**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2: R18 was admitted to the facility on [DATE] with diagnoses including in part, vascular dementia, hemiplegia and hemiparesis cerebral infarction, dysphagia, osteomyelitis left elbow, pressure ulcer stage 4 left elbow, type 2 diabetes mellitus, heart failure, and benign prostatic hyperplasia with lower urinary tract infections. R18 was admitted with 3 PIs and facility did not identify location, sizes, or stages and is unclear determining the condition of the pressure injuries at admission. R18's Minimum Data Set (MDS) assessment, dated 01/11/24, identified on admission that R18 had a Brief Interview for Mental Status (BIMS) score of 08. This indicated R18 had moderate cognitive impairment. The MDS assessment also identified R18 required total dependent assistance of two people for bed mobility, taking on and off footwear, rolling left to right, sit to lying, chair to bed, toileting, eating, and for transfers. MDS also indicated that R18 was determined to be at risk for PIs and currently had one stage 4 PI. Surveyor reviewed R18's right gluteal and left buttock pressure injury care plan initiated on 04/25/24 and revised 10/07/24, in part: -Educate and encourage good nutrition and hydration in order to promote skin integrity initiated on 04/25/24. -Observe/identify/document potential causative factors for alterations in skin integrity. Eliminate/resolve where possible initiated on 04/25/24. -Reposition resident every 1-2 hours initiated on 04/25/24. -Wound dressing treatments per provider initiated on 04/25/24 and revised on 10/07/24. -Roho cushion in wheelchair initiated on 09/25/24. -APM for pressure reduction and prevent sheering initiated on 09/25/24. -Monitor for signs and symptoms of infection: increased warmth, redness, swelling, purulent drainage, pain or tenderness initiated on 09/25/24. -Nutrition supplement three times a day to promote wound healing initiated on 09/25/24. -Resident will not develop any further skin breakdown, redness, blisters, or discoloration initiated on 10/07/24. Surveyor reviewed R18's physician orders, which state in part: -On 02/08/24: position resident on his side for 1 hour post meals three times a day. -On 04/04/24: . MEASURE EACH WOUND WIDTH, LENGTH, DEPTH, AND DOCUMENT WOUND DESCRIPTION (DRAINAGE, COLOR, ODOR, ETC.), tunneling, and what wound care was provided. -On 09/05/24: Check inflation of high low ROHO cushion every day and adjust as necessary to limit pressure while up in w/c or recliner every morning and at bedtime for Pressure Ulcer. Two times a day for wound prevention. - On 09/25/24: Check Alternating Air Mattress for proper functioning every shift. Surveyor reviewed Braden score assessment dated [DATE] incomplete. Surveyor did not find R18's score to determine the risk of PIs and skin breakdown. Surveyor reviewed admission nurse progress notes, which state in part: -On 01/04/24, R18 has Deep tissue injury to the left elbow, stage 4, 2x1x1.2cm, open lesions in 4 places on left buttock. No thorough assessment including documentation of location of PI, PI measurements, or description of condition of PIs noted on admission. -On 01/27/24, R18 has left buttock open lesion 4cmx2cm, left buttock open lesion 3.5cmx2cm, left buttock open lesion 3cmx1cm, left buttock open lesion 6cmx3cm, left elbow pressure injury 2.5cmx1x0.5cm. The open areas on the buttocks are not called PIs, or staged. R18 was hospitalized [DATE] and returned on 1/29/24. -On 01/29/24, nurses note in part, R18 has left buttock open lesion 6cmx3cm left buttock open lesion 3.5cmx2cm, left buttock open lesion 3cmx1cm, left buttock open lesion 6cmx3cm, left elbow pressure injury stage 4 2.5cmx1x0.5cm. No new interventions were put into place for R18's pressure injuries. -On 02/15/24, R18's left buttock is assessed as stage 2 PI 1.7x1.1x0.1cm, left buttock is assessed as stage 2 PI 1x0.5x0.1cm, right buttock is assessed as stage 2 PI 3.5x2x0.1cm, new right buttock stage 2 PI 0.6X0.6cm., right posterior thigh PI stage 3, 4x1x0.2cm. Facility did not identify exact locations on left and right buttocks and is unclear determining the condition of the pressure injuries. No new interventions were put into place for R18's pressure injuries. -On 