. She stated, Her hand was fixed in a fist. A previous evaluation from OT dated 11/26/2018 was also presented by the COTA. The assessment summary contained the following description of Resident #24, Functional Limitations as a result of Contractures: Patient presents with multiple contractures to her bilateral wrists and digits. Her right wrist contracted in a flexed position and left contracted in a position of extension. Patient exhibits swan neck deformity to digits bilaterally . The COTA was asked what a swan neck deformity was. She stated, Her fingers turned up on the ends. She was asked if there was a decline between the two evaluations. She stated, Yes. The COTA was asked what could have been done to keep Resident #24's hand from becoming fixed in a fist and her fingers stuck together. She stated, Hand hygiene .if you are cleaning the hand and massaging it to help the contractures, the skin won't fuse between the fingers and cause pressure as they rest on each other. She was asked how long it would take for Resident #24's hand to be in that condition if hand hygiene wasn't performed. She stated, Just a couple of days. The COTA was asked if the wound on Resident #24's hand was from pressure. She stated, Yes, from her fist being contracted and fixed. She was asked if she thought it was avoidable. She stated, Yes, if hand hygiene was provided that would have kept her fingers from being stuck together. One of the therapy technicians, (OS #10) came into the conference room during the interview. She and the COTA were asked how long they had been doing their jobs and had they ever seen anything like this before. The COTA stated, I've been doing this since 2018, I've never seen it happen before. OS #10 stated, I've been doing this for ten years, I've never seen this happen before. After the interviews discussed above, the DON was asked to present any additional information regarding the pressure area to Resident #24's left thumb. Further review of the clinical record was conducted. A skin integumentary note dated 04/04/2019 contained the following: 1st and 4th finger full thickness skin loss. Yellow and pink tissue noted to both areas. Depth noted to first finger. Resident fighting with staff while trying to assess. Foam dressing applied. Bleeding noted. MD aware. Stated to have treatment nurse address. On 04/12/2019 after the wound nurse evaluated Resident#24, a recommendation was made to send her to the emergency room. Transfer comments on the facility transfer note included: Resident sent to ER due to possible bone exposure to left thumb . The emergency room visit note dated 04/12/2019 included the following: .Patient presents for wound evaluation .open wound of left thumb. Patient digits are significantly contracted. Pt is non-verbal but it is apparent that the area is causing her pain .Musculoskeletal: Upper extremities: All digits malformed due to contractures. Exposed bone to IP joint of left thumb, medial aspect .area is extremely tender when manipulated . An X-ray was obtained. The report included: Two fingers of he left hand were stuck together. When they were separated the fingers, a sore was noted which exposed the bone of the left thumb. Given the degree of the contraction, the left thumb is very limitedly assessed. No gross abnormalities of thumb are noted. There does appear to be a pencil in cup type deformity involving the 5th PIP joint suggesting psoriatic arthritis. Impression: The hand is severely contracted. The left thumb is visualized. No gross abnormalities of the thumb are noted . An orthopedic consult was obtained on 04/15/2019, and contained the following: .Patient is extremely demented .Patient have [sic] deep laceration on dorsal aspect of the thumb. The thumb is deformed and curled up most probably from chronic arthritis. All fingers are deformed .At this point I recommend to continue daily dressing changes. I attempted to call patient's son who is POA [power of attorney] we discussed her treatment options. I suggested attempt to primarily close the laceration versus amputation of the thumb. The thumb is completely nonfunctional because of the significant deformity. The thumb is curled up under the index finger. Open wound can lead to infection and amputation might be better option with [AGE] year-old female patent having complete dementia and significant deformity of the thumb. The son wanted to see if there is any chance for wound will heal by itself. I stated that we can continue daily dressing change and check again within 1 week. If infection develops or wound worsens, then we can consider surgical treatment otherwise will continue daily dressing change by nurse . A follow-up orthopedic appointment on 04/17/2019 contained the following information: .Examination of the left thumb IP joint is difficult given the patient's dementia and combativeness when attempting to examine her left thumb given the amount of pain. The wound was examined by the wound care specialist .she feels minor granulation is starting. She has redressed the wound with hydrofera Blue and has agrees to continue watch and dressing changes every three days . During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that