**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents received treatment and care consistent with N6 Wisconsin Nurse Practice Act for 2 (R3 & R1) of 4 residents reviewed. R3 was admitted to the facility on [DATE]. During the night of [DATE], R3 experienced a change of condition including having shortness of breath, increased pulse and respirations, and oxygen (O2) saturations of 65% (as obtained by Licensed Practical Nurse (LPN)-N. LPN-N sought out Registered Nurse (RN)-L for a second opinion. LPN-N and RN-L had a miscommunication as RN-L believed R3's O2 sats were 85%. RN-L listened to R3's lung sounds but did not complete a comprehensive assessment of R3's change of condition. LPN-N obtained an order to transfer R3 to the hospital and called a private ambulance service. Upon EMS arrival, they found R3 to be in severe respiratory distress and unresponsive. R3 passed away in the ambulance while still at the facility. The facility's failure to have effective communication of R1's medical status between RN-L and LPN-N, the failure to complete a comprehensive assessment of R3's status by RN-L, the failure to recognize the acute change in condition to include hypoxia, and the delay in providing emergency medical care to R3 by not calling 911 when R3's oxygen saturation was 65% created a finding of Immediate Jeopardy (IJ) which began on [DATE]. NHA (Nursing Home Administrator)- A, DON (Director of Nursing)-B, & [NAME] President of Success-Q were notified of the immediate jeopardy on [DATE] at 2:03 p.m. The immediate jeopardy was removed on [DATE]. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the example involving R1 and as the facility continues to implement its action plan. *R1 was observed without the right lower extremity tubi grip on [DATE] & [DATE]. Findings include: The facility's policy titled, Change in Condition of the Resident and reviewed/revised [DATE] under Policy documents: A facility should immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention; a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); or a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). According to the State of Wisconsin Nurse Practice Act: N 6.03 - Standards of practice for registered nurses. (1) General nursing procedures. An R.N. shall utilize the nursing process in the execution of general nursing procedures in the maintenance of health, prevention of illness or care of the ill. The nursing process consists of the steps of assessment, planning, intervention, and evaluation. This standard is met through performance of each of the following steps of the nursing process: (a) Assessment. Assessment is the systematic and continual collection and analysis of data about the health status of a patient culminating in the formulation of a nursing diagnosis. (b) Planning. Planning is developing a nursing plan of care for a patient which includes goals and priorities derived from the nursing diagnosis. (c) Intervention. Intervention is the nursing action to implement the plan of care by directly administering care or by directing and supervising nursing acts delegated to L.P.N.'s or less skilled assistants. (d) Evaluation. Evaluation is the determination of a patient's progress or lack of progress toward goal achievement which may lead to modification of the nursing diagnosis. According to N6.04(1), In the performance of acts in basic patient situations, the L.P.N. shall, under the general supervision of an R.N. or the direction of a provider . (b) Provide basic nursing care. (c) Record nursing care given and report to the appropriate person changes in the condition of a patient . (e) Perform the following other acts when applicable: 1. Assist with the collection of data. 2. Assist with the development and revision of a nursing care plan. 3. Reinforce the teaching provided by an R.N. provider and provide basic health care instruction. 4. Participate with other health team members in meeting basic patient needs. According to https://www.yalemedicine.org People should contact a health care provider if their oxygen saturation readings drop below 92%, as it may be a sign of hypoxia, a condition in which not enough oxygen reaches the body's tissues. If blood oxygen saturation levels fall to 88% or lower, seek immediate medical attention. R3 is an [AGE] year-old male admitted to the facility on [DATE]. R3 was hospitalized from [DATE] to [DATE] following a fall in the bathroom. R3 presented to the ED (emergency department) in A Fib (Atrial Fibrillation) with rapid venticular response, concern for ST (sinus tachycardia), and troponin elevation. R3 received heparin during hospitalization but was transitioned to low dose Eliquis. R3's diagnoses include non-sinus tachycardia myocardial infarction, syncope and collapse, chronic kidney disease with heart failure, diabetes mellitus, depressive disorder, atrial fibrillation, and presence of left artificial hip joint. R3 was his own person and did not have an activated power of attorney for health care. The nurses note dated [DATE], at 17:05 (5:05 p.m.), documents: Resident is on follow up for: New Admission. The current status is Resident arrived facility at 1500 (3:00 p.m.) from [hospital initials]. Resident was in hospital after a fall at home. Resident has complaints of mild pain in both hips and lower back. Resident uses urinal in bed and is a check and change for BM (bowel movement) due to weakness until evaluated by therapy. Active bowel sounds in all four quads (quadrants), Lungs clear. Hospital states resident would be a candidate for sit to stand but it was never attempted in hospital. Resident is A&Ox3 (alert and orientated times three) sometimes a bit confused but easily redirected. Resident has a friend [first name] that is very involved and visits often. This nurses note was written by LPN (Licensed Practical Nurse)-T. The nurses note dated [DATE], at 00:38 (12:38 a.m.), documents: Resident is on follow up for: New Admission. The current status is Resident in bed resting with eyes closed at this time. Follow up, new admit. Resident adjusting well to facility. No c/o (complaint of) pain or discomfort. No sob (shortness of breath) or respiratory distress noted. All cares provided by staff PPOC (per plan of care). Will monitor. This nurses note was written by LPN-U. The nurses note dated [DATE], at 08:29 (8:29 a.m.), documents: Resident is a new admit who went into hospital after a fall at home. Resident has complaints of mild pain in both hips and lower back. Resident uses urinal in bed and is a check and change for BM due to weakness until evaluated by therapy. Active bowel sounds in all four quads, Lung clear. Hospital states resident would be a candidate for sit to stand but it was never attempted in hospital. Resident is A&Ox3 some confused at times but easily redirected. We will cont. (continue) ppoc. This nurses note was written by LPN-M. The nurses note dated [DATE], at 19:25 (7:25 p.m.), documents: Resident is on follow up for: New Admission. The current status is Follow up, new admit after a fall at home. Resident adjusting well to facility. No c/o pain or discomfort. No sob (shortness of breath) or respiratory distress noted. All cares provided by staff PPOC. Resident here post fall at home, resident here for weakness and strengthening. This nurses note was written by LPN-T. Review of R3's oxygen saturation under the weight/vitals tab reveals the following: [DATE], at 1543 (3:43 p.m.) 95% on room air. [DATE], at 0445 (4:45 a.m.) 93% on room air. [DATE], at 1132 (11:32 a.m.) 95% on room air. [DATE], at 1632 (4:32 p.m.) 96% on room air. [DATE], at 0131 (1:31 a.m.) 65% on room air. Review