**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility did not always ensure that 2 out of 4 (R27, R9) residents reviewed with pressure injuries received the necessary treatment and services to promote healing, prevent infection and prevent new injuries from developing. R27 was admitted to the facility with areas of skin impairment to the right lateral ankle- noted to be a stage 3 open area. An area to the right great toe which was noted to be a stage 3 open area and dark blue/purple areas on bottom of feet, possible DT (Deep Tissue). The facility failed to comprehensively assess these areas upon first observation and also failed to obtain a treatment for these areas from 11/4-11/15/21. The facility did not update the individual plan of care with interventions that would assist in healing these areas. R9 developed a suspected deep tissue injury to the right heel and the facility did not compressively assess the area from the initial observation on 12/2/21 until 12/9/22 when the area is noted to be necrotic by Wound MD- M. The facility had interventions in place at the time to avoid pressure injury development such as a speciality air- mattress but they did not updated the plan of care with further interventions to assist in the healing of the wound to R9's right heel. Findings include: 1.) R27 was admitted on [DATE] with diagnoses that included heart disease, anemia, chronic kidney disease stage 2, peripheral vascular disease, hypertension, muscle weakness, anxiety disorder and cognitive communication deficit. The facility conducted an admission Braden assessment on 5/4/22 and noted R27 was at risk for developing a pressure ulcer. A review of the admission assessment, dated 5/4/22, identified the following skin integrity concerns: Right anecdotal- bruising IV site Left anecdotal- bruising IV site Right lateral ankle- open area 1.5 x 1.9 x 0.7 Stage 3 Right great toe open area 0.3 x 0.6 x 0.1 stage 3 Heel inspection- mushy and discolored Comments: Dark blue/purple areas on bottom of feet, possible DT (Deep Tissue). Applied skin prep, made nurse aware, put-on blue boots to float heels. Applied dressing to ankle OA and great toe, d/t (due to) drainage. Will update wound team to wounds. This assessment was created by LPN (Licensed Practical Nurse) - E. Surveyor noted the wounds were not comprehensively assessed as there was no description of the wound beds and no treatment obtained until 5/15/22. R27's Individual Plan of Care, initiated on 5/4/22, states that R27 is at risk for skin integrity condition, or pressure sores due to impaired mobility, thin/ fragile skin. Interventions included apply alternating pressure mattress to bed if indicated. Assure proper inflation- check frequently. Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Frequent repositioning in bed and chair. Conduct pressure injury assessments (i.e.- Braden Scale) as indicated. Assess skin for redness or pressure related changes with each care encounter- report any changes immediately. The admission MDS (Minimum Data Set), dated 5/11/22, stated that R27 had a BIMS (brief interview for mental status) of 4 (severely impaired). R27 needs extensive 1 person physical assistance for all ADL's (activities of daily living). R27 did not experience any pain in the last 5 days prior to this assessment reference date. R27 is at risk for pressure injuries and yes- unhealed areas are noted. R27 had 1 unstageable- deep tissue injury that was present upon admission. 0- venous and arterial ulcers and no other wounds. The skin CAA (Care Area Assessment) dated 5/11/22 stated that R27 was admitted with DTI (Deep Tissue Injury) and osteomyelitis to right great toe. Currently has DTI to ankle and r great toe osteomyelitis. Is able to make needs known. Is frequently incontinent of bowel and bladder. Requires assist with transfers and mobility. No concerns with nutritional status, appetite poor on therapeutic diet, is diabetic. RISKS: skin breakdown, infection, pain. Surveyor continued to review R27's medical record which did not show any further documented, comprehensive assessment of R27's wounds to her right foot/ ankle and heel that were first observed upon admission on [DATE]. Surveyor conducted a review of the Treatment Administration Record (TAR) for May 2022. The TAR did not show evidence that any type of treatment had been administered to R27's right foot, heel or ankle from 5/4/22 