per interviews conducted with staff, Resident #24's hand was not fixed in a fist when restorative nursing was working with her. The hand could be opened and the thumb moved. Restorative was discontinued on 03/21/2019. There are no documented interventions from 03/21/2019 until 03/28/2019 when occupational therapy reevaluated her. When the COTA came in the room to do therapy on 04/04/2019, the fingers were stuck together and when Resident #24 pulled away, they became unstuck with resulting full thickness wounds. They were informed that the injury was being investigated at a harm level. A dressing change was observed on 05/30/2019 with LPN #6. An additional staff member was in the room to assist. LPN #6 used good technique to remove the old dressing. The wound on the left thumb was difficult to visualize as the resident pulled away from the nurse stabilizing her arm. The area that could be seen was open and bright red. At approximately 1:30 p.m., LPN #7 was asked if she could pull the bath record for Resident #24 and ascertain who bathed her from 03/21/2019 through 03/28/2019. She stated that the baths were divided up per shift on the unit. Resident #24 was bathed on the night shift. She pulled the requested information up on the computer. Per the documentation, Resident #24 received a bed bath every night and had one whirlpool bath during that time frame. LPN #7 stated, She has never been in the whirlpool, I don't know why that's there. She was asked if she could tell who bathed her. She stated she would try to run a report and bring the information to the conference room. On 05/30/2019 at approximately 2:55 p.m., the DON, the administrator and the QA (Quality Assurance) nurse came to the conference room to discuss Resident #24. The DON stated, We can't explain what happened from March 21 through March 28, there is no documentation showing what, if anything, was being done with her hand .but we have information that the therapist and the nurses were working together to treat her after that. The DON was informed that there were no issues with the treatment documented before March 21 or after the evaluation on March 28, the concern based on staff interviews, was the time frame after restorative was discontinued and the evaluation done seven days later by occupational therapy. The DON stated that she understood. The DON was asked who should have been providing hand hygiene to Resident #24. She stated, The CNA doing her bath should be doing that. The name and phone number of the CNA who had bathed Resident #24 on the night shift was requested. At approximately 3:45 p.m., the requested information for the CNA (CNA #22) who bathed Resident #24 on the night shift for five of seven nights between 03/21/2019 and 03/28/2019 was received. She was contacted via telephone at approximately 4:00 p.m. and interviewed regarding Resident #24. She was asked if she had cared for Resident #24 during the week of 03/21/2019 through 03/28/2019. She stated, Yes. She was asked what care she had provided. She stated, I turn her, I get her something if she needs it and I bathe her. CNA #22 stated, I start at her face and go down. I wash her face, her neck, her chest her arms, her hands, and work my way down all the way to her feet. CNA #22 was asked if she had washed Resident #24's hand. She stated, Yes, I run the wash cloth between her fingers. She was asked if she had done range of motion on Resident #24's left hand. She stated, I run the washcloth in and out between her fingers. She was asked if she had been able to open Resident #24's left hand at all or move her thumb. She stated, I run the washcloth in and out between her fingers. No further information was obtained prior to the exit conference on 05/30/2019. 2. Resident #5 admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Dementia, contracture of the hip joint, lumbar spine osteoarthritis, anxiety and depression. The a quarterly MDS (minimum data set) with an ARD (assessment reference date of 05/18/2019, assessed Resident #24 as being severely impaired in her cognitive status, with a summary score of 05. The clinical record was reviewed on 05/29/2019 at approximately 10:30 a.m. The POS (physician order sheet) did not contain any orders for pressure ulcer care. The quarterly MDS of 05/18/2019 documented that Resident #5 was at risk for pressure ulcers. The integumentary section of the clinical record was reviewed. On 02/01/2019, the following was documented: Stage III, 2.2 cm length, 2 cm width, Pressure Ulcer Bed description: Granulation tissue, non-granular, pale, pink, yellow; Pressure Ulcer Exudate Description: Serosanguinous, Small amount, Moderate Amount, Odor absent, Other: dried. The care plan for Resident #5 was reviewed and contained the following: LTC [long term care] Skin Integrity. Outcomes included but were not limited to: Skin Integrity Maintained. Interventions included but were not limited to: Monitor skin condition every shift. On 05/29/2019 at approximately 3:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 was interviewed regarding the pressure ulcer on Resident #5's heel. She stated, We found it [the pressure ulcer] at a