**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <Resident 7> Review of the 03/23/2023 significant change in status assessment, Resident 7 required extensive assistance of two staff to turn and reposition them in bed. The assessment showed the resident was at risk for developing skin issues and had no pressure ulcers. Per the record, Resident 7 had a Braden scale (a scale for predicting pressure sore risk) completed on 03/23/2023 and their score was 11, which showed the resident was at high risk for developing pressure ulcers. Resident 7 was noted to have a suspected deep tissue injury on their left heel on 03/28/2023. The left heel injury was not placed on the treatment administration record (TAR) to monitor until 04/06/2023, nine days after the pressure injury occurred. An incident investigation, dated 03/28/2023, showed Resident 7 had a 6.0 cm. x 3.5 cm. blister to the bottom of the left heel, that was painful to the touch. The care plan was updated at that time to float the resident's heels while in bed (for pressure relief to the area). The investigation showed the cause of the blister was due to the resident resting their heels on the bed, decreased nutritional intake, decreased mobility, and recent illness of COVID-19 (a highly contagious respiratory disease). Prior to that date, no interventions were in place to relieve the pressure from Resident 7's heels. During an interview on 06/01/2023 at 11:38 AM Staff J, RD, stated they were unaware Resident 7 had a deep tissue injury/blister to the left heel. Staff J reported if they had been made aware, a multivitamin and Vitamin C would have been added to Resident 7's medications, to aid in skin healing. Staff J additionally added that issues with skin had recently been missed, and stated they should have been notified of Resident 7's pressure injury. During an interview on 05/31/2023 at 2:00 PM Staff C, DNS, stated upon admission a Braden Scale was completed on every resident. Per Staff C, the nursing staff were expected to turn and reposition residents, provide incontinent care, and float heels. They stated that if a pressure ulcer developed, it would be placed on the TAR for monitoring once found. Staff C additionally added the facility was in crisis staffing during the COVID-19 outbreak and repositioning and floating of the heels did not occur on a consistent basis. Reference: WAC 388-97-1060 (3)(b) Based on observation, interview, and record review, the facility failed to implement interventions, consistently monitor pressure ulcers, and notify appropriate disciplines once pressure ulcers were identified for 3 of 3 sampled residents (Residents 3, 7, and 29), reviewed for pressure ulcer care. Actual harm occurred for Resident 3, when facility staff did not have preventive protective boots(cushioned devices placed on the feet to protect against pressure) implemented timely, the resident lost a significant amount of weight, developed an additional pressure injury, and the Registered Dietician (RD) was not notified of the resident's wounds. This failure placed the other residents at risk of harm from further deterioration of their skin conditions, and a decreased quality of life. Findings included <Resident 3> Resident 3 had diagnoses including left femur (thigh bone) fracture and paralysis (the loss of the ability to move some or all of your body), after a stroke. A 03/07/2023 quarterly pressure sore risk assessment showed the resident was at high risk for developing pressure ulcers (an injury that breaks down the skin and underlying tissue, related to pressure). A review of the record showed on 05/01/2023 Resident 3 was readmitted to the facility from the hospital after receiving care for a fractured thigh bone. A 05/06/2023 significant change in condition assessment showed the resident required extensive assistance of two staff for bed mobility, was totally dependent for transfers from bed, and used a wheelchair for locomotion. The resident had no weight loss, and weighed 190 pounds (lbs.). Review of the 05/08/2023 RD assessment showed Resident 3 had a 3.7 lb. weight gain from 04/16/2023 and had minimal fluctuations in their weight for past five months. The assessment also showed the resident was at high nutritional risk, and had decreased intake upon their return from the hospital on [DATE] (eating less than 25% of one meal daily). There were no additional RD assessments or interventions documented in the resident's record after their return from the hospital, with a known decrease in intake, and an increased nutritional risk. The comprehensive care plan had the following care areas (with date of initiation listed): -12/12/2018 Risk for nutritional problems; interventions included regular diet, mechanical soft texture, encourage fluids of choice, explain the importance of maintaining the ordered diet, monitor weight per policy, report significant losses or gains to the provider and RD, RD to evaluate and make recommendations, and offer snacks in between meals. On 05/01/2023, the plan was revised to include serve diet as ordered and monitor