until a physician order was obtained on 5/15/22. The order was written to Paint right lateral ankle and right great toe with betadine, spray right lateral heel with skin prep, pad right lateral heel with ABD and secure with rolled gauze every evening and as needed (PRN). The first comprehensive assessment of R27's wounds to her right foot/ ankle/ heel was completed on 5/17/22. The following note was documented in the electronic medical record: 5/17/2022 at 11:03 a.m.; Skin/Wound Note- [R27] with wounds to right foot since admission. Right great toe has an abrasion measuring 0.6 x 0.9 x 0.1 with 100% granulation, right lateral ankle with scab measuring 1 x 0.4 x 0 dry without drainage, right heel with S (suspected) DTI measuring 3 x 1.5 x 0 purple and closed. Treatments in place for all three of these wounds. Coccyx with pinkness that is blanchable and closed. Groin and peri-anus pink with cream ordered for MASD (moisture-associated dermatitis) r/t (related to) incontinence. Air mattress in place, blue boots on when resident is in bed, continue to turn and repo q 2 hours (reposition every 2 hours) and PRN. MD and daughter aware of wounds and in agreement with the plan. Resident denies pain to these areas. 5/19/2022 at 5:36 p.m. Skin/Wound Note MD- M was in to see R27 last night. R27 seen for right great toe, right lateral ankle, right heel wounds and MASD to perineal and peri-anal area. NOR (new order). Added additional supplement and vit (Vitamin) C BID (two times a day). Review of (name of clinic) Wound Physician Assessment: dated 5/18/22: CHIEF COMPLAINT: This patient has multiple wounds. HISTORY OF PRESENT ILLNESS At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. R27 has an unstageable DTI of the right, lateral heel for at least 4 days duration. There is no exudate. The patient verbalizes pain with score of 0 out of 10. Arterial Wound of the right, dorsal, first toe full thickness wound size: 0.6 x 0.9 x 0.1 cm 90% granulation, 5% bone, 5% necrotic tissue. Surveyor noted the Wound Physician is now referring to the right great as an Arterial wound versus previous reference to the area being a pressure injury. *ADDITIONAL WOUND DETAIL Pt w/ Hx osteomyelitis of R great toe, as seen on X-ray 3/29/22. Pt treated with 2 courses oral abx as outpatient. IV abx during recent hospitalization d/c'd due to new C diff infection. Pt evaluated 4/26/22 as inpatient by podiatry to discuss possible amputation--surgery deferred out of concern for advanced peripheral arterial disease *DRESSING TREATMENT PLAN Primary Dressing(s) Betadine apply once daily for 30 days *Arterial Wound of the right, lateral ankle partial thickness 1.0 x 0.4 x not measurable, dried scab Surveyor noted the Wound Physician is now referring to the right lateral ankle as an Arterial wound versus previous reference to the area being a pressure injury. DRESSING TREATMENT PLAN for the first dorsal toe, right foot and Lateral ankle: Primary Dressing(s) Betadine apply once daily for 30 days *Unstageable DTI of the right, lateral heel partial thickness pressure Wound size: 3.0 x 1.5 x not measurable surface area 4.5 cm DRESSING TREATMENT PLAN for the Unstageable DTI of the right lateral heel. Primary Dressing(s): Skin prep apply once daily for 30 days PLAN OF CARE REVIEWED AND ADDRESSED. Recommendations: Off-load wound; Reposition per facility protocol; Sponge boot; Vitamin C 500mg twice daily PO; Multivitamin once daily PO; Protein supplements 3x daily with meals PLAN OF CARE REVIEWED AND ADDRESSED: My goal for this wound is healing as evidenced by a decrease in surface area of the wound and/or a decrease in the percentage of necrotic tissue within the wound bed. Wound Care Note from, dated 5/31/22: NOTE: Signing off on patient (R27) who remains in the facility. Pt now enrolled in hospice services, who requested to take over primary management of pt's wounds. Skin / Wound note dated 5/31/2022 at 09:55 a.m.; Right heel sDTI remains intact and light purple in color measuring 3 x 1.5 x 0. Betadine paint BID per hospice orders. Right great toe abrasion measures 0.6 x 0.5 x 0.2 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. Right lateral ankle scab measures 1.4 x 0.3 x 0. adding BID Betadine treatment at this time. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Skin / Wound note dated 6/9/2022 at 2:31 p.m.; Right heel sDTI remains intact and light purple in color measuring 3.2 x 1.4 x 0. Betadine paint BID per hospice orders. Right great toe abrasion measures 0.9 x 0.9 x 0.4 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. Right lateral ankle scab measures 1.1 x 0.3 x 0. adding BID Betadine treatment at this time. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Skin/ Wound note dated 6/14/2022 at 08:19 a.m.; Right heel sDTI remains intact and dark brown in color measuring 3.5 x 1.5 x 0, it is 90% necrotic tissue and 10% granulation to the border. Betadine paint BID per hospice orders. Right great toe abrasion measures 0.9 x 1 x 0.4 with pinkness and slight swelling noted, minimal drainage noted with twice a week honey and foam dressing in place per hospice. It is 20% bone, 70% granulation and 10% slough with minimal s/s drainage. Right lateral ankle scab measures 1 x 0.3 x 0. adding BID Betadine treatment at this time. Right lateral bunion area 1 x 0.5 x 0 discoloration and intact. No s/s of infection noted. Hospice following wounds. Resident and family in agreement with hospice plan of care for wounds. Will add gauze wrap to foot/heel for protection. MD in agreement with the plan. Surveyor conducted a review of the current treatment orders for R27. The following was noted: Assist resident to turn and reposition q (every) 2 hours and PRN. No directions specified for order. Surveyor noted review of the plan of care showed that this intervention was not added for R27. Right great toe, clean with wound wash, apply thin layer of medi honey to slough, cover with foam dressing. Change 2 x a week and PRN until healed, at bedtime every Tues, Fri Right heel, right lateral bunion and right lateral ankle-paint with Betadine BID and wrap foot/ankle with rolled gauze for protection, keep heel boots on al all times, may remove when doing treatment. Every morning and at bedtime AND as needed for may change if soiled or dislodged. Place pillows or blue heels off device in a comfortable position to float residents' heels when in bed and chair as tolerated. No directions specified for order. Surveyor noted this intervention was not added to R27's individual plan of care. On 6/15/22 at 11:21 a.m., Surveyor observed LPN- D provide treatment to R27's wounds to her right foot/ ankle/ heel. The following was observed: R27 gives permission for Surveyor to observe treatment along side of LPN- D. LPN- D proceeds to the bathroom to wash her hands. LPN- D has placed the treatment supplies on R27's bedside table without any type of barrier for infection control. R27's table had candy wrappers, papers and miscellaneous belongings on the table along side the gauze, tape, scissors and treatment medication. It was observed that R27 did have boots on both her right and left feet and LPN- D removed the boots and socks. There was a bandage dated 6/14 to R27's right great toe that LPN- D removed. LPN- D then started to cut the tape that was applied to R27's right foot/ ankle holding the gauze in place. At this time R27 begins to show facial grimacing and winches in pain. LPN- D continues to remove gauze. LPN- D then lifts R27's right leg up to inspect the areas and R27 begins to state ouch, ouch, ouch. LPN- D does not address R27's pain level and begins to cleanse the right great toe with gauze that has been sprayed with wound cleanser. LPN- D then dries the area with gauze. LPN- D then removes her gloves, does not wash her hands and leaves the room to obtain additional supplies from the cart that is located in hallway. LPN- D then returns into the room and applies new gloves without washing her hands. LPN- D applies the medi-honey to the bandage and adheres it to R27's right great toe. LPN- D then removes her gloves and goes into bathroom to wash her hands. Surveyor asks R27 if she has pain from the areas on her right foot, R27 responds yes, my foot hurts all of the time. LPN- D applies new gloves and opens the Betadine/Iodine treatment and begins to paint the wound located on the side of R27's right foot. It was noted that LPN- D did not cleanse the right heel or lateral foot before applying the iodine. (Directions for use of Betadine state 1. Clean. Gently clean the affected area. 2. Treat. Apply a small amount of solution to affect area. 3. Protect. Let dry and cover with sterile bandage if needed.) LPN- D lifts R27's right leg to apply the Iodine treatment and R27 winces out in pain again. LPN- D continues to swab the heel