**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility did not provide the necessary care and services to prevent and/or promote healing for 2 Residents (R) (R32 and R18) of 4 residents reviewed for pressure injuries. R32 had an area of moisture-associated skin damage (MASD) that was identified on 12/18/23. R32 did not have a documented treatment for the area until 1/13/24 and did not see a wound doctor until 1/24/24. The area deteriorated to an unstageable pressure injury that became infected. The facility did not contact R32's physician when the wound deteriorated and R32's care plan was not updated until 1/24/24. In addition, on 2/28/24, Surveyor observed R32 sitting on a sling in R32's wheelchair. R18 was admitted to the facility with pressure injuries on the left buttock and left heel. R18's Treatment Administration Record (TAR) indicated R18's treatments were not consistently completed. In addition, R18's skin integrity care plan contained an intervention that was not implemented. Findings include: The facility's Pressure Injury Prevention and Wound Care Management policy, with a review date of 2/24/23, indicates: It is the policy of this facility that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well being, in accordance with the comprehensive assessment and plan of care. A resident who has a pressure injury will receive care and services to promote healing and to prevent additional ulcers .Risk Identification and Assessment: 7. Skin impairments, including pressure injuries, non-pressure wounds .should be assessed and documented weekly by the Wound Nurse, or designee, using PCC (Point Click Care) Weekly Wound Assessment. 9. Daily, the clinicians responsible for caring for the resident will assess the status of the dressing if present, (intact, soiled, leaking) and evaluate for complications such as infection and/or uncontrolled pain. 12. Wound and skin care interventions will be monitored for effectiveness. Care plans will include specific measurable goals and interventions. The care plan will be reviewed and revised at least quarterly, or with significant change in condition Prevention and Treatment Guidelines: The skin care program will be utilized following the guidelines of the Agency for Healthcare Research and Quality (AHRQ), the National Pressure Ulcer/Injuries Advisory Panel (NPIAP) and current standards of clinical practice .3. Wounds will be treated based on the etiology of the wound .9. Nursing staff should update the attending physician immediately of wounds that have developed complications and/or not healing as anticipated. The attending physician will also be updated upon assessment if a wound has not improved in 2 weeks. 1. R32 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the right buttock, unstageable, neuromuscular dysfunction of the bladder, aphasia following cerebral infarction, obesity, paraplegia (paralysis on one side of the body), and lumbar spina bifida (a birth defect in which the spinal cord fails to develop properly) with hydrocephalus (a build-up of fluid in the cavities of the brain). R32's Minimum Data Set (MDS) assessment, dated 1/30/24, contained a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R32 had intact cognition. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's medical record and noted the following care plans: ~Alteration in skin integrity related to decreased mobility, incontinence, and history of skin breakdown (initiated 5/17/23). Interventions included: Reposition every 2 hours or as needed; Heel suspension boots while in bed; Manage clinical conditions and contributing factors to decrease risk of skin breakdown; Use a pressure relieving cushion for wheelchair; Use A&D ointment, BAZA, or other skin barrier cream on skin as needed; Keep skin clean and dry. ~Alteration in elimination related to indwelling Foley and bowel incontinence (initiated 5/17/23). Interventions included: Apply barrier cream to peri area after each incontinent episode; Check and change as needed due to incontinence, incontinent of bowel. ~Infection: (R32) is on an antibiotic for wound infection multiple bacteria (initiated 2/11/24). Interventions included: Antibiotics per Medical Doctor (MD) order; Isolation precautions: Contact precautions; Communicate (R32's) status and precautions to all care providers; Monitor infected site daily and report changes to provider as applicable; Notify MD/Nurse Practitioner (NP) with any change in condition; Observe color and consistency of urine and report changes to nurse. ~Nutritional status related to spina bifida, paraplegia, neurogenic bowel, constipation, pressure ulcer of sacrum, obesity, hypertension, aphasia, dysphasia, and history of UTI (urinary tract infection) (initiated 5/17/23). Interventions included: Double protein portions; Provide supplements with med pass as ordered; Document and monitor acceptance. ~A resolved care plan in R32's medical record indicated R32 was admitted with a stage 4 pressure injury on the sacrum (initiated 6/7/23). The care plan was resolved on 10/23/23 when R32's pressure injury healed. ~Pressure Ulcer (unstageable) on the right buttocks related to decreased sensory perception, impaired mobility and functional ability, and paraplegia or quadriplegia (initiated 1/24/24). Interventions included: Monitor air mattress and ensure mattress settings are at manufacturer recommendations; Turn and reposition at least every 2 hours and on a schedule that is specific to routine and tolerance; Position body with pillows/support devices, and protect bony prominences; Foley catheter to prevent contamination of wound. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's orders prior to 12/18/23 (when the area of MASD was discovered) and noted the following: ~An intervention for an air mattress due to pressure sore and limited mobility every shift for wound was in place per R32's TAR prior to the discovery of the area of MASD on R32's gluteal fold on 12/18/23. ~An order for Pro-Stat AWC 30 cc (cubic centimeters) 2 times daily for wound healing was in place per R32's TAR prior to the discovery of the area of MASD on R32's gluteal fold on 12/18/23. Between 2/26/24 and 2/28/24, Surveyor reviewed R32's medical record and noted the following: ~A progress note, dated 12/18/23 at 3:35 PM, indicated: New open area to right buttock. Appears to be a result of shearing. Calling (MD-K) to update. Left voicemail to call back. ~A progress note, dated 12/18/23 at 3:40 PM, indicated: Cleansed and applied Mepilex to right buttock until MD-K calls back. ~A fax in R32's chart, dated 12/18/23, indicated: New areas of concern: .2. Right buttock: new open area looks like shearing. Did attempt to call related to both alterations since we could not contact you. Area cleansed and Mepilex in place. Please review and advise .Physician Response: 3rd floor call me to discuss tonight (MD-K). A note at the bottom indicated: Spoke with MD-K. MD-L updated. ~A progress note, dated 12/18/23 at 10:08 PM, indicated: Spoke with (MD-K). Writer was under the impression (MD-K) was on call, but MD-K sent email to MD-L regarding faxed updates. ~A weekly wound assessment, dated 12/25/23, indicated R32 had MASD related to incontinence-associated dermatitis (IAD) to the right gluteal fold that measured 1.9 cm (centimeters) x 3.4 cm. The treatment section was not filled out. ~A progress note, dated 12/29/23 at 1:57 PM, indicated: Advance Practice Nurse Practitioner (APNP)-J saw (R32). Refer to wound care for open area to right buttocks. ~On 12/29/23, APNP-J responded to the fax sent on 12/18/23 related to R32's open area and indicated APNP-J would refer R32 to wound care. ~A fax sent to MD-L, dated 12/31/23, indicated: Also note wound to right buttock .applying Mepilex at this time. Wound care to assess .Please advise at next facility visit. Physician response on 1/2/4: Can (R32) be seen by wound MD? A note on the fax indicated: Copy wound MD. ~A progress note, dated 1/2/24 at 3:03 PM, indicated R32 would be seen by the wound MD. ~A weekly wound assessment, dated 1/8/24, indicated R32 had MASD on the right gluteal fold related to IAD that measured 4 cm x 2.8 cm. The assessment indicated the wound contained moderate serous exudate (a type of drainage that appears as clear or pale yellow, thin, and watery plasma. During the inflammatory stage, serous is a regular part of healing, and small amounts are considered normal.) and no evidence of infection. The edges of the wound were attached and the surrounding tissue was fragile. The treatment section indicated the dressing was intact. No other treatment sections were filled out. A note indicated: New wound. Will be assessed by wound MD on next round. The wound was marked as deteriorating. ~A fax to MD-L, dated 1/13/24, indicated: Deep tissue wound right sacral buttocks. Can we cleanse with normal saline (NS) or soap water? Apply foam dressing daily and PRN (as needed). On 1/13/24, MD-L indicated Yes. R32's medical record indicated the first treatment for the area was initiated on 1/13/24. The treatment order indicated: Right buttocks, cleanse with soap and water or NS, apply form dressing daily and PRN in the evening. The order was discontinued on 1/23/24. ~A weekly wound assessment, dated 1/18/24, indicated R32 had MASD on the right gluteal fold related to IAD that measured 4.5 cm x 3.85 cm. The wound contained moderate serosanguineous exudate (drainage that contains blood and a clear yellow liquid known as blood serum and can be a sign of healing in small amounts) and there was no evidence of infection. The periwound tissue was attached and the surrounding skin was fragile. The treatment section indicated the dressing was intact, but no other treatments were marked. A note indicated: Wound care MD to assess area. Unstageable. Will continue to monitor. The wound was marked as deteriorating. ~On 1/23/24, a change in treatment indicated: Right buttocks cleanse with NS, apply Santyl to wound bed, cover with foam dressing daily and PRN for soiling every evening shift. The order was discontinued on 1/26/24. ~A weekly wound assessment, dated 1/24/24, indicated R32 was seen by the wound MD for an unstageable pressure injury that measured 7.6 cm x 6.6 cm. The wound bed contained eschar (necrotic tissue that is typically dry, black, firm, and usually adhered to the wound bed and edges) and there was no evidence of infection. The wound contained moderate serosanguineous drainage with a faint odor after cleansing and the edges were attached. The dressing was intact and the treatment indicated: Cleansing solution: Sodium hypochlorite; Debridement: Enzymatic; dry