intake. -05/24/2023 Actual alteration in skin integrity; interventions included to administer treatments as ordered, keep skin clean and dry, encourage good nutrition and hydration, evaluate the environment for causative factors, follow facility protocols, notify licensed nurse (LN) of changes to skin, encourage position changes, ensure pressure is kept off of left outer ankle and refer to the RD as needed. On 05/25/2023, the care plan was updated to include foot protectors on both feet (defined above) at all times while in bed, and on the left foot when up in chair. A review of the resident's weights showed the following: 02/16/2023-193.1 lbs. 04/16/2023-186.7 lbs. 05/02/2023-190.4 lbs. and 05/10/2023-183.2 lbs., a 3.8% loss in 8 days. A review of nursing progress notes showed on 05/15/2023, Resident 3 developed a cellulitis (infection of the skin) on their left lower leg on the outer calf area, and was sent to the local hospital. The resident returned on 05/17/2023. A 05/17/2023 initial skin ulcer/injury measurement and evaluation showed Resident 3 had a stage II pressure ulcer (intact blisters or a shallow open sore) on the left outer ankle that measured 1.0 centimeters (cm.) x 1.0 cm. x 0.0 cm. that was present when Resident 3 returned from the hospital. Additionally, there was a 1.0 cm. x 1.0 cm. suspected deep tissue injury on the same outer ankle. The plan was to monitor the areas until resolved, and if the blisters opened, they were to be treated with a foam dressing. The 05/17/2023 provider orders included elevating the left leg, avoid prolonged pressure to the red areas, regular diet, offer snacks three times a day, and give one multi-vitamin, Vitamin D and Vitamin B-12 daily for nutritional supplement. The 05/24/2023 weekly skin ulcer measurement and evaluation showed Resident 3's left outer ankle stage II pressure ulcer had not changed in size, had no drainage, undermining (skin separation), or tunneling (skin damage underneath a wound, which penetrates deeply underneath the skin). The treatment was updated to add protective booties while in bed and up in a chair. The [NAME] (care instructions for nursing assistants) in effect on 05/24/2023 instructed staff Resident 3 was to wear foot protectors on both feet at all times while in bed and up in a chair, to avoid prolonged pressure to red areas of left leg, ensure pressure was kept off the left outer ankle, and assist the resident with position changes. On 05/24/2023, Resident 3's weight was 178.0 lbs., a 6.5% significant weight loss from 05/02/2023. On 05/24/2023 at 9:07 AM, Resident 3 was observed in their bed. Their left leg was turned outward so that the outer ankle rested on the mattress. There were no protective boots on, and none observed in the room. The resident stated they used to weigh over 200 lbs. but had lost weight recently. The resident was also observed on the following dates: -On 05/25/2023 at 9:27 AM seated in their wheelchair wearing socks and shoes; -On 05/26/2023 at 9:45 AM asleep in their bed, wearing non-skid socks and no protective boots; the left leg was elevated on a pillow. At 11:48 AM the same day, the resident remained in bed, the left leg was no longer resting on a pillow and their ankle was positioned against the mattress. There were no protective boots on. On 05/29/2023 at 10:44 AM, an incident note documented the resident had a new suspected deep tissue injury on the left inner heel, possibly from care or handling. The note showed the resident's heel was limp, and needed to be moved by staff, as the resident did not move it. On 05/30/2023 at 1:14 PM, the resident's left inner heel and outer ankle area were observed with Staff K, Registered Nurse (RN), and Staff C, Director of Nursing Services (DNS). The left outer ankle had an area with a defined border that was not open, had no drainage, and had a grey-ish tint to it on the ankle bone. Staff K stated the area measured 1.7 cm. x 2.5 cm. x 0.0 cm. The left inner heel had a new round purple bruise that measured 3.5 cm. x 4.0 cm. x 0.0 cm. Staff K pressed on the area and stated it was boggy (soft or mushy). During the observation, Staff C stated they did not know where the new pressure on the left inner heel came from because the resident's leg rotated externally. Staff C was unsure if the resident's shoe caused the pressure or possibly their wheelchair. Staff C stated therapy was to evaluate the resident's wheelchair. During an interview on 05/31/2023 at 12:04 PM, Staff L, Nursing Assistant (NA), stated the padded boot was new for Resident 3 and had been added that week, 05/29/2023. Staff L stated they were able to find care planned interventions in the [NAME] on the computer; and stated if there were changes to a resident's care, it showed on a communication board in the computer. Staff L did not remember seeing anything regarding the protective boots for Resident 3 on the communication board. During an interview on 05/31/2023 at 2:17 PM, Staff E, RN, stated Resident 3 had a new area of pressure on their inner heel. Staff E was unsure when the protective