of R3's pulse under the weight/vitals tab reveals the following: [DATE] at 1543 (3:43 p.m.) 74 bpm (beats per minute). [DATE] at 0445 (4:45 a.m.) 65 bpm. [DATE] at 1132 (11:32 a.m.) 80 bpm. [DATE] at 1632 (4:32 p.m ) 60 bpm. [DATE] at 0131 (1:31 a.m.) 97 bpm. Review of R3's respirations under the weight/vitals tab reveals the following: [DATE] at 1543 (3:43 p.m.) 22 breaths per minute. [DATE] at 0445 (4:45 a.m.) 20 breaths per minute. [DATE] at 1132 (11:32 a.m.) 18 breaths per minute. [DATE] at 1632 (4:32 p.m ) 18 breaths per minute. [DATE] at 0131 (1:31 a.m.) 28 breaths per minute. Review of R3's Electronic Medical Record (EMR) indicates R3 experienced an acute change in condition on [DATE]. After receiving an oxygen saturation of 65% on [DATE], LPN-N left R3 to obtain oxygen and seek out Registered Nurse (RN)-L on a different unit for a 2nd opinion on R3's status. RN-L stated during interviews, she listened to R3's lung sounds but did not confirm/verify the information gathered by LPN-N or complete a comprehensive assessment of R3's change in condition. RN-L stated after listening to R3's lungs she agreed something was going on with R3. Both nurses left R3's room, LPN-N proceeded to call R3's physician/nurse practitioner's office to obtain an order to send R3 to the hospital for further evaluation (physician's office was called at 1:18am.) LPN-N obtained the order to transfer R3 to the hospital and called a private ambulance service (not 911) at 1:31am that arrived at the facility without lights and sirens. RN-L left R3 to get paperwork ready for R3's transfer to the hospital and was then called back to her assigned unit. During interviews with RN-L she shared she thought LPN-N said the pulse ox level was 85% not 65%. RN-L shared had she known that she would have immediately sent R3 out. When RN-L went back to check on LPN-N EMS (Emergency Medical Services) was already in R3's room. Upon EMS arrival to R3's room (at 1:38am) they were informed by facility staff R3 had exhibited severe lethargy and unusually slow respiratory pattern for approximately 30 minutes prior to EMS activation. BLS (Basic Life Support) EMS assessed R3 to be in severe respiratory distress, periodic breathing-Cheyne-Stokes breathing, unresponsive, no blood pressure, weak pulse at 56, blood glucose of 222, and agonal breathing at 70% O2 saturation on room air. BLS EMS used a BVM (Bag Valve Mask) and 15 liters of oxygen to assist R3 with breathing. ALS (Advanced Life Support) EMS arrived at the facility at 1:48am with lights and sirens to provided BLS EMS assistance. R3 was transferred into the ALS ambulance and was found to be in asystole and CPR was implemented. R3 was pronounced deceased in the ALS ambulance while still at the facility. On [DATE], at 6:30 a.m., Surveyor interviewed LPN-N, who was assigned to care for R3 and was the charge nurse for her shift on [DATE]. Surveyor asked LPN-N to walk Surveyor through what happened on [DATE] with R3. LPN-N informed Surveyor R3 was basically a new patient, he was doing fine, on report for new admission. LPN-N informed Surveyor she doesn't know the exact time, probably around 1:50 a.m. to 2:00 a.m., R3 had his call light on. LPN-N informed Surveyor she answered the light because the CNA was on break. LPN-N informed Surveyor she went into R3's room and he was having a hard time breathing so I asked him if this just started. LPN-N informed Surveyor she went to grab all her vital sign things, blood pressure cuff, pulse ox, thermometer. LPN-N informed Surveyor R3's SPO2 was 65%, R3 said this just started and she went to go look for oxygen and to get the other nurse. LPN-N then stated, I think I called her because I wanted to get the O2 (oxygen). LPN-N informed Surveyor she went back to R3 and thinks started the oxygen at 2 liters. LPN-N informed Surveyor R3's pulse ox was not going up, so she put a mask on him & increased the oxygen to 3 liters then the RN [RN-L's first name] was in assessing R3 as I wanted her to be a 2nd person. Surveyor asked if R3's oxygen saturations increased. LPN-N informed Surveyor it stayed at 65%. We listened to R3's lungs, could hear trach congestion and wheezing. LPN-N informed Surveyor they ended up calling [name of medical group] and the NP said okay to send to [hospital name]. LPN-N informed Surveyor she called the ambulance, emergency contact, and called in report to the RN at the hospital. LPN-N informed Surveyor a little while later, [name] ambulance came in and told her R3 had expired, and the protocol is for the cops to come so they will be talking with us. Surveyor asked who called the ambulance. LPN-N replied, I believe I did. Surveyor asked who she called. LPN-N stated [Name] of ambulance company. Surveyor asked LPN-N why she didn't call 911. LPN-N replied, the nurse practitioner didn't specify to call 911. LPN-N informed Surveyor she was conferring with the RN and asked if they should call 911 before. Surveyor asked LPN-N what assessments RN-L did. LPN-N informed Surveyor RN-L was listening to R3's lungs and asking him questions like how long he has felt like this, when did it start, did he want to go to the hospital. R3 said yes. That's all I believe I can recall. Surveyor asked LPN-N if she told RN-L what R3's oxygen saturation was. LPN-N replied yes. Surveyor asked LPN-N when she obtained an oxygen saturation of 65% for R3 why didn't she send R3 out to the hospital. LPN-N replied because I had to call the doctor. Usually, we have to get an order to send him out. Surveyor asked LPN-N if she was in R3's room prior to him placing on the call light. LPN-N replied, just to peek in. Surveyor asked LPN-N what she meant by peeking in. LPN-N informed Surveyor she checks to make sure the resident is not at the edge of the bed, positioning is good, bed is low, call light, things like that. Surveyor asked prior to R3 putting on his call light, had she taken R3's vital signs. LPN-N replied, I did not. Surveyor asked from the time she called for the ambulance, how long was it until they arrived. LPN-N replied 15 maybe 20 minutes seemed like they came pretty fast. Surveyor asked LPN-N who was the charge nurse this night. LPN-N replied I believe it was me but not positive. Surveyor asked who documents the assessments. LPN-N replied usually the RN puts their own note in. Surveyor asked if RN-L documented. LPN-N replied, I don't believe she did, no. Surveyor asked LPN-N if RN-L gave her any information to include in her note. LPN-N replied no, not that I'm aware of. Surveyor asked LPN-N after she received an oxygen sat for R3 of 65% how long was it until RN-L came to the unit. LPN-N replied maybe 5 minutes. Surveyor asked LPN-N if there was anything else she wanted Surveyor to know. LPN-N informed Surveyor she tried to put everything in her note. LPN-N's nurses note is dated [DATE], at 02:12 (2:12 a.m.), documents Patient C/O (complained of) SOB (shortness of breath). TPR (temperature, pulse, respirations) 98.4, 97, 28. BP (blood pressure) 124/78. SPO2 65%, RA (room air). O2 (oxygen) started at 2L (liters) and SPO2 remained at 65% so increased to 3L (liters) per NC (nasal cannula)/mask. Congested cough with tracheal congestion noted. LS (lung sounds) course with expiratory wheezes. HOB (head of bed) elevated. LPN (Licensed Practical Nurse) and RN (Registered Nurse) assessed. NP (Nurse Practitioner) notified and ok to send to [hospital initials] ER (emergency room) for evaluation. [Name] ambulance called. Emergency contact notified. [Name] ambulance here to transport to [hospital initials] ER. Report called to ER RN [Name]. This nurses note was written by LPN-N. LPN-N also had a nurses note