Stage three. LPN #6 was asked how often skin assessments were done by the nurses. She stated, They are suppose to be done weekly. She was asked how an area could be found at a stage three if weekly skin assessments were done. She stated, That's what we wondered when it was found. LPN #6 was asked to pull up the weekly skin assessments done prior to 02/01/2019. She looked in the computer and stated, There was one done on 12/05/2018 that documents her contractures and one on 01/02/2019 that documented an abnormality, but that's all that I see. She was asked what the abnormality on 01/02/2019 was. She stated, I can't tell. LPN #6 stated, She was admitted to us with contractures .her left leg crosses over her right at the hip .her legs are crossed scissorlike from the top of her leg .she has prevalon boots and we float her heels but she still got that place on her heel .it's all healed up now. During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that there was no documentation of weekly skin assessments and a pressure ulcer had been found on Resident #5's heel at a stage III. The DON was asked if other than the integumentary screen, was there any place else the weekly skin assessments would be documented. She stated she would look. On 05/30/2019 at approximately 7:30 a.m., LPN #3 was interviewed. She stated that Resident #5's skin was assessed on the night shift. She stated she had documented that abnormality in regard to the resident's thighs. She stated, Her legs are twisted I was documenting about the way her thighs are pushed together .I don't always have her. On 05/30/2019 at approximately 11:15 a.m., Resident #5 was observed with LPN #6. Resident #5 was lying in bed on her back. When the covers were pulled back, her legs were crossed at the hip level, her left foot was on her right side and her right foot was on the left side. She was wearing bilateral prevalon boots. She stated, What are you doing momma? Don't touch my feet momma. LPN #6 explained what she was going to do, she removed the prevalon boot and lifted the left foot revealing the heel which was healed. On 05/30/2019 at approximately 2:45 p.m., the DON was in the conference room. Concerns were voiced regarding the identification of the pressure area discovered at a Stage III on Resident #5's foot. She stated, I know .we had a mock survey in April. They identified problems with the staging of pressure ulcers and weekly skin assessments. I am working on the plan of correction and we have done some education but we aren't done yet. The DON was asked if there was any additional documentation as the survey team was identifying the pressure ulcer as harm. She stated, We don't have anything else. No further information was obtained prior to the exit conference on 05/30/2019. 3. Resident #2 was admitted to the facility on [DATE]. Her diagnoses included but were not limited to: Diabetes Mellitus, Hemiplegia, hypertension, dementia, depression, and anxiety. A quarterly MDS (minimum data set) was an ARD (assessment reference date) of 02/18/2019, assessed Resident #2 as severely impaired in her cognitive status, with a summary score of 05. On 05/28/2019 at approximately 12:00 p.m., Resident #2 was observed lying in bed. She was tearful and when asked what was wrong she stated, My foot hurts and my leg .I sprung it .I fell in a hole last night. LPN (licensed practical nurse) #4 was in the hallway and was assigned to Resident #2. She was asked if Resident #2 had any recent falls. She stated, No. She was asked if she knew what had happened to Resident #2's leg and foot. She stated, It looked bruised to me earlier today when I looked at it .she crosses one foot over the other. Resident #2 was observed with LPN #4. LPN #4 lifted the covers, exposing Resident #2's legs. Resident #2 had her right foot resting on top of left foot. A discolored area was observed on top of the left foot. A Skin tear and bruising were noted on the right shin. Steri strips were in place over a skin tear on the left shin. LPN #4 was asked about Resident #2's legs. She stated, Her skin is very fragile .they [CNAs] can tear it when they are taking her clothes off. She was asked what the facility was doing to protect/prevent that from happening. She stated, I can probably get her some protectors to put over them. LPN #4 stated She has an order for prevalon boots . I am going to put them on her after she eats lunch. LPN #4 then pointed to her computer screen and the order for the prevalon boots, .Prevalon boots as tolerated . LPN #4 was asked if they were to be on all the time, she stated, Yes. She was asked if she had offered them to her. She stated, I didn't ask her earlier, I don't know about the CNA [certified nursing assistant] I usually try to go through all my orders when I get here, but I haven't gotten to that yet. At approximately 12:35 p.m., CNA #23 was interviewed regarding Resident #2's prevalon boots. She stated, I offered to put her socks on today and she didn't want them .I didn't offer the prevalon boots .she usually won't let you put them on her. Resident #2 was observed with her prevalon boots in place after lunch. At approximately 3:22 p.m., LPN #4 stated, I