and then places R27's heel back down on the bedsheet. The bedsheet appeared with some stains prior to treatment and noted that the Iodine has also now left a stain to the bed sheet. LPN- D applies the Iodine to the lateral foot and then proceeds to wrap the right foot/ heel with gauze. LPN- D places the extra gauze, tape and scissors on the bed sheet next to R27. The gauze taped and dated and LPN- D applies the boots back to R27's feet. LPN- D then walks over to the garbage can and removes the trash bag with her gloved hands. LPN- D then removes additional garbage from the garbage can that was not in the trash bag and places into trash bag. LPN- D then removes hers gloves, grabs the tape and scissors and leaves the room without washing her hands. LPN- D then returns the tape and scissors back in the drawer of the treatment cart and then uses hand sanitizer. Surveyor conducted further review of R27's plan of care after observing R27's pain during the above treatment observations. The plan of care stated the following: Resident has pain or the potential for pain r/t or evidenced by: Decreased mobility . Interventions included: o Administer analgesics per MD orders. Give prior to treatments, therapy or cares. o Anticipate Resident's need for pain relief and respond as soon as possible to any complaint of pain. o Observe Resident during cares for signs of pain i.e. facial grimacing, hesitancy with movement, furrowed brows, saying Ouch, refusing to move or transfer. Always ask Resident about their pain with each encounter. On 6/15/22 at 7: 55 a.m., Surveyor interviewed DON- B and Director of Clinical Operations- N in regard to R27' skin impairments to the right foot and heel. DON- B stated that upon admission, R27 was wearing heel boots for protection and was receiving a multi vitamin. On 5/13/22 a protein supplement was added. Surveyor asked if there had been a physician order for the use of the skin prep. DON- B stated that she did not see one after reviewing the record for R27. DON- B confirmed that if a wound is identified, it should be comprehensively assessed, and a treatment should be ordered. DON- B stated she is not aware why a treatment was not initiated upon discovery of the areas. On 06/15/22 01:41 p.m. Surveyor interviewed DON- B in regard to R27's area of skin impairment to the right foot/ ankle and heel. Surveyor verified with DON- B that a treatment was not obtained for R27 upon admission when the areas to the right lateral ankle and right great toe and dark blue/purple areas on bottom of feet, possible deep tissue. Surveyor shared the above observation of the treatment provided to R27 on 6/15/22 by LPN- D. Surveyor spoke of the pain R27 experienced during the treatment that went unaddressed by LPN- D and the infection control concerns during the treatment. DON- B was asked what areas remain for R27. DON- B stated that the bunion listed on her assessment is a new area and developed sometime between 6/9/22 and 6/14/22. DON- B obtained an order for Betadine to treat all the areas on the right foot/ ankle and heel and the treatment to the right great toe remained the same. As of the time of exit, the facility was not able to provide additional evidence that they had Comprehensively assessed R27's wounds to her right foot, upon admission on [DATE]. The facility did not obtain a treatment order until 5/15/27 and did not update the plan of care with further interventions to assist with the healing of these areas. The facility originally identified the areas to R27's right foot as pressure injuries, they were then documented as a suspected deep tissue injury to the heel and possible arterial ulcers to the lateral foot and top of great right toe. The areas were then described as abrasions, suspected deep tissue area and the development of a new bunion. The facility staff did not practice safe infection control practices during the treatment observation and did not address the pain R27 was experiencing during the treatment administration. 