dated [DATE], at 02:19 (2:19 a.m.) which documents: Blood sugar 222. Surveyor notes LPN-N was calling the NP, responsible party, ambulance company, and giving report to the receiving hospital while RN-L was gathering the necessary paperwork for R3's transfer, however, RN-L was called back to her assigned unit, leaving CNA-V with R3 who continued to experience a more severe change in condition as noted by BLS EMS's assessment of R3 upon their arrival. On [DATE], at 2:34 p.m., Surveyor interviewed RN (Registered Nurse)-L regarding R3. RN-L informed Surveyor she works the back half which consists of the 200 & 300 units. RN-L informed Surveyor R3 was having trouble breathing and [first name of LPN-N] asked her to give a 2nd opinion. RN-L stated his lungs were not sounding great. RN-L informed Surveyor when she went in, he was alert and talking with both of them, stated he was having trouble breathing and his O2 (oxygen) was mid to high 80s. RN-L informed Surveyor she couldn't remember the exact number. Surveyor asked RN-L if she did any assessment. RN-L informed Surveyor she listened to R3's lungs, they weren't clear and wasn't sure if they were coarse. RN-L informed Surveyor she told LPN-N, you're right something is going on. Surveyor asked RN-L if LPN-N told her what R3's oxygen saturation was. RN-L stated, she (LPN-N) got, like I said, mid to high 80s. Surveyor informed RN-L R3's oxygen saturation was 65%. RN-L replied, Sh*t I didn't know it was that low thought 85, 88. Surveyor then read LPN-N's [DATE] note which documented R3's oxygen at 65%. RN-L replied, Sh*t I would have called [name of medical group] if it was 65 and sent R3 out. RN-L informed Surveyor O2 at 85 (%) she's worried but at 65 (%) she's panicking. Surveyor asked who called [name of medical group]. RN-L informed Surveyor she doesn't remember. RN-L informed Surveyor she was trying to get the paperwork ready but was having trouble with the printer. Surveyor asked RN-L if she remembers what time LPN-N came to get her. RN-L informed Surveyor she doesn't remember any of the times. Surveyor asked RN-L if she documented her assessment. RN-L informed Surveyor usually she has a notebook in her pocket so she can write things down and tear it out. Surveyor asked RN-L if she gave LPN-N any information. RN-L informed Surveyor she assumes she did but can't swear she did. Surveyor asked RN-L if she was the supervisor this night. RN-L replied no they have not made me charge nurse and explained usually, the nurse on the 100 unit is the charge nurse, who was LPN-N, was the charge nurse. Surveyor asked who would document an assessment. RN-L informed Surveyor the nurse who has the resident. RN-L informed Surveyor the nurse who has the resident would do the change of condition, call [name of medical group] and all that stuff. Surveyor asked who documented on R3. RN-L replied just the LPN and stated she was getting everything ready. RN-L informed Surveyor while she was with LPN-N she got called back to her unit and when she went back to check on LPN-N, EMS (emergency medical services) was already in the room ready to load R3 up. Surveyor asked RN-L prior to LPN-N getting her, had she been told anything about R3. RN-L replied no, explaining she is usually on unit 3 and didn't know anything about R3. RN-L informed Surveyor when LPN-N came to get her she was charting at the nurses' station on her unit and asked her if she could borrow her. RN-L informed Surveyor she checked R3's breathing. Surveyor asked RN-L who determined to place 2 liters of oxygen on R3. RN-L replied she did. RN-L informed Surveyor they were partners in assessing if that makes sense. Surveyor asked RN-L again if she knew R3's oxygen was 65. RN-L replied, I didn't realize it was that low, thought she said 85, I must have misheard. 85 is worrying & 65 is panic and I panic. Did not know it was 65. According to https://my.clevlandclinic.org, Hypoxia can be life-threatening and if you are experiencing symptoms of hypoxia, call 911. Surveyor notes LPN-N's evaluation of R3 was miscommunicated and/or misunderstood by RN-L. RN-L did not complete and document an assessment of R3. BLS Ambulance Crew arrived at the facility and assessed R3 to be experiencing a more severe change in condition as they were unable to get blood pressure, a weak carotid bradycardic regularly irregular pulse at 58, SPO2 was approximately 70% on room air, bradypneic at approximately 8 for irregularly irregular respiration rate. Crew used BVM (Bag valve mask) with oxygen at 15 liters per min (minute). Surveyor reviewed the private ambulance Patient Care Report, dated [DATE], which documents: Disp (dispatch) notified: 01:31(AM), [DATE] Recvd (received): 01:31 (AM), [DATE] En route: 01:31 (AM), [DATE] At scene: 01:37 (AM), [DATE] At patient: 01:38 (AM), [DATE] [NAME] (Transition of care): 01:45 (AM), [DATE] Crew 1 level: EMT-Basic Nature of the call: Respiratory Distress Unit type: BLS (Basic Life Support) Chief Complaint: Respiratory-Severe Distress (Primary) Primary Symptoms: Periodic Breathing; or Cheyne-Stokes Breathing (periods of shallow breathing alternating with periods of deeper, rapid breathing. The deep, rapid breathing may be followed by a pause before breathing begins again.); Abnormal breathing pattern. Assessment: [DATE], at 01:39 (AM), B/P (blood pressure) no; Pulse: 58, weak, regular; Respiratory: Weak, Agonal, irregularly irregular; SPO2 (oxygen saturation): 70% on room air. -Skin Temp-Cool; Skin color: Pale; Skin moisture: Clammy -Level of consciousness: Unresponsive, Arm Movement: Left-None, Right-None; Leg - Movement: Left-None, Right-none Treatment Summary: Time: 01:40 (AM): Oxygen -Device: Adult BVM (Bag Valve Mask) -Dosage Unites: Liters per Minute -Rate: 15 LPM (Liters per Minute) -Indication: Respiratory Failure -Response: Improved -Successful: Yes Time: 01:42 (AM) Indication: Respiratory Distress Response: Unchanged SpO2: 85% Time: 01:46 (AM) -Blood Glucose Measurement: 222 -Response: Unchanged Narrative: [Name of Ambulance Company] dispatched no lights and sirens to address above (address of the Facility) for [AGE] year-old male patient for respiratory distress.Upon arrival crew was directed to patient room. Crew did not receive paperwork from health care staff, when brought up health care professional states staff was getting the paperwork now. Upon arrival patient was found in bed unconscious, crew obtaining vitals. Crew unable to get blood pressure. Crew obtained a weak carotid bradycardic regularly irregular pulse at 58. SPO2 was approximately 70% on room air. Patient was bradypneic at approximately 8 for irregularly irregular respiration rate. Crew used BVM with oxygen at 15 liters per min (minute). Crew was unable to get a [sic] adequate seal on the patients mouth due to the patient's bariatric status. Crew tried to get a summary of what happened. Healthcare professional that guided crew to patient stated she was not the person that took care of the patient and didn't know what was going on. Crew asked the healthcare professional to get the person that has information about the patient. Crew monitored patients SPO2 and heart rate. SPO2 improved with BVM and 15 liters of oxygen up to approximately 80%. Crew obtained blood glucose measurement at 222. ALS (Advanced Live Support/EMS) arrived on scene with healthcare professional in charge of patient. Crew transferred care to ALS. Crew assisted ALS due to poor seal of the BVM. ALS provided crew with CPAP (continuous positive air-way pressure) mask to put on patient as well. Crew assisted ALS with 12 lead. When put on patient was asystole (A condition where the heart's electrical