**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on interview and record review, the facility failed to ensure treatments were implemented for a Stage 1 pressure ulcer (red area on the skin that does not turn white when pressed) upon admission and prevent further pressure ulcer development for 1 of 4 sampled residents (Resident 1) reviewed for pressure ulcers. This caused harm to Resident 1 when admitted with a Stage 1 pressure ulcer to the coccyx (boney structure at the bottom of the spine) and did not receive treatment or preventable measures for nine days after admission and the pressure ulcer progressed to an unstageable (base of wound is covered by a layer of dead tissue and cannot be seen) wound; and the resident developed an additional unstageable pressure ulcer to the right heel. This failure placed residents at risk for worsening of skin impairment, a change in health status and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture of the left hip and dementia. The Minimum Data Set, a comprehensive assessment tool, dated 08/16/2023, documented Resident 1 required 2-person extensive assistance with bed mobility, transfer status, dressing and toileting. Resident 1's Braden scale, an assessment tool used for assessing pressure ulcer risk, dated 08/09/2023, showed a score of 13 indicating resident was at moderate risk for pressure ulcer development. Resident 1's initial Skin Evaluation, dated 08/09/2023 at 4:37 PM, showed Staff D, Licensed Practical Nurse (LPN), identified a Stage I pressure ulcer to the sacrum (coccyx) measuring 2 centimeters (cm) in length and 2 cm in width. Resident 1's electronic medical record, dated 08/09/2023 to 08/16/2023, showed there were no orders for wound treatment and air mattress, or a care plan implemented for Resident 1's Stage 1 pressure ulcer. Resident 1's weekly Skin Evaluation, dated 08/16/2023 at 7:13 PM, showed Staff E, Registered Nurse (RN), checked a box entitled No new Skin Impairment. Resident 1's Nutrition Evaluation, dated 08/16/2023 at 7:25 AM, showed Staff G, Registered Dietician (RD), documented the resident had no skin breakdown, but several surgical incisions that increased energy needs for healing. Resident 1's weekly Skin Evaluation, dated 08/17/2023 at 2:30 PM, showed Staff G, LPN and Resident Care Manager (RCM), documented a New Skin Impairment. A Stage 1 pressure ulcer to the coccyx measuring 3 cm in length and 2 cm in width was identified during management wound rounds. Record review showed a treatment order and care plan were initiated on 08/18/2023 for Resident 1's Stage 1 pressure ulcer to the coccyx (9 days after admission with the Stage 1 pressure ulcer to the coccyx). The records showed a maintenance request form was placed for an air mattress but there was no order to direct the weight settings for the air mattress that were required to provide pressure relief. Resident 1's weekly Skin Evaluation, dated 08/23/2023 at 5:01 PM, showed Staff F, LPN, documented a New Skin Impairment, an unstageable pressure ulcer to the right heel. A progress note, dated 08/23/2023, documented physical therapy notified Staff F of a skin condition to Resident 1's right heel. The area appeared to be black and surrounding area red, non-blanchable (a condition where reddened skin does not turn white when pressed with a finger) and painful. Record review showed on 08/23/2023 a treatment order and care plan were initiated for Resident 1's unstageable pressure ulcer to the right heel. An order for the air mattress was not found. The August 2023 and September 2023 Treatment Administration Record did not show documentation of an order for an air mattress or monitoring of air mattress weight settings. Review of progress note, dated 08/31/2023 at 1:36 PM, showed Staff G documented Resident 1 was seen by the wound consultant for weekly tracking and wounds continued to deteriorate. A wound culture of the coccyx was collected. The Nurse Practitioner performed debridement (the removal of damaged tissue from the wound) with no complaints of pain. Santyl (a gel type medication used to cleanse wounds of damaged tissue) and NS (normal saline) soaked gauze covered with a foam dressing were applied to the wound. A broad spectrum antibiotic was initiated while waiting for results of the wound culture. Wound Progress Note, dated 08/31/2023, showed Resident 1 had an unstageable pressure wound to the coccyx. The resident's wound is deteriorating from last visit and covered with thick slough [dead tissue separating from living tissue]. [Resident 1] is presenting with a new deep tissue injury on her right heel . Sharp debridement provided to remove slough [on the coccyx] and restore blood flow to the wound . Wound consultant round notes, dated 09/14/2023 at 2:30 PM, showed Resident 1's coccyx wound to