**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary supervision for 1 of 3 residents (Resident 1) reviewed for wandering and elopement. The failure to provide necessary supervision caused harm to Resident 1 when found cold, wet, and confused after exiting the facility unsupervised, falling from their wheelchair (w/c) and subsequently located by a community member lying on the side of the road. Based on the reasonable person concept, Resident 1 was harmed and distressed not knowing where they were, how long they would lay there, or what might happen to them. This facility failed practice placed other residents at risk for elopement and injury. Findings included . Review of the facility's, Elopement/Unsafe Wandering policy, revised 01/2022, residents are assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment. The facility would provide the safest environment through an appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance, anxiety disorder, delusional disorder (a type of psychotic disorder), and alcohol and nicotine dependence in remission. Review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated 02/08/2023, showed the resident had wandering behaviors which occurred one to three days of the observation period. The wandering significantly intruded on privacy or activity of others and was worse compared to their prior MDS assessment. Resident 1 required supervision with physical assist of one staff for dressing, toileting, and hygiene, and required supervision and set-up help for locomotion. Review of Resident 1's orders revealed they had a Wander Guard (a system where the resident wore a bracelet and sensors mounted on doors sent alarms when the resident attempted to open the door) bracelet on their wheelchair (w/c), placed on 12/13/2022. Review of Resident 1's progress note, dated 02/04/2023, documented the resident tried to get out the door and stated they wanted to go home. Review of a progress note, dated 02/05/2023, documented Resident 1 was very agitated all night shift, packed their belongings, and went outside twice. Review of a progress note, dated 02/10/2023, documented Resident 1 got outside three times through three different doors during the night shift. Review of Resident 1's Medication Administration Record and Treatment Administration Records for March 2023, showed nursing staff monitored the resident for episodes of anxiety, as evidenced by agitation when redirected, perseveration about going home with their mother, or finding their dogs. Documentation showed the resident had symptoms ten times on the night shift (10:00 PM to 6:00 AM) on 03/14/2023-03/15/2023 when they eloped. Review of documentation for other night shifts in March 2023, showed the resident had symptoms between one and five times on four other nights, and no symptoms the remaining 26 nights. Review of Resident 1's most recent elopement/wandering evaluation, dated 03/15/2023, the date of elopement, showed the resident was mobile in their w/c, had intermittent confusion, made statements of desire to leave, and wandering placed them at significant risk of getting to a dangerous place. The assessment showed the resident's wandering was aimless, and their wandering was described as worse from the prior elopement/wandering assessment, completed on 07/09/2022. Review of the Montreal Cognitive assessment (MOCA), a rapid screening instrument for cognitive dysfunction, dated 03/17/2023, documented Resident 1 scored 10 out of 30 points. Scores of 10-17 may indicate moderate cognitive impairment. Scores of less than 10 show severe cognitive impairment. Review of the facility investigation, dated 03/15/2023, revealed a community member (CM-1) found Resident 1 somewhere between the facility and a nearby assisted living facility (ALF), and brought the resident to the ALF because they did not know where they lived. The nursing home facility staff brought Resident 1 back to the facility via their w/c. The ALF staff informed the facility staff that Resident 1 had arrived at the ALF at 4:10 AM, and they had immediately provided the resident with warm blankets. The facility's Director of Nursing Services (DNS) reported to the nursing home facility staff to immediately check all exit doors for function of the Wander Guard system and found the wander guard component, located at the exit door by the kitchen area, was not functioning properly. Staff statements were attached to the facility investigation documents. Review of an undated statement signed by Staff A, Registered Nurse (RN), documented Staff A reported Resident 1 had wandered since 1:00 AM the night of the elopement and they had last seen Resident 1 at 3:55 AM. Staff A reported they were informed at 4:30 AM Resident 1 had been found outside the facility and had been brought to a nearby