and mechanical activity completely stops, resulting in a lack of a heartbeat.). Crew assisted ALS by providing chest compressions and breathing for patient with BVM at 15 liters per minute. Crew alternated positions to maintain adequate depth and speed for compressions. Crew proceeded to do CPR until instructed by ALS to stop due to med (medical) control pronouncing patient deceased . ALS (Advance Life Support) Ambulance Narrative, dated [DATE]: Assessment at 1:48 (AM): -Breathing: Absent: agonal -Level of consciousness: unresponsive -Circulation: Pulses- Carotid-weak -Mental Status: Unresponsive [Name of private ambulance company] responded w/ (with) lights and sirens to the above location for respiratory distress. Crew arrived to discover an 85-y/o (year old) male PT (Patient) lying supine in bed assisted by SNF (Skilled Nursing Facility) staff, and [name of ambulance company number of BLS (Basic Life Support) crew] had been on the scene for a few minutes prior to (ALS)'s arrival, and immediately reported to crew that pt was in hypoxic shock due to inadequate ventilation PT had reportedly had severe bradynea at rate of 4-6 BPM on their arrival w/ thready pulses centrally and SPO2 measured ~60% on conventional device. Crew noted that pts skin was pale, cool, and dry. [BLS] had intervened immediately w/ BVM ventilation but were otherwise unable to intervene prior to [ALS]'s arrival. Staff indicated that PT had arrived [DATE] for rehabilitation of a recent procedure on the left hip. PT had reportedly exhibited severe lethargy and usually slow respiratory pattern approx. (approximately) 30 min (minutes) prior to EMS activation. PT's paperwork indicated PMH (Primary Medical History) of AKI (Acute Kidney Injury), primary hypertension, and Type 2 diabetes, w/ multiple antihypertensive and anticoagulants listed on the chart. Assessment was performed on scene. PT was found totally unresponsive/weak pulses noted in the carotid artery at ~30 BPM. Assessment from vitals was unsuccessful, as no numerical measurements were appreciable at [BLS] assessment. [DATE], at 01:57 (AM), Initial CPR: Attempted ventilation and initiated Chest Compressions. On [DATE], at 8:33 a.m., Surveyor called [name of medical group] to inquire who was the NP facility staff had contacted on [DATE]. NP-W informed Surveyor it was NP-Y and NP-W can email her as she doesn't have her phone number. On [DATE], at 9:02 a.m., Surveyor called [name of medical group] to try to speak with MD (Medical Doctor)-X. NP-W informed Surveyor MD-X is out on leave. Surveyor asked NP-W if she received a call from the facility telling her there is a new admission with oxygen sats at 65% what would she tell the nurse to do. NP-W replied call 911. NP-W informed Surveyor NP-Y works part time and wasn't working this day but could read Surveyor NP-Y's note. NP-W read to Surveyor NP-Y's note which read, nursing call request order ED for evaluation due to respiratory distress. Pt pulse ox 65% on 3L inspirations and expirations wheezing using accessory muscles. Nursing orders given. NP-W informed Surveyor NP-Y's note doesn't say to call 911. NP-W informed Surveyor this note was created on [DATE] at 2:16 a.m. On [DATE], at 9:15 a.m., Surveyor spoke with NP-W on the telephone along with Director of Operations-Z from [name of medical group] to inquire if NP-Y spoke with the facility when they called or if she had to call them back. Surveyor was informed the call from the facility came in at 1:18 a.m., the patient order given was time stamped at 2:16 a.m. for when it was created in the chart, but they don't know if NP-Y spoke to the facility at 1:18 a.m. or she had to call back. On [DATE], at 10:38 a.m., Surveyor spoke with DON (Director of Nursing)-B to inquire what the night shift staffing is. DON-B informed Surveyor there are 2 nurses and 3 to 4 CNAs. One nurse is on the 100 unit and the other nurses takes 2 & 3. Surveyor asked if there is a charge nurse. DON-B informed Surveyor the charge nurse is working on the 100 unit. Surveyor asked what happens when a resident has a change of condition. DON-B informed Surveyor they typically wait for an order if it's an emergency the nurse could use their judgement and send them out. Surveyor asked about oxygen orders. DON-B informed Surveyor there is a standard nursing order for 2 liters and then call the doctor if it needs to go up. Surveyor asked if an LPN is working the unit, and a resident has a change of condition what should be done. DON-B informed Surveyor the LPN should observe the findings what they see, call the RN in the building, the RN can assess, and if it's an emergency send them out. Surveyor asked about R3. DON-B informed Surveyor LPN-N came into the room to answer the call light, R3 was SOB, she called RN-L who came and assessed. DON-B informed Surveyor he was responsive, his O2 was 85, respirations were high, they called [name of medical group] and gave an order. Once the ambulance came, they took over. Surveyor asked DON-B if the RN does their own vital signs. DON-B replied, she said they were doing vitals together. Surveyor asked DON-B if a resident has O2 sats of 65 what would you expect staff to do. DON-B replied hope they called for ambulance and prepare for code. DON-B informed Surveyor personally she would have cranked up the oxygen. Surveyor asked DON-B if she was aware when LPN-N took R3's oxygen sats it was 65. DON-B replied no, not until I looked at the progress note. RN-L told me 85. Surveyor asked DON-B if the NP doesn't specifically say to call 911 could the nurse call 911. DON-B replied, I don't know what our policy is I'll have to get back to you. On [DATE], at 3:07 PM, Surveyor interviewed Deputy Director of Operations for the EMS ambulance company (DDO)-AA who stated BLS did report to ALS R3 was in hypoxic shock upon their arrival. The facility's failure to ensure R3 received appropriate care and treatment when R3 experienced a change in condition including shortness of breath, increased pulse and respirations, and low oxygen sats led to a finding of immediate jeopardy. The immediate jeopardy was removed on [DATE] when the facility implemented the following action plan: * Director of Nursing completed an audit of residents requiring transfer from facility to higher level of care within the last 14 days, to verify appropriate provider notification and Emergency Medical Services activation. [DATE] * Facility Licensed Nursing staff reeducated by Director of Nursing or designee on Change of Condition of the Resident policy starting [DATE] and will be completed prior to next scheduled shift. This re-education included information on assessing (done by the RN if available) or data gathering (done by the LPN) and reporting findings requiring immediate notification to the medical provider. Re-education includes use of the INTERACT 4.5 Change in Condition Guidelines for when to immediately notify the physician/provider. Reeducation also includes when to activate Emergency medical services by calling 911 for residents requiring emergency intervention. * The Director of Nursing, Executive Director, and [NAME] President of Success reviewed established Change in condition of resident policy. No changes were necessary to this policy. [DATE]. * Director of Nursing or Designee will review facility charting daily to identify resident change in condition, to ensure proper documentation of change of condition and notification of provider including method of transfer and if 911 contacted or ambulance service contacted. These audits will be completed daily 2 weeks, then with morning clinical 5 days per week for 10 weeks or until substantial compliance is maintained. Results of these audits will be brought to QAPI (quality assurance performance improvement) for review and recommendation. * ADHOC QAPI review of this plan was completed with Medical Director, VP (Vice President) of Success, Director of Nursing, and Executive Director. [DATE] The deficient practice continues at a scope/severity of D (harm/isolated) as evidenced by the following example with R1. 