05/09/24, R18's Right posterior thigh PI stage II, 1x0.3cm. New right posterior thigh PI at stage 2 measures 3x5cm. This contradicts documentation in note on 2/15/24. Surveyor interviewed Interim DON H about this entry. Interim DON H stated they were stage 2 on admission, just not clearly documented. Facility did not identify wounds by numbers and is unclear determining the condition of the pressure injuries. No new interventions were put into place for R18's pressure injuries. -On 10/09/24, R18 has PI noted to the right gluteal fold buttock measures 0.3x1.1x0.1cm. Provider will be updated of new area assessed. Observations: On 10/07/24 at 9:28 AM, Surveyor observed R18 lying in bed. R18 appeared to be sleeping, but Surveyor observed R18 to have contracted hands bilaterally. Surveyor observed R18's bed positioned high and R18 lying supine on back in bed. On 10/07/24 at 9:56 AM, Surveyor observed R18 yelling for assistance from R18's room. On 10/07/24 10:07 AM, Surveyor observed Certified Nurse Assistant (CNA) F enter R18's room. R18 indicated R18 was cold and needed a blanket. CNA F gave R18 a blanket and exited R18's room. Surveyor observed R18 lying supine on back in bed. On 10/07/24 at 10:20 AM, Surveyor observed R18 yelling for assistance from R18's room. On 10/07/24 at 10:23 AM, Surveyor observed CNA D enter R18's room and ask R18 what R18 needed. R18 stated that R18 wants to get up out of bed. CNA D indicated to R18 that staff just laid R18 down in bed and would get R18 up before lunch. Surveyor observed R18 lying supine on back in bed. On 10/07/24 at 11:35 AM, Surveyor observed CNA D and CNA J transfer R18 via Hoyer lift to wheelchair. Surveyor did not observe R18 repositioned on side post meal for an hour or repositioned every 1-2 hours as the care plan instructs. Observations on 10/08/24: On 10/08/24 at 6:48 AM, Surveyor observed R18 sitting in wheelchair in dining room. On 10/08/24 at 8:00 AM, Surveyor observed R18 sitting in wheelchair in dining room. Surveyor did not observe R18 repositioned as ordered. On 10/08/24 at 9:05 AM, Surveyor observed R18 in wheelchair in room with call light attached. R18 utilized call light for assistance. CNA D entered and asked R18 what was needed. R18 indicated that R18 wanted to lie down in bed. CNA D exited R18's room. Surveyor did not observe R18 repositioned as ordered. On 10/08/24 at 9:08 AM, Surveyor observed CNA J and CNA D enter R18's room to transfer with Hoyer. On 10/08/24 at 9:18 AM, Surveyor observed R18 on back lying in bed. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 9:39 AM, Surveyor interviewed LPN G and RN C about R18's wound dressing changes. RN C indicated that LPN G would be doing wound rounds with Interim DON H tomorrow on Wednesdays. RN C indicated that R18's wounds are on both buttocks and left side opened is a stage 2. On 10/08/24 at 10:26 AM, Surveyor observed CNA J and CNA D enter R18's room and reposition R18 to right side slightly with pillow under left side. On 10/08/24 at 1:23 PM, Surveyor observed R18 lying in bed on back. R18's wife in visiting R18. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 2:12 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned on side post meal for an hour as ordered. On 10/08/24 at 2:43 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/08/24 at 3:04 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/08/24 at 3:33 PM, Surveyor observed R18 lying in bed on back. Surveyor did not observe R18 repositioned every 1-2 hours as ordered. On 10/09/24 at 7:02 AM, Surveyor observed Interim DON H perform wound dressing change on R18. Interim DON H indicated through assessment and wound cleaning, R18 has a stage 2 PI, 1.6x1x1.0 cm of the left gluteal inferior area. On 10/09/24 at 10:20 AM, Surveyor interviewed CNA D and asked about repositioning R18. CNA D indicated that R18 is repositioned every 2 hours and as needed. Surveyor asked CNA D if R18 was repositioned every 2 hours for the past 3 days. CNA D indicated that R18 should be repositioned every two hours and has an air mattress in place. Surveyor asked CNA D if CNA D follows physician orders that indicates R18 should be repositioned onto side post meals for an hour three times a day. CNA D indicated that CNA D is unaware of this order and