really don't think that is a bruise on [Name of Resident #2] left foot, I think that is a site of an old skin tear. LPN #4 was asked why Resident #2 was ordered to have prevalon boots. She stated, To keep her from getting breakdown on her heels and to help protect her legs. The POS (physician order sheet) was reviewed on 05/28/2019 at approximately 4:00 p.m. The following order was observed: 02/05/2019 Skin care: Site: Left Site: Rt [right] heel, Prevalon booties/booties as tolerated, check for placement every shift . The care plan for Resident #2 was requested and received. The following information was observed: LTC [long term care] Skin Integrity; Outcomes included but were not limited to: Skin Integrity Maintained. Interventions included but were not limited to: Apply skin moisturizer for dryness; Monitor skin condition every shift. There was no mention of the prevalon boots on the care plan. Resident #2 was observed with her prevalon boots on bilaterally throughout the day on 05/29/2019. During an end of the day meeting on 05/29/2019 with the DON (director of nursing) and the administrator, the above information was discussed. The DON was asked if there was a treatment record that the nurse's used to remind them to check for things like whether or not the prevalon boots were in place. She stated, No. No further information was obtained prior to the exit conference on 05/30/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, the facility staff failed to provide services to prevent an avoidable decline in range of motion for one of 28 residents, Resident #24. Resident #24 suffered an increase in the contractions of her left hand. Restorative nursing was being provided three times per week and was stopped on 03/21/201 pending an evaluation by occupational therapy for a hand orthotic. The evaluation was not done until 03/28/2019. At the time of the evaluation on 03/28/2019, Resident #24's hand had contracted into a fixed fist and the skin on her fingers had fused together. This was identified as harm by the survey team. Findings were: Resident #24 was originally admitted to the facility on [DATE]. Her diagnosis included but were not limited to: Hypertension, anxiety, diabetes mellitus, congestive heart failure, and chronic Atrial fibrillation. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 03/04/2019 assessed Resident #24 as having problems with short term memory and daily decision making skills. Initial tour of the facility was conducted on 05/28/2019 at approximately 11:30 a.m. Resident #24 was observed lying in bed. Her left hand was wrapped in gauze. LPN (licensed practical nurse) #4 was in the hallway and was asked about the dressing. She stated, She had an injury .there was some exposed bone. The clinical record was reviewed from 05/28/2019 through 05/30/2019. Observed on the POS (physician order sheet) was an order dated 04/12/2019, Cover left thumb with hydrofera blue foam and pad between fingers and palm-Change Q [every] 3 days. The care plan for Resident #24 included the following: LTC ADL [long term care activities of daily living] Function Rehab Outcomes included but were not limited to: Resident Will Not Have a Decline in Level of ADL Function; Interventions included but were not limited to: RNP-PROM BLE in all planes as tolerated. LTC Musculoskeletal Outcomes included but were not limited to: [Name} will not have further decline of her bilateral hand contractions'; [Name} will allow staff to clean, move her bil. hands to prevent further declin in contracture. Interventions included but were not limited to: Position [Name] upper extremities, hands for comfort and to prevent immobility complications. On 05/29/2019 at approximately 2:00 p.m., the wound nurse, LPN (licensed practical nurse) #6 came to the conference room to discuss Resident #24's left thumb. She was accompanied by the DON. LPN #6 stated that occupational therapy had been working with Resident #24 in her room doing range of motion to her hand and had informed her that there was a wound present. It was requested that the occupational therapist that had worked with Resident #24 be brought into the conversation. The COTA (certified occupational therapy assistant) that worked with Resident #24 came to the conference room. She stated, We [occupational therapy] picked her up around the end of March for contracture management. At that time her hand was stuck in a fisting position .I first saw her on April 2nd .the skin of her thumb and fingers had fused together .I was working with her and she pulled away .her fingers became unstuck and were open at the knuckle of her thumb .it looked like bone .nursing was informed and they started the dressing changes then. The COTA was asked about an order on the POS dated 01/07/2019 for RNP [restorative nursing] -PROM [passive range of motion] in BUE [bilateral upper extremities] in all planes as tolerated by patient. The COTA stated, She had been getting that, but it stopped when therapy came back in. It was requested that the Restorative aide be brought into the conversation. The CNA (certified nursing assistant) #4 who provided restorative nursing care to Resident #24 came to the