2.) R1's diagnoses includes atherosclerotic heart disease, chronic kidney disease, and hypertension. The physician orders dated [DATE] documents RLE (right lower extremity) tubi grip in AM (morning) for RLE swelling. On in AM/off at bedtime and remove per schedule. On [DATE], from 8:43 to [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) R13 was admitted to the facility on [DATE]. R13's admission MDS (Minimum Data Set) dated 6/17/22 indicates that they require total assistance with activities of daily living including bed mobility. R13 is rarely to never understood. R13 was noted to be at high risk for pressure injuries. On 9/14/22 at 3:50 PM Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 9:50 AM, Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 12:35 PM, Surveyor observed R13's feet resting directly on their mattress. On 9/14/22 at 3:00 PM, Surveyor observed R13's feet resting directly on their mattress. On 9/15/22 at 8:35 AM, Surveyor observed R13's feet resting directly on their mattress. On 9/15/22 at 10:40 AM, Surveyor observed R13's feet resting directly on their mattress. On 9/15/22 at 1:05 PM, Surveyor observed R13's feet resting directly on their mattress. Surveyor reviewed R 13's skin integrity care plan dated 7/17/22 reads Resident is at risk for skin integrity condition, or pressure sores r/t: Diabetes, PVD, end-stage renal, History of pressure sores, Impaired mobility, Incontinence, Thin/Fragile skin. R13's skin integrity care plan interventions include prevalon boots while in bed with an initiation date of 7/27/22. R13's CNA Kardex indicates R13 is to wear prevalon boots while in bed. On 9/19/22 at 2:30 PM, Surveyor shared concerns related to observations of R13's feet resting directly on their mattress on 9/14/22 and 9/15/22. No additional information was provided to Surveyor at this time. Based on interview and record review, the facility did not ensure Residents (R) without a Pressure Injury (PI) do not develop pressure injuries, and receive appropriate care, treatment, & preventative measures to promote healing for 2 (R18 & R13) of 8 Residents reviewed for pressure injuries. *An unavoidable skin integrity care plan was developed for R18 on 09/02/20, which was R18's admission date. On 07/13/21, R18 was identified with a Stage 3 coccyx pressure injury. On 07/15/21, the facility developed a pressure ulcer actual or at risk care plan. R18's coccyx pressure injury healed on 07/20/21. On 08/18/21, the weekly skin review documents a Stage 2 sacrum pressure injury. On 08/19/21, the pressure injury weekly tracker documents a Stage 3 coccyx pressure injury with measurements of 4.6 x 2.5 x 0.1 The facility did not clarify R18's at risk for unavoidable skin integrity condition or pressure sores intervention of encouraging frequent repositioning in bed and chair when R18 required extensive assistance with one person physical assist for bed mobility. The facility did not revise R18's pressure ulcer actual or at risk care plan after R18 developed the stage 3 coccyx pressure injury. This care plan did not include repositioning until 06/16/22. On 09/07/21, R18's coccyx pressure injury declined to unstageable. There was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. On 11/29/21, R18's coccyx pressure injury with measurements of 2 x 2 x 0.4 is identified as a Stage 4. WD (Wound Doctor) R's recommendations of limit sitting to 60 minutes; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able, were not implemented into R18's plan of care or clarified with WD R and R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. On 11/29/21, WD R ordered treatment of: wash with soap and water, dry, apply Dakins soaked gauze to wound bed, apply bordered gauze, change twice daily and as needed. This pressure injury treatment was not started until 12/02/21, three days later. On 06/06/22, R18's coccyx pressure injury was identified as being infected and Doxycycline (an antibiotic) 100 mg (milligrams) twice daily was ordered. On 06/20/22, WD R recommended R18 be sent out to the ER (emergency room) for debridement under GA (general anesthesia), due to necrotizing fasciitis. R18 was hospitalized from [DATE] to 06/25/22. On 09/15/22 & 09/20/22, Surveyor observed R18 in bed with the air mattress off. The facility's failure to revise R18's skin integrity care plan when R18 developed a Stage 3 coccyx pressure injury on 08/19/22, not revising the care plan after the pressure injury declined to unstageable on 09/07/21, and not clarifying encourage frequent repositioning when R18 required extensive assistance with bed mobility and the progression of the coccyx pressure injury to a Stage 4 on 11/29/21, created a finding of Immediate Jeopardy (IJ) which began on 11/29/21. Surveyor notified Nursing Home Administrator (NHA) A & ADON (Assistant Director of Nursing) D of the immediate jeopardy on 09/21/22 at 2:05 p.m. The immediate jeopardy was removed on 09/22/22. The deficient practice continues at a scope and severity of D (potential for harm/isolated) related to the example involving R13 and as the facility continues to implement its action plan. *R13's heels were not off-loaded according to the plan of care. Findings include: The Pressure and Non-pressure Injuries policy & procedure with an original effective date of 08/2/21 documents under Policy: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries in our residents. Under procedure documents: Complete the Braden scale to assess risk of developing a PI (pressure injury). It consists of six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. A Braden Scale assessment tool will be completed: i. Upon admission/re-admission ii. Weekly for 3 more weeks in addition to initial assessment. iii. Upon a significant Change in Condition iv. Quarterly with the MDS (minimum data set) schedule v. As needed. Under the Care Plan section documents: A Comprehensive Skin Integrity Care Plan is based on resident history, review of Skin Assessment, Braden Scale Scoring, Nutritional Assessments, resident and family interviews, and staff observations. Consider the area of risk, as well as overall risk assessment score of the Braden Scale. Communicate identified risk factors and interventions to direct care staff. 