that staff make sure R18 is repositioned every 2 hours from side to side. On 10/09/24 at 10:24 AM, Surveyor interviewed Interim DON H and asked about repositioning R18. Interim DON H indicated that R18 is to be repositioned every 1-2 hours. Surveyor indicated to Interim DON H that R18 was not repositioned every 2 hours for the past 3 days. Surveyor did not observe R18 positioned off back and buttocks but twice in the last 3 days. Interim DON H indicated that R18 should be repositioned every 1-2 hours. Interim DON H indicated to Surveyor the physician order for repositioning on side for one hour post meals is a dumb order but will update care plan after verifying order is correct. On 10/08/24 at 3:09 PM, Surveyor interviewed Interim DON H and asked about wound documentation for R18. Interim DON H indicated that wound documentation has not been being recorded accurately and is in 4-5 different skin assessment sections throughout the electronic health record. Surveyor asked Interim DON H if R18 had pressure injuries on admission. Interim DON H was not here at that time. Interim DON H indicated that Interim DON H could not specify if R18's right posterior thigh was from admission or acquired in facility. Surveyor asked Interim DON H to clarify open areas. Interim DON H stated, [R18] has pressure injuries on buttocks that is being staged at a 2 and wound rounds weekly. Interim DON H indicated that once Interim DON H observed that wound care was not going the best, Interim DON H started a full facility skin sweep and implemented a PIP in September. Based on observation, interview, and record review, the facility did not provide care consistent with professional standards to prevent development of a pressure injury (PI) for two of three residents (R) reviewed for pressure injuries (R29 and R18.) R29 was admitted to the facility with no skin impairments and developed a stage 3 pressure injury to the coccyx area (tailbone) which remains unhealed, due to lack of comprehensive assessments, lack of timely care plan interventions, and lack of repositioning. This example is being cited at actual harm. Facility did not complete comprehensive assessment on admission of R18's present PIs and did not implement care plan interventions timely or follow the repositioning schedule to prevent a stage 2 pressure injury from occurring. Findings include: According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, Reposition all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved. According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, A pressure injury is defined as localized damage to the skin and/or underlying tissue, as a result of pressure or pressure in combination with shear. Pressure injuries usually occur over a bony prominence but may also be related to a device or other object. Facility policy and procedure entitled Pressure Injury Prevention and Management, dated 08/02/24, states in part, .Assessments of pressure injuries will be performed by a licensed nurse, and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set] . R29 was admitted to the facility on [DATE] with the following diagnoses, in part, spina bifida (congenital disorder of the nervous system), morbid obesity, adult failure to thrive, changes in skin texture, history of diseases of the skin and subcutaneous tissue, and generalized muscle weakness. On 10/07/24 at 9:08 AM, Surveyor interviewed R29, who reported he had a sore on his bottom that the nurses are changing a bandage on daily. R29's admission MDS assessment, dated 12/05/23, stated R29 was completely dependent on caregivers for all Activities of Daily Living (ADLs) and all mobility. The MDS assessment also identified R29 was at risk for the development of pressure injuries but had no current unhealed pressure injuries. Under the skin and ulcer treatment section of the MDS assessment, no was marked for pressure reducing device for chair, pressure reducing device for bed, turning/repositioning program, and nutrition or hydration program to manage skin problems. There were no refusals or rejection of cares documented on the MDS. R29's MDS assessment, dated 08/12/24, identified R29 had one stage 2 pressure injury and one stage 4 pressure injury. Under the skin and ulcer treatment