ALF. Review of a statement, dated 03/15/2023, showed Staff E, Licensed Practical Nurse (LPN), documented they went to the ALF and brought Resident 1 back at 4:45 AM. Staff E documented Resident 1 was wearing shoes and a jacket. Review of a statement, dated 03/15/2023, showed Staff D, Nursing Assistant (NA), documented they last saw Resident 1 when the resident received medication from the nurse, and then they received a call at 4:30 AM, from a friend who worked at the nearby ALF, that Resident 1 was there. Review of a statement, dated 03/15/2023, showed Staff B, NA, documented Resident 1 was wandering from 1:00 AM on 03/15/2023, and they had last seen the resident at 3:30 AM. Staff B stated they started their rounds at 3:45 AM. Review of a statement, dated 03/15/2023, showed Staff C, NA, documented they observed Resident 1 wandering up and down the hall numerous times during the night shift, and the last time they saw the resident was at 3:00 AM when they started their rounds. Review of Resident 1's hospital records, dated 03/15/2023 - 03/16/2023, showed Resident 1 was evaluated in the Emergency Department (ED) and was diagnosed with a urinary tract infection. In an interview on 04/04/2023 at 12:45 PM, showed Staff F, NA, stated they had observed Resident 1 attempt to exit the facility at times. In an interview on 04/04/2023 at 1:09 PM, Resident 1 stated they did not know why they had left the building that night and did not know where they were going. Resident 1 was unable to provide any details other than stating staff came and got them from wherever they were. In an interview on 04/04/2023 at 1:32 PM, Staff G, NA, stated Resident 1 had exited through the 100-hall door the previous day about 10:30 or 11:00 AM and another NA had brought them back inside. Staff G stated prior to the elopement, Resident 1 would attempt to exit the building and staff would stop them. In a telephone interview on 04/06/2023 at 10:10 AM, Staff B stated they were Resident 1's assigned NA on the night of their elopement. Staff B stated Resident 1 had not wandered much at night in the past; however, recently had been wandering about two nights a week of which they were aware. Staff B stated on the night of Resident 1's elopement, staff had tried to keep an eye on the resident because they were wandering so much. Staff B stated they had last seen Resident 1 between 3:30 AM and 3:45 AM and started doing last resident care rounds close to 4:00 AM. Staff B stated one of the other staff received a call from a nearby ALF that Resident 1 was there, and Staff E brought Resident 1 back to the facility. Staff B stated Resident 1 complained of being cold when they had assisted Staff A to assess the resident for injury. Staff B stated Resident 1 had been wearing a dress, jacket, and slippers that night. In an interview on 04/06/2023 at 1:00 PM, the DNS stated Staff E had picked up Resident 1 from the ALF the night of the elopement, and stated Staff E was currently out of the country. The DNS stated Resident 1 was seen in the ED the day of the elopement and tested positive for a urinary tract infection. In an interview on 04/06/2023 at 3:40 PM, Staff H, LPN, stated this was the first they had heard that Resident 1 had eloped. Staff H stated Resident 1 had gotten out the door in the past, but staff had gone out and brought her back in the facility. In a telephone interview on 04/07/2023 at 10:36 AM, a CM-1 stated when driving home from work on 03/15/2023 at approximately 4:00 AM, they saw a w/c on the side of the road the facility was located on. CM-1 stated they did not know the precise location of the nursing home facility as they were not familiar with it, but according to landmarks discussed with CM-1, it appeared it was a short distance north of the facility. CM-1 stated the weather was cold, was raining quite hard, and visibility had been poor. CM-1 stated they slowed down and saw a person laying in the gutter still partially on the road, obscured by the w/c. CM-1 stated they stopped and discovered a frail elderly female laying on the ground. CM-1 stated Resident 1 stated they had been there a long time and said they were from Louisiana. CM-1 stated Resident 1 was unable to tell them exactly where they had come from, so they put the resident in the w/c and put their (CM-1's) coat over the resident as they were wet from the rain and wearing a thin dress or nightgown and a thin jacket. CM stated they brought the resident to a nearby ALF because they did not know where Resident 1 lived. CM-1 stated ALF staff immediately got warm blankets for the resident. CM-1 stated staff at the ALF stated Resident 1 was not one of their residents, and called the nursing home and found that was where Resident 1 was from. CM-1 stated a staff member from the facility arrived