room. She was asked about Resident #24's left hand. She stated, We got her back in restorative around the end of December or the first part of January .I did Passive range of motion to her uppers, her arms and hands .when I was working with her there wasn't nothing wrong with her left hand like open areas or anything .her hand was contracted but I could get it open by rubbing it and putting lotion on it to loosen it up .I could move her thumb out and get to her palm, it wasn't stuck in a fist CNA #4 was asked when she stopped providing services. She left the room and returned with documentation. She stated, Here is the referral .we got that on January 7 .I saw her three times a week starting January 10 .my last visit with her was March 21 .therapy was coming in and we can't do restorative if the resident is getting therapy. The referral contained the following information: Restorative Nursing Program Referral .Program: PROM [checked]. Goals to Maintain Resident's Current Functional Status: 1. PROM to BUE [bilateral upper extremities] in all planes as tolerated by patient.; Frequency: 3 X week/ 12 weeks [3 times per week for 12 weeks]; Start Date: 1-10-19. The form was signed by CNA #4 and the traveling OT who was no longer at the facility. The COTA was asked when Occupational therapy started. She stated, The evaluation was done on March 28 .it looks like the request was made on March 20 for her to be evaluated for an orthotic for that hand .usually after we get the request it's done in the next day or two .It must have gotten overlooked. The therapist that did the evaluation was a traveler and she is not here any more. The COTA and the Restorative CNA were asked what services Resident #24 received to treat her left hand contractures from 03/21/2019, the day of the last restorative visit until the date of the evaluation, 03/28/2019. Neither could provide an answer. The evaluation completed on 03/28/2019 was presented by the COTA. Per the evaluation: Range of Motion .UE ROM [Upper extremities range of motion]: RUE ROM = Impaired (contractures and deformities present at all joints, able to grasp items); LUE ROM = Impaired (contractures and joint deformities present at all joints of hand, with flexion. Patient's hand contracted in flexion) .Joints: Shoulder = WFL [within functional limits]; Elbow/Forearm = WFL, Wrist = WFL; Hand = Impaired; Shoulder = WFL; Elbow/Forearm = Impaired (contracted in elbow flexion); Wrist = Impaired (contracted in extension); Hand = Impaired (all digits and joints contracted and deformities present, in flexed position). The COTA was asked what a flexed position meant. She stated, Her hand was fixed in a fist. A previous evaluation from OT dated 11/26/2018 was also presented by the COTA. The assessment summary contained the following description of Resident #24, Functional Limitations as a result of Contractures: Patient presents with multiple contractures to her bilateral wrists and digits. Her right wrist contracted in a flexed position and left contracted in a position of extension. Patient exhibits swan neck deformity to digits bilaterally . The COTA was asked what a swan neck deformity was. She stated, Her fingers turned up on the ends. She was asked if there was a decline between the two evaluations. She stated, Yes. The COTA was asked if the delay in the evaluation and lack of restorative during that time could have contributed to the decline. She stated, Yes. The COTA was asked what could have been done to keep Resident #24's hand from becoming fixed in a fist and her fingers stuck together. She stated, Hand hygiene .if you are cleaning the hand and massaging it to help the contractures, the skin won't fuse between the fingers and cause pressure as they rest on each other. She was asked how long it would take for Resident #24's hand to be in that condition if hand hygiene wasn't performed. She stated, Just a couple of days. The COTA was asked if the wound on Resident #24's hand was from pressure. She stated, Yes, from her fist being contracted and fixed. She was asked if she thought it was avoidable. She stated, Yes, if hand hygiene was provided that would have kept her fingers from being stuck together. One of the therapy techs, (OS #10) came into the conference room during the interview. She and the COTA were asked how long they had been doing their jobs and had they ever seen anything like this before. The COTA stated, I've been doing this since 2018, I've never seen it happen before. OS #10 stated, I've been doing this for ten years, I've never seen this happen before. During an end of the day meeting on 05/29/2019 with the DON and the administrator, concerns were voiced that per interviews conducted with staff, Resident #24's hand was not fixed in a fist when restorative nursing was working with her. The hand could be opened and the thumb moved. Restorative was discontinued on 03/21/2019. There were no documented interventions from 03/21/2019 until 03/28/2019 when occupational therapy reevaluated her. When the COTA came in the room to do therapy on 04/04/2019, the fingers were stuck together and when Resident #24 pulled away, they became unstuck with resulting full