2. Develop interventions based on individual Risk Factors including, but not limited to, weight, presence of edema, overall health status/comorbidities, use of medical devices, presence of acute infection, end-of life/hospice, resident choice/preferences, or medications that may impact healing. a. In the context of the resident's choices, clinical condition, and physician input, the resident's care plan should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations, and other interventions aimed at limiting the effects of risk factors associated with pressure injuries. Alternatively, center staff and practitioner should document clinically valid reasons why such interventions were not appropriate or feasible. For a resident to exercise his or her right appropriately to make informed choices about care and treatment or to decline treatment, the center and the resident (or if applicable, the resident representative) must discuss the resident's condition, treatment options, expected outcomes, and consequences of declining treatment or interventions. Centers should document this discussion in the Risk vs Benefit UDA in the electronic medical record. The care plan should be updated to reflect the resident's choice and what interventions will be in place to minimize risk to the resident. R18 was admitted to the facility on [DATE]. Diagnoses include diabetes mellitus (DM), Parkinson's Disease, and hypertension. R18 was admitted to hospice on 06/17/21. The at risk for unavoidable skin integrity condition or pressure sores r/t lymphedema, edema, DM care plan initiated 09/02/20 & revised 06/27/22 has the following interventions: * Apply pressure reduction chair cushion on wheelchair and pressure reduction mattress on the bed. Ensure cushion is properly placed, clean and dry. Initiated 09/20/20 and revised & canceled on 07/28/22. * Assess skin for redness or pressure related changes with each care encounter. Report any changes immediately. Initiated 09/02/20 & revised 07/28/22. * Conduct pressure injury skin assessments (i.e. Braden scale) as indicated. Initiated 09/02/20. * Encourage frequent repositioning in bed and chair. Initiated 09/02/20 & revised 09/30/20. * Encourage to float heels off the surface of the bed. Initiated 09/30/20. * Head to toe assessment by licensed nurse performed weekly at minimum. Initiated 09/02/20. * Keep resident clean and dry. Use barrier cream after good peri-care. Apply proper incontinent products as indicated. Initiated 09/02/20 & revised 07/19/21. * Place washcloth (palm guards) between hands check placement every shift. Initiated 12/10/21 & revised 07/28/22. * Unavoidable statement signed by MD (medical doctor). Initiated 05/27/22. * Apply alternating pressure air mattress to bed if indicated. Assure proper inflation check frequently. Initiated & revised 07/28/22. * Avoid friction/shearing while repositioning: if Resident is unable to assist use at least 2 staff members, use lift sheet, bed should be as flat as possible with lifting. Initiated 07/28/22. * Prevalon boots on while in bed and as tolerated by resident. Initiated 08/03/22. The significant change MDS (minimum data set) with an assessment reference date of 06/24/21 documents R18 has short term & long term memory problems and is severely impaired in cognitive skills for daily decision making. R18 requires extensive assistance with one person physical assist for bed mobility, transfer, eating, & toilet and does not ambulate. R18 is coded as always being incontinent of urine and frequently incontinent of bowel. R18 is at risk for pressure injuries and is coded as not having any pressure injuries. The pressure injury CAA (care area assessment) dated 06/24/21, under analysis of findings documents: Significant change in status assessment. Resident signed onto hospice services. Diagnoses include; Parkinson's, DM2 (diabetes mellitus) with Neuropathy, HLD (hyperlipidemia), HTN (hypertension), Lymphedema, UTI (urinary tract infection). Always incontinent of bladder and frequently incontinent of bowel during the look back period. Staff provides incontinence cares. Incontinent briefs in place. Takes diuretic which can contribute to urgency and frequency. Staff to provide incontinence care in timely manner to maintain clean dry skin. Staff to assess skin integrity. Staff to assist with repositioning while in bed and/or chair. The wound evaluation tracker dated 07/13/22 for the question, When was the wound identified? documents 07/13/2021. Under current wound status/additional comments documents, New acquire stage III (3) pressure injury to coccyx. 0.4 x (times) 0.4 x 0.1 in dimensions. 100% granular tissue. No drainage, no s/s (signs/symptoms) of infection, surrounding tissues are warm, dry and intact. No pain with cleansing. New wound care orders received. Applying air mattress through hospice care. Hospice nurse in to eval. (evaluate). POA (power of attorney) [name] updated. [Name] NP (Nurse Practitioner) updated. A treatment to wash, dry, apply foam dressing with directions to change every 72 hours and as needed was implemented on 07/14/21 and continued until the treatment was discontinued on 09/08/21. A pressure ulcer actual or at risk care plan was initiated on 07/15/21. The Braden Scale assessment dated [DATE] has a score of 15 which indicates at risk. Surveyor noted the next Braden was completed 07/02/22. The pressure ulcer actual or at risk care plan initiated 07/15/21 & revised 08/03/22 documents interventions of: * Air mattress - monitor for proper setting/function q (every) shift and prn (as needed) (keep at 150 pounds). Initiated 7/15/21 & revised 7/28/22. * Complete Braden scale per Living Center Policy. Initiated 7/15/21. * Conduct weekly skin inspection. Initiated 7/15/21. * Do not massage over bony prominence. Initiated 7/15/21. * Nutritional and hydration support. Initiated 7/15/21. * Prevalon boots on while in bed and as tolerated by resident. Initiated 7/19/21 & revised 8/3/22. * Provide pressure reducing wheelchair cushion. Initiated 7/15/21. * Provide pressure reducing/relieving mattress. Initiated 7/15/21. * Provide thorough skin care after incontinent episodes and apply barrier cream. Initiated 7/15/21. * Skin assessment to be completed per Living Center Policy. Initiated 7/15/21. * Treatments as ordered. Initiated 7/15/21. * Weekly wound assessment. Initiated 7/15/21. * Turn and reposition Q (every) 1-2 hours. Initiated 06/16/22. The social service note dated 07/16/21 documents: Writer met with husband this date. Aware of change in transfer status; Res currently requires hoyer lift with staff due to decreased strength/difficulty standing. Support provided to husband. No concerns noted at this time. SS (social service) will cont (continue) to follow. The wound evaluation tracker dated 07/20/21 under current wound status/additional comments documents: Wound is now closed. Continue to monitor weekly for re-opening with wound rounds. Surrounding tissues are warm, dry, and intact. The nurses note dated 08/18/21 documents: CNA called writer to room to report open area, pressure injury to top crease of buttocks. Writer cleansed area with saline and covered with Mepilex. Resident skin warm and dry. No active bleeding noted, no s/s (signs/symptoms) of infection noted. Call out to MD (medical doctor) to update. Call out to POA (power of attorney) to update. All aware. Will monitor. The weekly skin review dated 08/18/21 documents: Sacrum Stage 2 pressure injury in top crease of buttocks. Surveyor noted there are no measurements or description of wound bed for this weekly skin review. The pressure injury weekly tracker dated 08/19/21 documents: Coccyx, Pressure, with measurements of 4.6 x 2.5 x 0.1. Stage III (3), 100% granulation. The nurses note dated 08/19/21 documents: Follow up O/A (open area) to crease in buttocks. O/A (open area) measured today by unit manager. Treatment changed and C/D/I (clean dry intact). Skin warm and dry. Resident in bed resting at this time. Will monitor. The nurses note dated 08/20/21 documents: IDT (interdisciplinary team) reviewed new pressure injury to coccyx. Resident with stage 3 4.6 x 2.5 x 0.1 cm pressure injury to coccyx. Resident often sitting in Broda chair with limited mobility to reposition off of one spot d/t (due to) disease process. Resident with air mattress in place and protective foam dressing. Reposition side to side q 2 hours and as patient tolerates while in bed. POA, ADON, and MD aware and dressing order received. Will follow with weekly wound rounds. The Facility did not clarify R18's at risk for unavoidable skin integrity condition or pressure sores intervention of encourage frequent repositioning in bed and chair when R18 required extensive assistance with one person physical assist for bed mobility. The Facility did not revise R18's pressure ulcer actual or at risk care plan after R18 developed the stage 3 coccyx pressure injury. This care plan did not include repositioning until 06/16/22. The pressure injury weekly tracker dated 08/24/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1, Stage III (3) and the wound bed described as 100% granulation. The pressure injury weekly tracker dated 08/31/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1, Stage III (3) and the wound bed described as 100% granulation. The pressure injury weekly tracker dated 09/07/21 for the coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1. The stage is unstageable and the wound bed is 75% slough and 25% granulation. Under comments, documents slough scattered throughout wound bed, new order received for santyl. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. R18's treatment was changed on 09/09/21 with directions to wash with 1/2 strength Dakins, dry, apply santyl to wound bed, apply foam dressing and change every day and as needed. This treatment was discontinued on 11/23/21. The nutrition note dated 09/09/21 documents: Last weight was 152.9# (8/9), has order for d/c (discontinue) weights per hospice. Has S-DTI (suspected deep tissue injury) to L (left) heel (unchanged per 9/7 wound tracker) and PI unstageable to coccyx (worsening per 9/7 wound tracker). Estimated needs are 1738-2085 kcal (kilocalorie's) (25-30 kcal/kg(kilogram)) and 70-83 g (grams) PRO (protein)(1-1.2 g/kg). Intake is 73% avg (average) plus snacks of a regular diet. Meal intake provides approximately 1791 kcal and 70 g PRO. Has order for 2 cal supplement 4 oz BID (twice daily) (480 kcal and 20 g PRO), per MAR (medication administration record) res (resident) drinks 50-100% of supplement. Meeting estimated needs. No new nutrition interventions recommended at this time. Goal is comfort cares. Will continue to monitor/follow-up PRN. The pressure injury weekly trackers dated 09/14/21 & 09/21/21 for coccyx pressure injury documents measurements as 4.0 x 3.0 x 0.1. Stage is unstageable and wound bed is 100% slough. The quarterly MDS with an assessment reference date of 09/24/21 documents R18 has short & long term memory problems and is severely impaired in cognitive skills for daily decision making. R18 is dependent with two plus person physical assist for bed mobility & transfer, does not ambulate, requires extensive assistance with one person for eating, and is dependent with one person physical assist for toilet use. R18 is always incontinent of urine and bowel. R18 is at risk for developing pressure injuries and is coded as having 1 Unstageable pressure injury. The pressure injury weekly tracker dated 09/28/21 for coccyx pressure injury documents measurements as 2.7 x 2.0 x 0.1. Stage is unstageable and wound bed is 25% granulation and 75% slough. The pressure injury weekly tracker dated 10/05/21 for coccyx pressure injury documents measurements as 2.0 x 1.5 x 0.1. Stage is unstageable and wound bed is 50% granulation and 50% slough. The pressure injury weekly tracker dated 10/12/21 for coccyx pressure injury documents measurements as 2.0 x 1.1 x 0.1. Stage is unstageable and wound bed is 90% granulation and 10% slough. The pressure injury weekly tracker dated 10/19/21 for coccyx pressure injury documents measurements as 2.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 10/26/21 for coccyx pressure injury documents measurements as 1.8 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The NP (nurse practitioner) note dated 10/28/21 documents no new open areas on skin noted. Under plan, includes pressure offloading. The pressure injury weekly tracker dated 11/02/21 for coccyx pressure injury documents measurements as 1.5 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 11/08/21 for coccyx pressure injury documents measurements as 1.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 100% granulation. The pressure injury weekly tracker dated 11/15/21 for coccyx pressure injury documents measurements as 1.0 x 1.0 x 0.1. Stage is Stage III (3) and wound bed is 95% granulation and 5% necrotic. Under comments documents same as previous week. Small amount of necrotic tissue noted towards wound margin. Scant serous drainage noted. No pain. Surveyor noted there was no MD notification on this pressure injury weekly tracker. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22 and the treatment was not changed until 11/24/21. The pressure injury weekly tracker dated 11/22/21 for coccyx pressure injury documents measurements as 1.3 x 1.2 x 0.2. Stage is unstageable and wound bed is 25% granulation and 75% slough. Surveyor noted there was no revision to either at risk for unavoidable skin integrity condition or pressure sores or pressure ulcer actual or at risk care plan until 05/27/22. R18's treatment was changed with a start date of 11/24/21 with direction to wash coccyx pressure injury with 1/2 strength Dakins, dry, apply medihoney to wound bed, apply foam dressing change every day and as needed. This treatment was discontinued on 12/01/21. The nutrition note dated 11/23/21 documents Using 11/3 weight res (resident) triggers for 6.3% weight loss over 1 month and 10.7% weight loss over 3 months. Weight loss likely r/t (related to) varied intake at times and overall decline in condition, on hospice. Weight is PRN per hospice. Per wound trackers on 11/15 res has shearing to R (right) butt and PI stage 3 to coccyx (unchanged). Intake is 71% avg plus snacks of a regular diet x 7 days. Meal intake provides approximately 1754 kcal and 68 g PRO. Has order for 2 cal supplement 4 oz BID (twice daily) (480 kcal, 20 g PRO, Per MAR drinking avg 68% of supplement). Estimated needs are 1586-1904 kcal (25-30 kcal/kg) and 76-95 g PRO (1.2-1.5 g/kg). Meeting estimated needs. BMI is 26.4 (overweight but optimal for geriatric population). Potential for weight fluctuations r/t fluid shifts d/t (due to) diuretic tx. Potential for weight loss r/t decline in condition. Goal is comfort cares. Will monitor/follow-up PRN. The MD note dated 11/23/21 includes pressure offloading and wound cares as ordered. The pressure injury weekly tracker dated 11/29/21 for coccyx pressure injury documents measurements of 2.0 x 2.0 x 0.4. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. On 11/29/21, WD (wound doctor) R assessed R18's coccyx pressure injury. The initial wound evaluation & management summary dated 11/29/21 for site (1) documents: Stage 4 pressure wound sacrum full thickness with measurements of 2 x 2 x 0.4 cm (centimeters). Under surgical excision debridement procedure for indication for procedure documents. Remove necrotic tissue and establish the margins of viable tissue. Under dressing treatment plan for primary dressing(s) documents: Sodium hypochlorite solution (Dakins) apply twice daily for 30 days: soaked gauze. Secondary dressing(s) documents: Gauze island w/bdr (with border) apply twice daily for 30 days. For plan of care reviewed and addressed under recommendations documents: Limit sitting to 60 minutes; off-load wound; reposition per facility protocol; Turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The treatment to R18's coccyx pressure injury to wash with soap and water, dry, apply Dakins soaked gauze to wound bed, apply bordered gauze, change twice daily and as needed was not started until 12/02/21, three days later. This treatment was discontinued on 12/07/21. Surveyor noted WD R assessed R18's coccyx pressure injury weekly with the exception of the week of 05/01/22 to 05/07/22 and 07/03/22 to 07/09/22. The pressure injury weekly tracker dated 12/06/21 for coccyx pressure injury documents measurements of 1.5 x 2.2 x 0.5. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. WD R's wound evaluation & management summary dated 12/06/21 under dressing treatment plan for primary dressing(s) documents: Leptospermum honey apply once daily for 30 days and secondary dressing(s) documents: Gauze island w/bdr apply once daily for 23 days. The Facility started a treatment to wash with soap and water, dry, apply medihoney to wound bed, apply bordered gauze, change daily and as needed on 12/08/22, two days later. This treatment was discontinued on 12/17/21. WD R continues to recommend limit sitting to 60 minute; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. Surveyor noted there is no indication the facility clarified WD R's recommendation if there were questions regarding WD R's recommendations on repositioning for R18. The pressure injury weekly tracker dated 12/13/21 for coccyx pressure injury documents measurements of 2.0 x 2.5 x 0.5. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. On 12/17/21 the treatment was changed from the day shift to the evening shift. The pressure injury weekly tracker dated 12/20/21 changes the pressure injury site to sacrum. Measurements are 1.8 x 2 x 0.7. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. Under additional intervention/plan documents: slowly improved no s/s of infection. The pressure injury weekly tracker dated 12/27/21 for the coccyx pressure injury documents measurements are 1.8 x 2.8 x 1.2. Stage is Stage 4 and wound bed is 60% granulation and 40% slough. WD R's wound evaluation & management summary dated 12/27/21 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents: Deteriorated. Under dressing treatment plan for primary dressing(s) documents: Collagen gel/paste apply once daily for 30 days; Alginate calcium apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply once daily for 30 days. The Facility started the treatment to wash with soap and water, dry, apply silvakollagen to wound bed, cover with calcium alginate followed by bordered gauze change daily and as needed on 12/29/21, two days later. This treatment was discontinued on 01/19/22. WD R continues to recommend limit sitting to 60 minutes; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The pressure injury weekly tracker dated 01/03/22 for the coccyx pressure injury documents measurements of 2.0 x 3.0 x 1.5. Stage is Stage 4 and wound bed is 30% granulation, 40% slough, & 30% necrotic. Under comments documents continue treatment x 1 more week if continues to deteriorate then change larger in size moderate drainage no s/s of infection wound doctor debrided necrotic/slough tissue as able 30% necrotic. The pressure injury weekly tracker dated 01/10/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 1.5. Stage is Stage 4 and wound bed is 40% granulation, 40% slough, & 20% necrotic. The physician progress note dated 01/13/22 under plan includes every two hours turning and skin & back care. The pressure injury weekly tracker dated 01/17/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 1.5. Stage is Stage 4 and wound bed is 40% granulation, 40% slough, & 20% necrotic. WD R's wound evaluation & management summary dated 01/17/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents no change. Under dressing treatment plan for primary dressing(s) documents Alginate calcium apply once daily for 9 days; Leptospermum honey apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply once daily for 9 days. The Facility started the treatment to wash with soap and water, dry, apply medihoney to wound bed, cover with calcium alginate followed by bordered gauze change daily and as needed on 01/19/22, two days later. This treatment was discontinued on 02/01/22. The pressure injury weekly tracker dated 01/24/22 for the coccyx pressure injury documents measurements of 2.5 x 2.4 x 2.0. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. The pressure injury weekly tracker dated 01/31/22 for the coccyx pressure injury documents measurements of 2.5 x 2.0 x 2.0. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. WD R's wound evaluation & management summary dated 01/31/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents improved. Under dressing treatment plan for primary dressing(s) documents Sodium hypochlorite solution (Dakins) apply twice daily for 30 days: pack the wound with a wet gauze, wet to dry dressing and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 23 days. The Facility started the treatment to wash with soap and water, dry, lightly pack with Dakins soaked gauze, cover with bordered gauze twice daily and as needed on 02/01/22. This treatment was discontinued on 02/15/22. The pressure injury weekly tracker dated 02/07/22 for the coccyx pressure injury documents measurements of 3.0 x 3.0 x 2.5. Stage is Stage 4 and wound bed is 30% granulation, 30% slough, & 40% necrotic. Under comments documents worsening. No s/s of infection. New wound treatment started last week. Improvement to wound bed noticed. Larger in size. WD R's wound evaluation & management summary dated 02/07/22 continues to recommend limit sitting to 60 minute; off-load wound; reposition per facility protocol; turn side to side and front to back in bed every 1-2 hours if able. Surveyor noted R18's care plans were not revised to include turn and reposition every 1-2 hours until 06/16/22. The pressure injury weekly tracker dated 02/14/22 for the coccyx pressure injury documents measurements of 3.0 x 3.0 x 2.5. Stage is Stage 4 and wound bed is 50% granulation, 30% slough, & 20% necrotic. Under comments documents Size remains same. Tissue to wound bed improving significantly since prior week. More granular tissue present with less amount of slough/necrotic tissue. Surrounding tissue is warm, dry and intact. No s/s of infection. Debrided with wound doctor. New treatment ordered. WD R's wound evaluation & management summary dated 02/14/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents improved. Under dressing treatment plan for primary dressing(s) documents Leptospermum honey apply once daily for 30 days; Alginate calcium apply once daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 9 days. The Facility started the treatment to cleanse, dry, apply medihoney to wound bed, cover with calcium alginate then bordered gauze daily and as needed with a start date of 02/16/22, two days later. This treatment was discontinued on 02/21/22. The pressure injury weekly tracker dated 02/21/22 for the coccyx pressure injury documents measurements of 4.5 x 3.5 x 3. Stage is Stage 4 and wound bed is 10% granulation, 30% slough, & 60% necrotic. Under comments documents Wound is larger in size with worsening tissue noted to wound bed. New treatment ordered. Wound debrided by wound doctor. Surrounding tissue is warm, dry and intact. No pain noted to area. WD R's wound evaluation & management summary dated 02/21/22 includes the same measurements as the Facility's pressure injury weekly tracker. Under wound progress documents deteriorated. Under dressing treatment plan for primary dressing(s) documents Metronidazole gel apply once daily for 30 days; Sodium hypochlorite solution (Dakins) apply twice daily for 30 days and secondary dressing(s) documents Gauze island w/bdr apply twice daily for 30 days. The Facility started the treatment to cleanse, dry, apply Metronidazole cream to wound bed for AM shift followed by Dakins soaked gauze. Change twice daily and as needed with a[TRUNCATED]