on foot to pick up the resident. In a telephone interview on 04/07/2023 at 1:00 PM, Staff D stated they were working the night Resident 1 eloped. Staff D stated on night shift of the day of elopement, the resident had been wandering the hallways looking for their puppy and their mother and was moving around very quickly in their w/c. Staff D stated staff were taking turns watching the resident, and stated when the resident was wandering like that, nothing staff did seemed to distract the resident from wandering. Staff D stated the time the resident was able to exit the building was a terribly busy time of the night shift as staff was starting their last rounds for resident cares. Staff D stated the last time they personally saw the resident was about 3:30 AM. Staff D stated they received a call that night from an acquaintance who worked at the nearby ALF asking if they had a missing resident because they had a female there, they thought belonged at the facility. Staff D stated they were shocked when the ALF staff showed them Resident 1 on a video call. In a telephone interview on 04/07/2023 at 2:30 PM, Staff A stated they were the assigned nurse for Resident 1 on the night of their elopement. Staff A stated Resident 1 was an exit-seeker and would go to all the exit doors to attempt to get out. Staff A stated Resident 1 had tried to exit several times that night. Staff A stated they worked three nights a week, and Resident 1 had been wandering and exit seeking two of the past three nights. Staff A stated they had last observed Resident 1 at approximately 3:50 AM when they started their resident rounds. Staff A stated interventions were often ineffective with Resident 1 when they were on the go, and they could rarely distract the resident. Staff A stated when (Resident 1) was looking for her dogs and her mom, nothing gets through to her. Staff A stated staff had not realized Resident 1 had left the building until Staff D received a call from staff at the ALF. Staff A stated Resident 1 complained of being cold when they returned so they got them warmed up. Staff A expressed surprise that Resident 1 had scored as cognitively intact on their last MDS assessment, and stated the resident was confused and often thought they were in Louisiana and did not know what town or state they lived in. In a telephone interview on 04/08/2023 at 9:45 AM, Staff C stated they had been working on the night of Resident 1's elopement. Staff C stated Resident 1 had been wandering from hall to hall the night of the elopement and stated the resident had been very quick propelling their w/c. Staff C stated usually when Resident 1 had a real focus on leaving the building like they did that night, another NA watched the resident when the assigned NA did their rounds. In a telephone interview on 04/10/2023 at 10:53 AM, a staff member from the nearby ALF stated they were present when CM-1 brought Resident 1 to the ALF sometime after 4:00 AM on 03/15/2023. ALF staff stated CM-1 brought Resident 1 to the ALF and stated they had found the resident laying on the side of the road in the pouring rain, after falling out of their w/c. The ALF staff stated when Resident 1 arrived at the ALF, complained of being cold and stated they were very wet from the rain, so they wrapped up Resident 1 in three blankets. The ALF staff stated the resident was wearing a thin, lightweight jacket when they arrived. In an interview with Staff I, Social Services, staff referred to Resident 1 as an escape artist. Staff I stated even with their office door being so heavy and the door latch broken, Resident 1 could open it independently. Staff I stated the facility staff loved Resident 1 and hated to have the resident discharge to another facility; however, they were always exit-seeking, and needed to be in a locked facility. Staff I stated Resident 1's cognition ranges from 100% to total confusion. Reference: (WAC) 388-97-1060(1)(3)(g)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed implement a safe discharge plan that included ensuring home health was set up for wound care treatments one of one residents (1) reviewed for discharge planning. In addition, failed to ensure clear concise instructions for care and follow up were given to the resident and their representative. This failure caused harm to Resident #1 when their pressure ulcer worsened due to lack of treatment required for pressure ulcers. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses including caude equina syndrome (dysfunction of lower spinal nerves), and conus medullaris syndrome (spinal injury that cause numbness). Review of the Admissions Minimum Date Set (MDS) Assessment completed on 07/27/2022 showed the resident had intact cognition, no refusals of care or treatment. Resident 1 required extensive two person assist for bed mobility for turning side to side, transfers between surfaces and extensive one person assist for toilet use, personal hygiene care and dressing themselves. Review of the care plan with a focus dated 07/21/2022 stated the resident wished to return to their home with care givers. Interventions dated 07/28/2022, showed home health services will be needed for discharge, evaluate motivation to return to community, schedule follow up appointment with primary care physician, and encourage to discuss feelings. Review of a wound assessment by the Physician's Assistant (PA) on 10/26/2022 (day before discharge) showed the PA debrided their Stage III (full thickness skin loss) pressure injury to the right buttock that measured 8.2 centimeters (cm) in length by 2.7 cm in width by 0.2 cm in depth. The PA's recommendation for care was to use wound cleanser to the wound bed, skin prep to outside of the wound, medi-honey (type of wound ointment) inside the wound and cover with a border dressing every Monday, Wednesday, and Fridays or as needed for accidental removal, saturation or soiled. Review of the discharge summary given to the resident and their representative dated 10/27/2022 (day of discharge), showed the resident had been referred to a home health agency for nursing, physical therapy, occupational therapy, and bathing assistance. There was no contact information provided for the referred home health agency. The discharge summary did not include the updated wound orders from 10/26/2022. The document showed the box was checked that indicated the facility reviewed all discharge instructions with the resident and the resident's representative. Review of the resident progress note dated 10/27/2022 showed the resident discharged home and that the resident's skin was intact, which was incorrect. Review of the facility document titled, Face to Face Encounter for Home Health, dated 10/27/2022 signed by the physician showed the following services that were requested by the facility to the home health agency was a bath aide, physical therapy, and occupational therapy. There was no referral for nursing or wound care requested. In an interview and record review on 12/28/2022 at 1:55 PM with Collateral Contact (CC) 2, home health agency clinical coordinator, they stated a note report dated 11/01/2022 through 11/16/2022 showed the home health agency did not receive referral orders for wound care from the facility. The home health agency was alerted to a wound on the buttocks when the physical therapist arrived at the resident's home on [DATE], 5 days after discharge. The home health agency conducted a nurse assessment at the resident's home on [DATE], 9 days after the discharge. The nurse documented that the wound was found to be uncovered and was unstageable. The documentation stated that the resident was unable to follow wound orders due to the location of the wound and the resident required a skilled assessment and wound dressings by a nurse. The documentation showed on 11/13/2022 the home health agency had requested a wound physician referral related to the wound had not improved. In an interview on 12/19/2022 at 3:12 PM, CC 1 stated they assisted the resident home from the facility on 10/27/2022. CC1 stated they did not receive any wound care education or supplies for the resident from the facility when they assisted the resident home the day of their discharge. CC1 stated the home health agency was unaware the resident required wound care, and had only received referral for a bath aide, physical therapy, and occupational therapy. CC1 stated the home health agency obtained orders to have a nurse referral, and the resident was assessed on 11/04/2022 for their wound. CC1 stated that the home health agency nurse informed them that the wound needed a wound specialist, and that they would make a referral and continue to provide wound care. CC1 stated on 11/18/2022 they took the resident to the emergency room at the hospital related to wound on the buttocks. Review of the hospital admission note dated 11/18/2022 the resident was admitted to the hospital related to septic shock (blood infection) related to Stage to the buttocks, osteomyelitis (bone infection) of the coccyx (butt bone) related to Stage IV pressure injury. Review of hospital wound consultation note dated 11/21/2022 showed the resident presented with a Stage 4 pressure injury that measured 4.5 cm in length by 3.8 cm width by 2.5 cm with 6 cm undermining (significant erosion underneath the outwardly visible wound margins which results in more extensive damage beneath the skin surface) at 7 o'clock and 1.8 cm undermining from 10 o'clock to 2 o'clock. In an interview on 01/12/2023 at 9:35 AM, Staff G, Social Services stated the face to face was completed by the RCM, then