2. Resident 9 was admitted on [DATE] with diagnosis that included Multiple Sclerosis, abnormal posture, muscle weakness generalized, insomnia, mood disorder, visual hallucinations, major depressive disorder, hypertension. Upon admission, R9 was noted to have an unstageable (due to Necrosis ) area on her sacrum. R9 has been seen by a wound MD prior to admission to the facility to treat the area. Surveyor conducted a review of the weekly skin assessments and on 12/2/21 it was noted that R9 had a New skin impairment- see note DTI ( Deep Tissue Injury) right heel- assessment 12/2/21 Surveyor noted that there was not a comprehensive assessment, completed by a Registered Nurse (RN) of the DTI to R9's right heel following the initial observation on 12/2/21. Nursing note dated 12/2/2021 at 9:22 p.m. stated R9 returned from shower, writer informed of darkened area to right heel, assessment of site, area dark purple in color, no open areas, measures approximately 5.5 cm x 5.5 cm, DON (Director of Nursing), NP (Nurse Practitioner) for MD, and family made aware, treatment order per DON of Betadine, pad with ABD and wrap with Kerlix daily, fax to MD to update, orders for blue boots and elevator to keep heels off bed, wrier explained to resident how injury occurs and treatment of injury, skin to left heel intact, clean and dry. It was noted that this entry was written by LPN- E A physician order was obtained on 12/2/21 stated right heel (possible DTI) - cleanse with soap/ water, pat dry, swab with betadine, pad with abd, wrap with kerlix, and secure with tape at bedtime for wound care. Clinical Follow-up note dated 12/3/2021 at 12:45 a.m., late Entry: Note Text: R9 is on follow up for: late entry for 12/3/21. f/u IR on 12/2/21 right heel deep tissue bruise. The current status is Resident does not c/o heel pain. Wound is dressed per Dr orders. Clinical Follow- up note dated 12/3/2021 at 5:38 a.m., R9 is on follow up for: R heel (possible DTI). The current status is R heel bandaged. remains dry and intact. no complaints of pain or other concerns Health Status Note dated 12/3/2021 at 9:25 a.m., Late Entry: Note : IDT met to review the sDTI noted to this R9's right heel on PM shift last night. R9 was given a shower and the CNA told LPN- E about the findings. R9 was not aware of the injury as she does not have much feeling in her legs related to her multiple sclerosis. She also has thrombocytopenia. R9 prefers to lay on her back with a pillow under her legs. She does state that often times the pillow doesn't keep her heels off the bed but that's how she likes it. Offloading was discussed and foam boots were added to her careplan. She is in agreement with the plan to wear blue boots and off load when she is in bed. (name of clinic) wound MD will be into see this resident 12/09/2021. Treatment was obtained from the MD and R9's brother was notified. Health status note dated 12/3/2021 at 11:16 p.m Resident is on follow up for: R heel (possible DTI). The current status is R heel bandaged. remains dry and intact. See TAR for Tx for healing pressure ulcer Clinical Follow- up note dated 12/4/2021 at 8:45 p.m , R9 is on follow up for: IR - right heel - DTI. The current status is f/u IR - DTI to right heel, no new skin issues noted, no c/o pain r/t wound, blue boots in place for protection, treatment to site per orders, no other c/o. Clinical follow-up note dated 12/5/2021 at 12:45 a.m., R9 is on follow up for: DTI to right heel, dressing/treatment per orders. Resident denies pain. Skin intact The current status is DTI has intact skin, resident denies pain, following treatment orders; blue boots on. It was noted that there still was not a comprehensive assessment of the Suspected deep tissue injury from 12/2/21 to 12/9/21. There was no description of the area, measurement or investigation as to how the deep tissue injury may have been caused. On 12/9/21, R9 is seen by (name of clinic) Wound Physician. Chief complaint- multiple wounds. Site #2 Unstageable (due to Necrosis) of the right heel. Pressure, Duration- greater than 12 days. Wound size (LxWxD) 6.5 X 3 X no measurable cm. Surface area 19.50 cm. Exudate- moderate Serous. Thick adherent black necrotic tissue (eschar)- 100%. Dressing Treatment Plan: Santyl apply once daily for 30 days; Xeroform sterile gauze apply once daily for 30 days. Site #2- surgical excisional debridement procedure . Remove necrotic tissue and establish the margins of viable tissue. Plan of care recommendations: reposition per facility protocol; off-load wound. EZ boot to be worn in bed and chair to off-load wound. Surveyor noted that in the nursing notes from 12/2/21 until 12/9/21, the SDTI to R9's right heel was never described as having necrosis present on the wound bed. The next skin wound note was dated: 12/16/2021 at 4:25 p.m