thickness wounds. On 05/30/2019 at approximately 2:55 p.m., the DON, the administrator and the Quality Assurance nurse came to the conference room to discuss Resident #24. The DON stated, We can't explain what happened from March 21 through March 28, there is no documentation showing what if anything was being done with her hand .but we have information that the therapist and the nurses were working together to treat her after that. The DON was informed that there were no issues with the treatment documented before March 21 or after the evaluation on March 28, the concern based on staff interviews, was the time frame after restorative was discontinued and the evaluation done seven days later by occupational therapy. The DON stated that she understood. The DON was asked who should have been providing hand hygiene to Resident #24. She stated, The CNA doing her bath should be doing that. The name and phone number of the CNA who had bathed Resident #24 on the night shift was requested. At approximately 3:45 p.m., the requested information for the CNA (CNA #22) who bathed Resident #24 on the night shift for five of seven nights between 03/21/2019 and 03/28/2019 was received. She was contacted via telephone at approximately 4:00 p.m. and interviewed regarding Resident #24. She was asked if she had cared for Resident #24 during the week of 03/21/2019 through 03/28/2019. She stated, Yes. She was asked what care she had provided. She stated, I turn her, I get her something if she needs it and I bathe her. CNA #22 stated, I start at her face and go down. I wash her face, her neck, her chest her arms, her hands, and work my way down all the way to her feet. CNA #22 was asked if she had washed Resident #24's hand. She stated, Yes, I run the wash cloth between her fingers. She was asked if she had done range of motion on Resident #24's left hand. She stated, I run the washcloth in and out between her fingers. She was asked if she had been able to open Resident #24's left hand at all or move her thumb. She stated, I run the washcloth in and out between her fingers. No further information was obtained prior to the exit conference on 05/30/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and clinical record review, the facility staff failed to ensure sufficient fluid intake to maintain proper hydration for one of 28 residents in the survey sample, Resident #45. Resident #45 was admitted to the hospital with a primary diagnoses of dehydration due to not receiving physician ordered fluids to keep hydrated. This was identified as harm. The Findings Include: Resident #45 was admitted to the facility on [DATE]. Diagnoses for Resident #45 included; Anemia, chronic kidney disease, crohn's disease, and dumping syndrome. The most current MDS (minimum data set) was a initial assessment with an ARD (assessment reference date) of 3/7/19. Resident #45 was assessed with a score of 15 indicating cognitively intact. On 5/29/19 at 8:45 AM Resident #45 was interviewed. During the interview Resident #45 was asked about being admitted to the hospital. Resident #45 stated that she had recently been admitted to the hospital twice, one time for infection the other time because of dehydration. A central line (Peripherally Inserted Central Catheter [PICC] line) inserted into the chest area was observed. When asked about the PICC line, Resident #45 stated the PICC line was inserted because of receiving fluids each night so that she doesn't get dehydrated. Resident #45 stated that she has dumping syndrome and if she eats or drinks too much at one time the fluids and food dump out into a colostomy without being absorbed. On 5/29/19 Resident #45's clinical chart was reviewed. A nursing note dated 2/20/19 documented Blue lumen [line] PICC torn, red line patent and flushes without difficulty. On call MD [name of nurse practitioner] notified. Advised to call ER [emergency room] to see if someone is available to replace. Call placed to ER nurse in ER states no one available to replace PICC tonight. States infusion can be run in red lumen. ER nurse stated by being a two line PICC nothing will come out of the blue line because it is a separate line. Staff will secure blue line until able to replace in am. DON [director of nursing] notified. Another clinical note dated 2/23/19 by the emergency department documented Patient has a hx [history] of dumping syndrome and receive around a liter of fluids everyday. Her [Resident #45] PICC line has a hole in it so it can not [sic] be used until it is fixed. She [Resident #45] has not received fluids for 3 days. C/O [complaint of] dehydration, no appetite, HA [headache], stomach pain. A surgery consult dated 2/25/19 evidenced that Resident #45 had a surgical procedure performed (replacement of PICC line) due to a [ .] malfunctioning [NAME] [central line] catheter and the patient was unable to use get [sic] IV [intravenous] fluids and is dehydrated on admission [ .] The hospital records also included an image of the torn PICC line and documentation that read note tape on line-there is damage and line is split - port not in use needs replacement of [NAME] [central line] split in tubing [ .] continues with heavy