section of the MDS assessment, no was marked for pressure reducing device for chair, pressure reducing device for bed, and turning/repositioning program. Yes was marked for nutrition or hydration program to manage skin problems. There were no refusals or rejection of cares documented on the MDS. R29 had a Braden risk assessment score of 12 on 11/29/23. This identified R29 was high risk for developing pressure injuries. R29's Braden score was 9 on 08/09/24, which indicated R29 was very high risk for developing pressure injuries. R29's baseline care plan, dated 11/28/23, had nothing checked under current or history of skin integrity issues. R29 had the following care plan: The resident has potential for pressure ulcer development r/t [related to] Immobility, incontinence, weakness, diagnoses/medications that can/may affect skin integrity. Coccyx. Date initiated: 12/06/23. Revision on: 10/07/24 Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Date initiated: 10/07/24 Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date initiated: 12/06/23 Administer treatments as ordered and monitor for effectiveness. Date initiated: 12/06/23 APM [Alternating Pressure Mattress] on Bed to Alleviate Pressure. Date initiated: 10/07/24 Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. Date initiated: 12/06/23 Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date initiated: 12/06/23 Instruct and assist as needed to shift weight in W/C [wheelchair] q [every] 15 minutes. Date initiated: 12/06/23, revision on: 02/29/24 Monitor for s/sx [signs or symptoms] of infection: Redness, swelling, purulent drainage, warmth, tenderness or pain, Date initiated: 09/25/24 Monitor nutritional status. Serve diet as ordered, monitor intake and record. Date initiated: 12/06/23 Nutrition Supplements Liqua Cell for wound healing. Date initiated: 10/07/24 Patient goes to wound clinic. Date initiated: 09/25/24 Roho W/c [wheelchair] Cushion. Date initiated: 09/25/24 Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes. Date initiated: 12/06/23 The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned q4h per his request. Date initiated: 01/17/24 Surveyor identified a Weekly Summary-Skin Condition document, dated 02/07/24, that indicated R29 had no skin impairments. The only preventative measure currently in place was barrier cream, and R29 required the assist of two for repositioning. The Weekly Summary-Skin Condition document, dated 02/21/24, indicated R29 had no skin impairments. Preventative measures in place were turning/repositioning program, heels elevated when in bed, and barrier cream. The Weekly Summary-Skin Condition document, dated 03/13/24, indicated R29 had open lesions to the back of knees from sling. The only preventative measure currently in place was barrier cream, and R29 required assist of two for repositioning. There was a communication sent to the provider updating about the open areas. R29's skin integrity care plan was not updated. A physician's orders sheet from a Nurse Practitioner (NP), dated 03/21/24, identified R29 had unstageable pressure injuries to both lateral knees. The order sheet included Pad wheelchair sides where knees meet w/c to offload pressure. PT [physical therapy] involved to reduce pressure areas. R29's skin integrity care plan was not updated. The Weekly Summary-Skin Condition document, dated 03/22/24, identified R29 had pressure injuries to right and left lateral knees. Skin preventative measures checked included: special pressure relieving mattress, pressure relieving cushion in chair, pillows for repositioning, and barrier cream. R29's skin integrity care plan or treatment orders were not updated to reflect these interventions. There is no further documentation of assessments with description or measurements of the pressure injuries until 04/04/24. A Skin Only Evaluation document, dated 04/04/24, identified R29 had a newly identified stage 3 pressure injury to the coccyx measuring 2 centimeters (cm) long by 2 cm wide by 0.5 cm deep. The wound had undermining of 0.5 cm at 5 to 7 o'clock. There was a physician's order sheet dated 04/04/24 from the NP with orders for treatment of the new pressure injury to the coccyx. The orders also included: Dietician eval and treat for diet to enhance