once completed with all the orders and referrals given to the physician to be signed on day of discharge. Staff G stated the resident should had been referred to home health agency for nursing, bath aide, and therapy. Staff G acknowledged that the facility document titled, Face to Face Encounter for Home Health, dated 10/27/2022 signed by the physician did not request nursing services. In an interview and record review on 01/12/2023 at 10:25 AM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated the discharge progress note on 10/27/2022 that read the resident's skin was intact was invalid, as they were the one that had documented the note. Staff C stated the resident's skin was not intact, and that they had a wound on their buttocks. Staff C stated they were the responsible staff member that provided the discharge summary to the resident and their representative on 10/27/2022, however they did not review the instructions of care, wound treatments, or medications with them. Staff C stated that they had been busy at the time the resident had discharged from the facility and had assumed someone else had provided them with that information. In an interview on 01/12/2023 at 11:08 AM, Staff F, RN/Staff Development stated the expectation for a discharged resident was the discharging nurse would review all medication and treatment orders with the resident and their representative. Staff F stated they had only initiated the discharge assessment in the electronic medical record on 10/26/2022, they had not been involved in the resident's discharge. In an interview on 01/12/2023 at 11:19 AM, Director of Nursing Services (DNS) stated they assisted as needed and completed some of the sections of the discharge summary assessment for the resident in the electronic medical record. The DNS stated that Staff C had been responsible to review the medication and treatment orders with the resident and their representative and was unaware they had not. The DNS was unaware that the face-to-face referral sent to the home health agency did not include nursing/wound care. The DNS did not offer any other information regarding the discharge of Resident 1. Reference WAC 388-97-0080.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to identify risk factors, initiate preventative measures, and monitor the assessment of the treatment ordered for the development of a facility-acquired pressure ulcer for one of two residents (1) reviewed for pressure ulcers. This failure caused harm to Resident 1, who developed a Stage III (full thickness skin loss) to their buttocks that was not present upon admission. This failed practice placed other potential residents at risk for the development of a pressure ulcer. Findings included . PRESSURE ULCER DEFINITION AND STAGES The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, defined Pressure Ulcer (PU) Definition and Stages as: -A PU 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 because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction). -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. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -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. Review of the facility policy titled, Skin Monitoring and Management, revised 06/2016 stated that the facility would identify risk factors which would relate to the possibility of skin break down and/or development of a pressure ulcer .such as impaired feeling to extremities, incontinence (lack of bowel/bladder control) .nursing will implement appropriate and consistent approaches to prevent a pressure ulcer by monitoring and modifying interventions based on any change in condition .if an assessment shows a change in condition related to a pressure ulcer the nurse is document in the medical record. Resident 1 admitted to the facility on [DATE] with diagnoses including caude equina syndrome (disfunction of lower spinal nerves), conus medullaris syndrome (spinal injury that causes numbness), congestive heart failure, difficulty walking, weakness, major depression disorder. Review of the residents admission Skin assessment dated [DATE] showed that the resident had no skin impairments to their buttocks. Review of the Braden Assessment (a tool used to determine the risk for pressure injury) dated 07/21/2022 failed to document that the resident had a sensory impairment to their legs, failed to document that the resident was incontinent of bowel, and failed to document that the resident required extensive assist for transfers. Review of the Admissions Minimum Date Set (MDS) Assessment completed on 07/27/2022 showed the resident had intact cognition, no refusal of care or treatment. Resident 1 required extensive two person assist for bed mobility for turning side to side, transfers between surfaces and extensive