boots were brought into the resident's room, but stated it sounded as if there was an opportunity to get the resident the boots sooner. Staff E stated just by looking, it appeared the resident had lost weight, and stated the Resident Care Manager (RCM) notified the provider and the RD if there was significant weight loss, but currently there was no RCM. The RD was to be notified of new skin issues as well, but Staff E was unsure if that happened, and stated if that had not occurred, it was concerning. During a telephone interview on 05/31/2023 at 4:21 PM Staff J, RD, stated they had assessed Resident 3 on 05/08/2023, when they returned from the hospital after being treated for a fracture from a fall. Staff J was unaware the resident was hospitalized on [DATE] but stated normally if a resident left the facility they were reassessed when they returned, and stated that since Resident 3 had just been assessed on the 8th, Staff J probably would have just done a progress note instead. Staff J stated Resident 3 was reviewed during the Nutrition at Risk meetings, but the weight of 178 lbs. on 05/24/2023 had not been recorded in their record before their last meeting. Staff J stated they had not been notified of the resident's wounds when they were identified on 05/17/2023, and stated it sounded like the resident got missed at the 05/24/2023 meeting. They stated if they had been made aware, changes would have been made to Resident 3's nutrition plan of care such as double portions of protein, extra proteins, or a supplemental shake of some kind. <Resident 29> Per the 04/20/2023 quarterly assessment, Resident 29 needed extensive assistance from one to two staff to complete activities of daily living such as turning in bed and personal hygiene. In addition, the assessment showed the resident was at risk for developing skin issues and had no pressure ulcers or open lesions. Review of the progress notes from 03/01/2023 through 05/31/2023 showed the following: On 05/09/2023 at 3:10 PM, Resident 29 was found to have a blister on their left leg stump (the leg below the knee had been amputated) that had opened. The area was cleaned, a foam type dressing was applied, and the provider was notified; on 05/10/2023 at 12:13 AM, the dressing was removed, the area cleaned, and a new dressing applied; and on 05/12/2023 at 8:19 AM, it was documented the provider acknowledged being notified of the blister. Further review of the progress notes found no additional documentation regarding the blister. The May 2023 Treatment Administration Record (TAR) showed an order dated 05/24/2022 which instructed the licensed nursing staff to check Resident 29's skin every Tuesday, and mark the TAR with a plus sign for new issues or a negative sign to show no new skin conditions had been found. In addition, instruction was given to document a progress note and initiate the skin documentation form when a new skin condition was found. Review of the May 2023 TAR showed on 05/09/2023 the TAR was marked with a negative sign to indicate no new skin issues were found. A progress note, on the same date, documented Resident 29 had a blister on their left leg, which was not there previously. Review of the skin documentation assessment forms showed the form was not initiated for the blister as instructed, nor were other skin assessment forms found that showed the blister was being monitored. Review of the skin care plan showed interventions were implemented on 04/14/2023, but the care plan had not been updated to inform the nursing staff of the blister on the left leg, or what Resident 29's care needs were for the treatment of the blister. In an interview on 05/31/2023 at 9:53 AM, Staff G, NA, stated Resident 29 had a blister on the back of the left leg, but was not sure if it was still there since they had been off work for a few days. In an interview on 05/31/2023 at 2:13 PM, Staff F, RN, stated they were not aware of any skin issues or Resident 29 having a blister. After review of the resident's physician orders, progress notes, skin documentation forms, and TAR, Staff F confirmed there were no orders or additional documentation after the progress note on 05/09/2023 and confirmed skin assessments were supposed to be done weekly and the skin documentation form was to be filled out if any new issues were found. On 05/31/2023 at 2:27 PM, Resident 29 was observed lying in bed watching television. Staff F asked if they could assess the resident's skin and the resident turned to their right side. The back of the left thigh/stump area was assessed, and no dressing or visible open areas were found. In an interview on 05/31/2023 at 2:40 PM Staff C, DNS, confirmed skin assessments were done weekly, and the skin documentation form was to be completed when there were new skin issues found. When informed about the progress note on 05/09/2023 regarding the blister, Staff C stated they would need to follow up. In a follow-up interview on 3:17 PM, Staff C confirmed there was no follow-up monitoring, and the facility process for skin assessments had not been followed.