be unstageable with measurements of 5 cm in length, 4 cm in width, and 3.5 cm in depth. The unstageable right heel ulcer had measurements of 3 cm in length, 4.5 cm in width, and 0.0 in depth. Record review showed Resident 1 was sent to the hospital on [DATE] at 1:00 AM for a change in condition. Hospital records, dated 09/20/2023, showed Resident 1 was found with unstageable pressure ulcers to the coccyx and right heel. On 10/10/2023 at 1:40 PM, Staff D said when a resident was admitted with a pressure ulcer, they would notify the provider and request treatment orders, notify care managers, and initiate a care plan. When asked about requesting a therapeutic mattress, Staff D said the RCMs would address that. At 2:45 PM, Staff C, RN and Risk Management, said if a resident came in with a pressure ulcer the expectation was to request a physician's order and air mattress right away. Staff C said a care plan was initiated and an air mattress was obtained on 08/18/2023 for Resident 1's pressure ulcer to the coccyx. Staff C said the care plan was updated on 08/25/2023 for Resident 1's pressure ulcer to the right heel, and a safety assessment was completed on 08/28/2023 for the air mattress. Staff C said there was not an order for the air mattress. At 2:50 PM, Staff B, RN and Director of Nursing Services, said her expectation, if a resident was admitted and assessed as having a pressure ulcer, would be to contact the provider, obtain treatment orders, and to request an air mattress if a pressure ulcer had been identified. On 10/13/2023 at 12:32 PM, Staff E said when No New Skin Impairment was checked on the weekly Skin Evaluation document, this did not mean there were not previous skin impairments noted. Staff E indicated she was not able to remember if Resident 1 had a pressure ulcer. Staff E said if a pressure ulcer was found on evaluation the provider would be notified and a treatment order obtained. When asked who was responsible for initiating an order for a therapeutic mattress, Staff E said she was unsure, and would notify the provider or management staff for direction. On 10/13/2023, at 1:07 PM, Staff G said the expectation for staff if a resident was admitted with a pressure ulcer was to notify the provider and RCM, initiate treatment orders, initiate a care plan, request an air mattress if the resident had a pressure ulcer on their coccyx, and initiate therapeutic boots if the resident had a pressure ulcer to the heels. When asked about an order for Resident 1's air mattress, Staff G said she remembered obtaining and care planning for an air mattress but might have overlooked getting an order. Reference WAC 388-97-1060 (1) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, interview and record review, the facility failed to implement prevention and treatment strategies and failed to implement wound treatment orders for 1 of 3 sampled residents (64) reviewed for pressure ulcers (a skin wound caused by pressure preventing blood flow to the skin). This caused harm to Resident 64 when seven facility acquired Stage 4 (full thickness skin and tissue loss extending into muscle, tendon, ligament, cartilage or bone) pressure ulcers developed. This failure placed residents at risk for infection, wound development and worsening and a diminished quality of life. Findings included . Review of National Pressure Ulcer Advisory Panel position paper entitled Unavoidable Pressure Injury during COVID-19 Pandemic, dated 06/16/2020, showed, Avoidable pressure injury has been defined by CMS [Center for Medicaid/Medicare Services] as those pressure injuries that develop in [residents] for whom the [healthcare provider(s)] did not do one or more of the following: [properly] evaluate the [resident's] clinical condition and pressure injury risk factors; define and implement interventions that were consistent with [resident's] needs, goals for care, and recognized standards of practice; monitor and evaluate the outcome of the interventions; and/or revise the interventions as appropriate. Facility policy entitled Prevention of Pressure Injuries, revised April 2022, showed residents with pressure injuries must be repositioned on an individualized basis, determined by the interdisciplinary care team. The frequency for repositioning was based on the resident's risk factors and current clinical practice guidelines. Pressure redistribution and support surfaces were selected based on the resident's risk factors, in accordance with current standards. Resident 64 was admitted to the facility on [DATE] with diagnoses including quadriplegia (paralyzed arms and legs) and respiratory failure requiring dependence on life support. The admission Minimum Data Set (MDS), an assessment tool, dated 12/12/2022, documented Resident 64 was cognitively intact, was dependent on