which stated, Wound team saw patient (R9) this morning. coccyx/right buttock unstageable pressure injury worsening. Odor present. Dr. updated via phone and she will be in tomorrow to assess and treat the wound. measurements 6 x 6 with undermining at 0000 2.5cm, 0300 2cm, 0600 1.2cm, wound is all necrotic inside and we will continue Santyl treatment daily. Right heel unstageable pressure injury improving. Measurements 4.5 x 5 x 0 and it appears to be a fading purple color. Will continue same treatment and have Dr assess tomorrow as well. Resident denies pain and discomfort. She is on an air mattress with blue boots and pillows under her legs, she is encouraged to lay side to side and chooses to lay in her back often. She verbalizes understanding of need to side lay. A review of the Individual Plan of Care for R9 stated that R9 has 2 pressure injuries (sacrum and right heel) r/t Immobility. This plan of care was initiated on 4/1/22. Interventions included: *The residents will Pressure ulcer will show signs of healing and remain free from infection by/through review date. ·Follow facility policies/protocols for the prevention/treatment of skin breakdown. The plan of care was not updated with the interventions for the use of the blue boots and to elevate the heels off the bed. R9 continued to receive treatment to the deep tissue injury located on the right heel daily and continued to be seen by Wound MD- M weekly for assessment of the areas. Skin Wound note dated 4/14/2022 at 4:33 p.m., per most recent hospitalization D/C orders IV ABX's Vancomycin and Ceftriaxone were only to be given for 32 days ending this weekend, however, per wound MD -M assessment on res's (sic) wounds on Wed. 4/13/2022 there are worsening S/S of wound and healing process, wound culture to Right heel was picked up by lab and results pending at this time, Infectious Disease (ID) MD was called and notified of wound MD - M concerns regarding worsening wounds and concern for IV ABX's ending this weekend, writer and wound RN/DON - B present during call with ID MD, ID MD gives orders at this time to D/C end date for IV ABX Vanco and Ceftriaxone and to continue both IV ABX's until further notice from ID MD, continue with weekly labs and fax results to ID on Mondays, when wound culture results from Right heel are final please send to ID for orders, and to update ID in 1 week with appearance and assessment of wounds from Wound MD- M. Skin Wound Note dated 4/15/2022 at 3:26p.m. stated Wound MD- M was provided a copy of R9's preliminary right heel culture results. It showed gram negative rods. Wound MD- M stated that this could be why her right heel is worsening. He would like to see the final culture when available and no new orders are needed at this time based on the preliminary culture. Skin/ Wound note dated 6/9/2022 at 2:46 p.m. stated Wound MD- M off this week. Nursing wound rounds done by DON- B. Right heel wound improving and measures 0.2 x 1 x 0.3 50% gran and 50% slough, skin tear to right heel 0.9 x 0.4 x 0 almost healed. On 6/15/21 at 8:40 a.m., Surveyor interviewed DON-B who stated that she is pretty sure she was made aware of the SDTI to R9's right heel on 12/2/21 when it was first observed. DON- B stated that the expectation is that any wound is comprehensively assessed by a Registered Nurse. DON- B stated that she recalls the area to R9's heel being purple and that she did call the physician to get a treatment order. DON- B stated that R9 had MS and really doesn't have feeling in her legs/ feet and that she will have her heels lifted by a pillow in bed or wear the blue boots. R9 was also on an air-mattress at the time the area developed. R9 does get up in her wheelchair twice daily for 1-hour periods of time and is to wear the blue boots when up. As of the time of exit, the facility was not able to provide evidence that R9's SDTI was comprehensively assessed upon the initial observation of the wound. The first comprehensive assessment was completed on 12/9/21 when Wound MD- M assessed the area to the right heel and documents there is an area of necrosis present. The facility did obtain a treatment on 12/2/21 and R9 was using a specialty air mattress at the time of discovery. The facility also did not provide evidence that they had updated the plan of care with all of the interventions that were to be in place to promote the healing of the wound to R9's right heel.