one person assist for toilet use, personal hygiene care and dressing themselves. Review of the Skin section of the MDS dated [DATE] showed the resident did not have any pressure injuries. A focused Care Area Assessment (CAA) triggered for the resident that they were at risk for a pressure injury. Interventions to be addressed on the care plan did not address the resident's decreased mobility, decreased sensory perception, weakness, or incontinence. Review of the resident's care plan showed a focus dated 07/21/2022 that the resident was at risk for a pressure injury related to, the space was blank. The interventions that were dated 07/21/2022 did not identify preventative measures that were specific to the resident and their diagnosis and functional abilities. Review of the Weekly Skin Evaluation assessment dated [DATE] showed no documentation of a skin impairment, and the comment read no new skin issues at this time. Review of the physician orders dated 10/06/2022 showed an order for zinc oxide (topical ointment) to buttocks and sacrum every shift related to moisture associated skin damage (MASD). Review of the resident's progress notes dated 10/06/2022 through 10/12/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. There was no notification to the physician. Review of the Weekly Skin Evaluation assessment dated [DATE] by the licensed nurse showed the resident had two open areas to their buttocks. Wound 1 was documented as MASD to the right buttock fold that measured 3 centimeters (cm) in length by 2.5 cm in width and the depth was unable to be determined. Wound 2 was documented as MASD to the middle buttock fold that measured 5 cm in length by 1 cm in width and the depth was unable to be determined. The documentation stated the resident had MASD that had now opened with minimal blood to resident's linens. The document stated the facility would obtain a referral for a contract wound provider to assess the wounds, they would request an air mattress, and the resident had been encouraged to reposition however the resident had refused. Review of the resident's progress notes dated 10/13/2022 through 10/19/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. Review of the contracted wound assessment by the physician assistant (PA) dated 10/19/2022 showed the resident had a Stage III pressure injury to the right buttock that measured 9.5 cm in length by 5 cm in width and 0.1cm in depth. The PA recommendation for care was wound cleanser to the wound bed, skin prep to outside of the wound, medi-honey (type of wound ointment) inside the wound and cover with a border dressing every other day or as needed for accidental removal, saturation or soiled. The documentation recommended to have the resident reposition and offload the wound. Review of the Interdisciplinary Team Skin Review dated 10/19/2022 showed the resident had a pressure ulcer/injury to coccyx and right buttock. Treatment orders were per the contracted wound assessment recommendations. The document was signed by the Director of Nursing Services (DNS), Staff C Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM), Staff D Registered Nurse (RN)/RCM, and the registered dietician. Review of the Weekly Skin Evaluation assessment dated [DATE] showed that the resident had two open areas to their buttocks. Wound 1 was documented as MASD to the right buttock fold that measured 5 centimeters (cm) in length by 2.5 cm in width and the depth was unable to be determined. Wound 2 was documented as MASD to the middle buttock fold that measured 3 cm in length by 3 cm in width and the depth was unable to be determined. The document stated the resident had MASD to right and middle buttocks, the nurse documented the treatment that was applied was zinc oxide to the wound bed. Review of the physician orders showed the wound treatment orders given on 10/19/2022 for; wound cleanser to wound bed, skin prep to outside of wound, medi-honey (type of wound ointment) inside wound and cover with border dressing every other day or as needed for accidental removal, saturation or soiled were not started till 10/22/2022, three days after they were ordered. Review of the resident progress notes dated 10/20/2022 through 10/26/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. Review of the contracted wound assessment by the PA on 10/26/2022 showed the resident had a Stage III pressure injury to the right buttock that measured 8.1 cm in length by 2.6 cm in width by 0.1 cm in depth. The PA performed a debridement (removal of damaged tissue) procedure at the resident's bedside and the measurements of the wound after the procedure were then 8.2 cm in length by 2.7 cm in width by 0.2 cm in depth. The wound care orders were updated to be completed on Monday, Wednesday, and Fridays. Review of the resident