staff for activities of daily living including bed mobility, had one Stage 4 pressure ulcer and a surgical incision, and was not on a turning/repositioning program. Review of Resident 64's quarterly MDS, dated [DATE], documented Resident 64 had four Stage 4 pressure ulcers and three deep tissue injuries (an injury to underlying tissue, below the skin's surface, that results from prolonged pressure, restricting blood flow in the tissue causing the tissue to die), that three of the Stage 4 pressure ulcers were facility acquired, and Resident 64 was not on a turning/repositioning program. Review of wound provider note, dated 03/31/2023 showed Resident 64 had the following pressure ulcers: --Coccyx (low back/upper buttock)- Stage 4, 7.4 centimeters (cm) x 7.6 cm x 0.5 cm with palpable bone and exposed muscle/fascia (connective tissue). Resident admitted with this ulcer. --Left Ischium (pelvis/hip bone)- Stage 4, 4.7 cm x 3.4 cm x 2 cm with palpable bone and exposed muscle/fascia. --Right Ischium- Stage 4, 3.6 cm x 4.1 cm x 1.2 cm with palpable bone and exposed muscle/fascia. --Right Posterior Lower Leg- Stage 4, 11.7 cm x 2 cm x 0.2 cm with exposed tendon/ligament (connective muscle and tissue). --Left Heel- Deep tissue pressure injury. --Right Heel- Deep tissue pressure injury, 2.3 cm x 0.9 cm. --Right proximal heel- Stage 3. --Proximal Spine- unstageable (Full thickness tissue loss in which the actual depth of the ulcer is completely obscured), 9.4 cm x 4.2 cm, increased odor, exudate, and necrotic tissue (dead skin) with wound breakdown. --Distal Spine- unstageable, 1.8 cm x 1.5 cm. <Failure to Turn/Reposition and Failure to Manage Refusals> Review of Resident 64's impaired skin integrity care plan, dated 12/07/2022, documented Resident 64's goal of care was to have the skin heal without any signs or symptoms of infection and his skin would remain intact. Staff were to float heels (position legs so heels do not touch the bed surface) and turn frequently/reposition. Review of Resident 64's quadriplegia care plan, dated 12/15/2022, documented Resident 64 was to be Reposition/Ambulate as tolerated and at least every 2 hours. Review of Resident 64's pain management care plan, dated 12/15/2022, documented Resident 64 was to be pre-medicated for pain prior to activity to optimize participation. Review of Resident 64's behavioral care plan, dated 12/19/2022, documented Resident 64 had a behavior problem related to refusal of repositioning. Staff were to administer medications as ordered and monitor/document for side effects and effectiveness. Review of Resident 64's March 2023 Medication Administration Record (MAR) documented an order for oxycodone (pain relieving medication) 10 mg (milligram). Give 10 mg as needed for pain related to pressure ulcer of sacral region (low back), one hour prior to wound care. The MAR showed the medication was given five times that month, and three times correlated with successful completion of wound care. Review of Resident 64's behavior symptom task sheet, dated 03/06/2023 to 04/05/2023, documented rejection of care occurred twice out of 53 entries. The other 51 entries were documented as 'none of the above observed.' On 04/03/2023 at 2:37 PM, Resident 64 said he had wounds on his heels and bottom. Resident 64 was observed laying on his back in bed, arms propped on pillows. There were booties (cushioned barriers) on both feet. Resident 64's heels were not floated. On 04/04/2023 at 9:00 AM, Resident 64 was observed laying on his back with a pillow under each arm. His heels were not floated. At 11:06 AM, Resident 64 was observed laying in the same position. Resident 64 said he did not know why or how he got a new wound on his leg. At 1:08 PM and 3:00 PM, Resident 64 was observed in the same position. On 04/05/2023 at 8:04 AM, Resident 64 was observed laying on his back, a pillow under each arm and the heels not floated. At 8:12 AM, Staff F, Registered Nurse (RN), said Resident 64 did not like to turn to the right side and he preferred to turn to the left. Staff F said Resident 64's head was tilted to the left so his neck was getting contracted (stiff with limited motion) due to lack of movement and was tight now when they moved him. Staff F said Resident 64 complained of pain in his neck and other places. Staff F said they premedicated Resident 64 with oxycodone if he wanted. Staff F said Resident 64's refusals were why his wounds were getting so bad. Staff F said the Certified Nursing Assistants (CNAs) did the turning, and they asked the resident every two hours to turn. Staff F said Resident 64 had refused wound care yesterday and last night. The April 2023 MAR did not show Oxycodone was administered to pre-medicate for wound care. At 8:31 AM, Staff K, CNA, said she tried to turn Resident 64 every two hours but