producing ileostomy which requires fluid replacement. [ .] Note the image showed that there were 2 lines (ports of entry) to the central line (indicating if one line can't be used then the other line can be). A hospital discharge summary evidenced that Resident #45 was discharged back to the facility on 2/27/19 with a diagnoses of dehydration. Resident #45's physician orders were reviewed for the month of February 2019 and evidenced an order was in place for Resident #45 to receive Sodium Chloride 1,000 ML [milliliters] IV bedtime, [ .] use rate of 125 ML per hour [ .] Resident #45 medication administration record (MAR) for the month of February 2019 was then reviewed. The MAR evidenced that Resident #45 did not receive IV fluids via central line on 2/20/19, 2/21/19, and 2/22/19 documenting no iv access [sic]. This documentation was written by three different nurses (a different nurse for each day). Resident #45's care plan (for the time period in question) was then reviewed. A care plan for Dehydration/Fluid Maintenance had been initiated with interventions that included encourage fluids and to give IV fluids nightly. On 05/30/19 at 11:15 AM, license practical nurse (LPN) #9, identified as one of the nurses who were assigned to Resident #45 and did not give IV fluids on one of the nights identified above, was interviewed via telephone. LPN #9 was asked about Resident #45 not receiving fluids during a shift that LPN #9 had worked. LPN #9 stated that the PICC line was torn and couldn't be used. LPN #9 was asked if the second line could be accessed. LPN #9 stated that she thought that there was only one line. It was explained to LPN #9 that according to documentation and an image of the PICC line, there were two access points. LPN #9 stated that she really could not remember but if there were two access lines, then she would have used the other line unless that line could not be accessed. The other nurses that did not give IV fluids were unavailable to interview. One of the nurses no longer worked at the facility and the other nurse was a part-time nurse on an as needed basis and unable to be contacted. On 5/30/19 at 11:45 AM, the director of nursing (DON) was informed of the above concern and was asked to present any additional information regarding physician notification of the fluids being stopped due to torn PICC line or any physician orders regarding the PICC line. The DON presented a nursing note dated 2/25/19 (indicating a late entry) that read provider updated on care status: MD [Medical Doctor] was notified due to central line was not in use and resident is on iv fluids. MD gave orders to hold fluids until line is replaced. The date of when the physician was notified was given as 2/21/19. There was no evidence provided that an actual physician order was placed in Resident #45's clinical record to stop the IV fluids, and the MAR did not evidence that the IV fluids had been placed on hold. On 05/30/19 at 3:10 PM the administrator and DON, were informed of concerns about the nursing note indicating that the physician was informed on 2/21/19 and that the physician stated to stop the IV fluids without any indication when a new PICC line was going to be replaced or any order regarding how Resident #45 was going to receive sufficient fluid intake to ensure hydration. The DON stated that the clinical coordinator should have certainly followed up on stopping the fluids and when a PICC line was going to be replaced. On 05/30/19 at 3:21 PM, Resident #45's physician was interviewed via telephone. The physician stated that he was aware that the PICC line could not be use and also stated this has happened before and it usually only takes a day to get a Resident into the hospital so that a new PICC line can be placed. The physician stated that he was aware of Resident #45's dumping syndrome but by encouraging the Resident to drink fluids then there was usually no concern for dehydration for a day but would not be appropriate for a long period of time. The physician stated that he had never seen a PICC line take a long time to be scheduled to get replaced and would think that staff would have let him know that the Resident had not had IV fluids for 3 days. The physician also stated that he was not aware of Resident #45's condition until Resident #45 was admitted to the hospital. The physician stated this was a lesson learned. On 05/30/19 at 3:40 PM, Resident #45 was interviewed regarding going to hospital due to dehydration. Resident #45 stated that the staff didn't give her fluids for 3 evenings and she became dehydrated. Resident #45 stated that she has been dehydrated before and when the feeling comes on then she goes down hill fast. When asked if the staff were giving oral fluids, Resident #45 stated she can't drink that much fluid because she has just a small section of colon and the fluids don't get absorbed and go right through due to dumping syndrome. Resident #45 was asked how long the PICC line had been in place. Resident #45 stated it had been in place since she was admitted to the facility and that it really helps with hydration. No other information was presented prior to exit conference on 5/30/19.