progress note dated 10/27/2022 showed the resident discharged home and that the resident's skin was intact. Review of the Discharge summary dated [DATE] showed the resident had a wound that required daily wound dressing changes. Review of the MDS discharge assessment dated [DATE] showed the resident had never had a pressure injury. In an interview on 01/10/2023 at 10:11 AM Staff A, Nursing Assistant Certified (NAC) stated they worked with Resident 1 during their admission at the facility. Staff A stated they recalled the resident did not have any skin impairments before they took two weeks off, when they returned to work the resident had a dressing on their buttocks. In an interview on 01/10/2023 at 11:18 AM, Staff B, LPN stated that they recalled the resident had complained their bottom was sore. Staff B stated they looked at the area and they thought it was MASD, they stated they cleaned the area and applied zinc ointment. Staff B stated they were going to get orders for a wound treatment, however found the active zinc oxide physician order so did not do anything else. Staff B stated the resident tended to sit in one place often. Staff B stated if a resident had any form of skin breakdown, they were educated to place the resident on alert to be monitored every shift. Staff B could not recall if they placed the resident on alert, Staff B acknowledged there was no documentation in the progress notes that showed ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. In an interview on 01/12/2023 at 9:01 AM, Staff E, LPN/MDS stated they did not code the pressure injury on the MDS due to conflicting documentation. Staff E stated the wound documentation showed the resident had a Stage III pressure injury, but the weekly skin notes stated the wound was MASD. Staff E stated that they were informed by Staff C that the wound was MASD so that was how they coded the MDS. In an interview on 01/12/2023 at 10:25 AM, Staff C, LPN/RCM stated they transitioned to the RCM role from floor cart nurse in October/2022. Staff C stated they were told the resident had MASD on their buttocks and was unaware of the contracted wound assessments that was completed on 10/19/2022 and 10/26/2022 had staged the wound as a Stage III pressure injury. Staff C acknowledged they did not participate or review the IDT Skin review dated 10/19/2022 even though they were listed as part of the team. Staff C stated they never assessed the residents' buttocks and did not review any skin review documentation for the resident. Staff C acknowledged they should have reviewed the documentation. In an interview on 01/12/2023 at 10:51 AM, Staff D, RN/RCM stated they rounded with the wound PA for the residents' wound assessments completed on 10/19/2022 and 10/26/2022. Staff D was unaware as to why the wound was not updated in the orders. Staff D was unaware why the care plan was not updated to reflect the wound was a Stage III pressure injury. Staff D confirmed the contracted wound assessment documentation was available to all nursing staff. In an interview on 01/12/2023 at 11:08 AM, Staff F, RN/Staff Development confirmed they opened the discharge assessment on 10/27/2022, and stated it was completed by the DNS. Staff F confirmed they were the RCM for the resident, however in October had transitioned to Staff Development and Staff C was responsible for Resident 1's skin evaluations and review. Staff F confirmed they never reviewed the contracted wound assessments and were aware the resident had an open area to the buttocks. Staff C confirmed they did the admission skin assessment and confirmed the resident did not have any skin impairment to their buttocks on admission. In an interview on 01/12/2023 at 11:19 AM, DNS confirmed they never assessed Resident 1's wound, and stated that Staff D would have been the nurse that would round with the contracted wound PA. The DNS confirmed that the contracted wound PA had staged the wound as a Stage III pressure injury, and they documented the wound was pressure on the IDT Skin review dated 10/19/2022. The DNS stated they had not reviewed the contracted wound assessment dated [DATE] and was unaware the wound had been debrided. The DNS confirmed that MASD was not a wound that would require debridement, and that a pressure injury would. The DNS stated the expectation for all new skin impairments were that the nursing staff would complete a change in condition assessment, notify the physician, start a treatment plan, and place the resident on monitoring for effectiveness of the treatments and interventions set in place to prevent further skin breakdown. The DNS confirmed that monitoring would be in the resident's progress notes. The DNS acknowledged that these were not completed. No further information provided. Reference WAC 388-97-1060 (3)(b)