he had the right to refuse. Staff K said if he refused, she would reapproach three times, 15 minutes apart. Staff K said Resident 64 had not let her reposition him that day. Staff K said she asked a few times. Staff K said Resident 64 was sensitive to pain. Staff K said the bed was supposed to alternate [side to side]. At 8:48 AM, Resident 64 said he had not been asked to reposition that day, and he would if they asked. At 8:54 AM, Resident 64 was approached again and stated he had not been asked to turn that day. When asked if he refused, Resident 64 said Staff K had not asked or turned him because he had been sleeping and had not been woken up. Resident 64 said the last time he was repositioned had been on the night shift. Resident 64 said he would turn if he was asked. Resident 64 said he did not refuse turning. At 9:05 AM, Staff K and Staff D, Resident Care Manager (RCM) and Licensed Practical Nurse (LPN), was observed in Resident 64's room repositioning him. Resident 64 did not refuse. At 9:07 AM, Staff L, CNA, said in the beginning Resident 64 would refuse but now was more understanding. Staff L said Resident 64 usually allowed turning and if he did refuse it was because of no pain medication. Resident 64 would have you come back after pain medication, so did not refuse totally. At 9:12 AM, when asked how she was made aware of turning refusals, Staff F said it depended on the CNA. Staff F said the CNAs would leave then come back and Resident 64 would be approachable. Staff F said Resident 64 was better now with refusals from when he got here. Staff F said there were some CNAs he was more comfortable with and did not refuse turning for, then gave an example of a staff on the weekend shift. Staff F said Resident 64 allowed turning but not every two hours now and would allow changing with incontinence care. At 10:26 AM, Staff D said interventions to prevent and treat pressure ulcers included offloading pressure. Staff D said the CNAs rounded every two hours and repositioned when in the room. Staff D said all care staff with a license were responsible to reposition residents. Staff D said if a resident refused, the staff reapproached three times and then documented it. Staff D said they would update the care plan to make it work for the resident. Staff D said Resident 64 had, in the past for a period, refused care but was doing better. Staff D said Resident 64 did refuse because of pain with movement. Staff D said they would tell the nurse to medicate him with 10 mg Oxycodone which did help. Resident 64's biggest barrier was pain which had improved a lot. Staff D said Resident 64 was a reliable historian. When asked about staff failing to turn Resident 64 that morning, Staff D said she and Staff K went in and turned him no problem. Staff D said she would look into CNA training. When asked if the CNAs used the care plan, Staff D said she expected the CNAs to use the [NAME] (task list). Staff D stated, Hard to know if they use the care plan, should be though. At 11:17 AM, Staff J, LPN, said she was the former RCM for Resident 64. Staff J said Resident 64's refusals had gotten better but not gone away. Staff J said Resident 64 refused wound care, obtaining weight, and repositioning on admit. Staff J said if he refused, the nurses explained the reasoning and 90 percent of the time a direct approach worked well for him. Staff J said Resident 64 was a lot more compliant than when he first got to the facility. Staff J said she was his nurse all weekend and he did great. Staff J said if Resident 64 was premedicated with Oxycodone, he was compliant. Staff J said Resident 64 was turned frequently, every one to two hours was standard, and he did not require more frequent turning than the standard. Staff J said the nurse or CNA was responsible to float Resident 64's heels. At 12:54 PM, during a wound care observation, two pillows were under Resident 64's neck, two pillows were removed from under his arms, a foam wedge and one other flat pillow were in the room. There were not enough pillows in the resident's room to float both heels and turn the resident on his side while supporting his painful and stiff neck. At the end of wound care, staff positioned Resident 64 on his side. His legs were not floated. At 2:01 PM, Staff B, Director of Nursing Services and RN, and Staff C, Director of Quality Assurance and LPN, said they expected residents to be turned every two hours. When asked what 'frequently' meant on the care plans, Staff B said staff should reposition as frequent as possible. Staff B said it was not possible every 2 hours, so a range of 1.5-2.5 hours was acceptable. Staff B said she expected staff to approach residents (to turn) even when sleeping. <New Skin Injuries> Review of Resident 64's skin assessment, dated 04/02/2023, documented