wound healing yet decrease caloric intake. There is no documentation of an evaluation by a dietician until 06/11/24. R29's skin integrity and nutrition care plans were not updated to reflect interventions for the new pressure injury to the coccyx to promote wound healing and prevent further breakdown. There was no documentation of assessments of R29's pressure injuries with staging, description of wounds, or measurements between 04/05/24 to 04/26/24. The next documentation of assessment of R29's pressure injuries was dated 04/26/24. The documentation identified the coccyx wound as a stage 4 pressure injury with measurements of 3 cm long by 3 cm wide by 3 cm deep. The documentation indicated the wound had tunneling and undermining 1 cm around 1 o'clock and 2 cm at 7 o'clock. It is of note that on 10/09/24 at 1:18 PM, Surveyor interviewed Registered Nurse (RN) C, who was the first nurse to document that R29's coccyx wound was a stage 4 pressure injury on 04/26/24. Surveyor asked RN C what they based that assessment on. RN C stated they labeled R29's coccyx wound stage 4 based on assessment by a wound care NP who made wound rounds in the facility on that date. RN C searched the medical record and found a handwritten order from the NP that documented Coccyx ulcer stage III . RN C stated they were in error and mistakenly documented R29's coccyx wound a stage 4. All weekly wound documentation between 04/26/24 through 09/13/24 labeled the coccyx wound stage 4. There was weekly documentation of assessment of the wounds with description and measurements that were essentially unchanged from 04/26/24 through 06/07/24. Surveyor identified a nutritional assessment completed by the dietician dated 06/11/24. The note identified R29 had several wounds and made recommendations for increasing a liquid protein supplement to three times per day and adding liquacel protein supplement twice per day. R29's skin and nutrition care plans were not updated to reflect these recommendations. The weekly wound documentation on 06/14/24 identified R29's coccyx wound had increased in size to 4 cm by 4 cm by 2.5 cm with undermining. There was weekly documentation with assessments and measurements of wounds that were essentially unchanged from 06/14/24 through 07/05/24. There was no documentation of wound assessments between 07/05/24 and 07/19/24. The weekly wound assessment documentation of R29's coccyx wound from 07/19/24 through 09/13/24 was essentially unchanged. All other pressure injuries were resolved by 09/13/24. Beginning 09/18/24, the facility began using a new system for documenting wounds and all weekly wound documentation and summaries were complete on the medical record from that date. The coccyx wound from that date going forward was staged as a stage 3 pressure injury. On 10/07/24, Surveyor observed R29 seated in wheelchair from 10:45 AM through 4:00 PM. On 10/08/24 at 10:26 AM, Surveyor observed RN C provide wound care for R29's coccyx wound. No concerns were identified with infection control or wound care procedure. The wound was observed to be a deep crater in the center of coccyx area. The wound bed appeared clean with minimal slough and no signs of infection. RN C stated Interim Director of Nursing (IDON) H would do wound care tomorrow with a full assessment of the wound with measurements. On 10/08/24, Surveyor observed R29 seated in wheelchair from 10:45 AM through 4:00 PM. On 10/09/24 at 9:33 AM, Surveyor interviewed Certified Nursing Assistant (CNA) D and asked if they did any special turning or repositioning for R29. CNA D stated when R29 was in bed they offered to turn R29 about every 4 hours, but R29 spent most days up in the wheelchair all day from the time they got R29 up which was mid-morning today. On 10/09/24 at 10:42 AM, Surveyor interviewed IDON H who took over as interim DON in July. IDON H stated a different nurse was managing wound care at that time. IDON stated they did not discover there was a problem with wound assessments and documentation until September. Surveyor reviewed the documentation of R29's wound care described previously with IDON H. IDON H agreed the facility staff did not care for or document R29's wound appropriately to prevent development of pressure injuries and promote healing.