Resident 64 sustained a new pressure ulcer to his left lower leg. The wound was described as dark red/purple and and measured 6 cm x 1 cm. The shape of the wound was described as line. On 04/05/2023 at 12:54 PM, during a wound care observation, the left lower leg dressing was removed which was stuck to the skin. Staff F used wound cleaner to moisten the skin and dressing to separate them. As the bandage was peeled back, the skin from the lower half of the wound peeled back with the dressing. Staff F said the wound was now open. Resident 64's urinary catheter bag was observed hanging off the bed on the left side allowing the tubing to run next to the left lower leg. The skin injury was of similar shape and size as the catheter tubing. When adjusting Resident 64, a new red baseball size area was observed on the left hip. Staff K said the area was new. Staff F applied skin prep to the area. <Failure or Delay in Implementation of Wound Orders> 1) Review of Resident 64's electronic health records (EHR) documented a wound care order, dated 03/16/2023, which included leaving both heels open to air. Review of Resident 64's wound provider note, dated 03/24/2023, documented a foam dressing was to be applied to both heels daily and as needed during wound care. Review of Resident 64's EHR showed the order was updated on 04/04/2023, 11 days after the order was written. 2) Review of Resident 64's wound provider note, dated 03/10/2023, documented a change in wound care orders for the Stage 4 pressure ulcers to the coccyx, left ischium and right ischium. The order was to apply Hydrofera blue, a medicated foam, to the base of the wound. The previous order for Dakin's (a liquid wound treatment) soaked gauze packing, was not continued. Review of Resident 64's wound provider note, dated 03/17/2023, documented a change in wound care orders for the stage 4 pressure ulcers to the coccyx, left ischium and right ischium. The order was to apply Vashe (a liquid wound care treatment) to soak gauze and pack into base of the wound. The order for Hydrofera blue was not continued. Review of Resident 64's wound provider note, dated 03/24/2023, documented Recommend Vashe treatment. However, the facility team provided Hydrofera blue . Review of Resident 64's March 2023 MAR documented the facility failed to discontinue the Dakin's solution and start the Hydrofera blue until 03/16/2023, six days after the order changed. The MAR documented the facility failed to implement the Vashe soaked gauze packing completely and instead continued the Hydrofera blue. On 04/05/2023 at 10:26 AM, Staff D said the RCMs accessed a program to get the new wound orders because all the notes were uploaded. Staff D said if the wound provider gave a verbal order, they could put it in right away but usually they waited for the notes to be uploaded to put orders in the EHR. Staff D said wound rounds were on Friday, so by Tuesday they typically aimed to have orders updated. At 11:17 AM, after looking at Resident 64's wound orders in reference to the missing Vashe treatment, Staff J said she did not know why it was not given. At 2:01 PM, Staff B and Staff C said it was the RCMs' responsibility to update the orders as soon as they were uploaded into [an online program]. Staff C said she expected the RCMs to look for new orders on Monday. Staff B said she expected the staff to follow orders unless the house provider had an alternative. <Improper Air Mattress> Resident 64's Skin Integrity Care plan, dated 12/15/2022, documented Resident 64 required an air mattress related to a pressure ulcer. The goal was for Resident 64 to remain free of complications including skin breakdown. Staff were to monitor and document for side effects and effectiveness including skin breakdown. Review of Resident 64's skin grid, dated 12/21/2022, documented weekly skin assessments for a second facility-acquired pressure ulcer to the spine which started as a deep tissue injury and progressed to an open wound. Review of Resident 64's EHR showed an order, dated 03/09/2023, for House Air Mattress. Type: Medicure Settings: 720 (internal air pressure of the mattress). Check to ensure functioning of air mattress every shift. If any issues notify administration. There were multiple discontinued orders for mattresses including orders without pressure settings. Review of Resident 64's wound provider note, dated 03/24/2023, documented after the facility changed the air mattress, Resident 64's wounds started to show improvement. On 04/05/2023 at 11:17 AM, Staff J said staff switched out the air mattress because the old one was not pressure relieving correctly and was caving in the middle. Staff J said it was the same type of mattress, just a different one and was now less painful for the resident. Reference WAC 388-97-1060 (3)(b) .