dressing. A note that indicated: Call placed to Power of Attorney (POA) for verbal permission for debridement. Bedrest order until improvement in wound. The wound was marked as deteriorating. ~On 1/24/24, an unstageable pressure injury care plan was initiated. ~On 1/24/24, an order was initiated for bedrest (no wheelchair time) while wound to buttocks heals. Every shift for wound rounds. ~On 1/26/24, R32's treatment was changed to: Right buttocks wound, cleanse with Dakins, apply Santyl to wound bed, cover with ABD pad, and tape daily and PRN for soiling every evening shift. The order was discontinued on 2/6/24. ~A weekly wound assessment, dated 1/31/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar on the right gluteal fold that measured 6.3 cm x 3.9 cm. The wound bed contained granulation(granulation tissue formation is required for the healing of deep pressure ulcers), eschar, and moderate exudate. The treatment section was not filled out. The wound was marked as improving. ~A weekly wound assessment, dated 2/7/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 7 cm x 4.6 cm with no evidence of infection. The wound contained light serous exudate with a faint odor after cleansing. The periwound edges were attached with fragile surrounding tissue and the dressing was intact. The treatment was NS and enzymatic debridement; primary dressing: Calcium Alginate, secondary dressing: dry. The wound was marked as improving. ~On 2/7/24, R32's treatment was changed to: Cleanse with Dakins, apply Santyl to area of eschar and Calcium Alginate to granulation wound bed, cover with moist gauze daily and PRN every evening shift. The order was discontinued on 2/24/23. ~A progress note, dated 2/10/24 at 9:21 PM, indicated: Per on-call MD, new order for culture swab of coccyx wound and UA (urinalysis) with culture and sensitivity due to fever of 102.7 degrees Fahrenheit (F). Keflex 500 mg (milligrams) TID (three times daily) for 2 days. ~On 2/11/24, MD-K ordered to stop Keflex and start ciprofloxacin 500 mg BID (twice daily). ~On 2/12/24, R32 started ciprofloxacin for a UTI and completed the course of antibiotics on 2/17/24. ~A weekly wound assessment, dated 2/14/24, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 6.5 cm x 3.3 cm. The wound bed contained granulation with eschar and moderate serosanguineous exudate with a faint odor after cleansing. The dressing was intact. The remainder of the treatment section was not completed. The wound was marked as improving and the section for MD/Provider indicated an infection. A note indicated: Slow improvement. (R32) to see outpatient wound care on 2/15/24 for further management. On 2/15/24, R32 saw the wound clinic. The wound clinic note indicated: .for evaluation of sacral pressure ulcer. Reports it has been there for approximately 3 weeks. Was treated by a wound provider who came to the facility; however, the contract recently ended recently with no new provider stepping in so (R32) is here for ongoing care. Culture was obtained on 2/10/24 without antibiotics prescribed. (R32) grew out proteus mirabilis, strep agalactiae group B, and Escherichia (E) coli. Large amount of boggy eschar to wound base was debrided, however, unable to get to a viable wound bed in this area because there's more slough underneath. Very heavily draining. No foul odor. Some surrounding erythema (redness), but no increased warmth, fluctuance, or induration. No bone probed. Measured 10.4 cm x 8 cm x 1.9 cm. Plan: Due to the amount of necrotic tissue and drainage, .prescribed Augmentin based on culture results. Will also order an X-ray to rule out osteomyelitis (infection of the bone). Would like to start a referral to general surgery as was not able to get to the base of the wound. Still quite a bit of dead tissue that could cause more infection if not removed. For now, will have facility start BID Dakins moist dressing changes. ~On 2/15/24, R32's treatment was changed to: Sacrum: Remove dressing, irrigate with saline then apply .5% Dakins, moist gauze to wound, and cover with .dressing. Change BID and as needed two times daily. The order was discontinued on 2/27/24. ~A weekly wound assessment, dated 2/21/14, indicated R32 had an unstageable pressure injury due to slough and/or eschar that measured 8.6 cm x 4.1 cm. The wound bed contained granulation, slough, and no eschar and had heavy serosanguineous drainage. The periwound was attached with surrounding fragile tissue and the dressing was intact. The treatment indicated: NS cleansing solution; sodium hypochlorite. The primary dressing was antimicrobial, the secondary dressing was foam. The wound was marked as improving and the MD/Provider indicated an infection. A note indicated: Continue bedrest and outpatient wound clinic. ~On 2/22/24, R32 saw the wound clinic. The wound clinic note indicated: Unstageable pressure ulcer of sacrum, quality improving. Plan: There is less necrotic tissue present today, but still unable to get to base of wound. Surgery office contacted. (R32) can be seen on (2/26/24). Will continue with Dakin's .25% moist gauze for now. Wound measures 10.5 cm x 10 cm x 2.3 cm. The wound was noted to be improving. ~On 2/28/24, R32 saw the wound clinic. The would clinic note indicated: The wound measured 8.6 cm x 11.2 cm x 1.9 cm. Sacral/coccyx X-ray: Impression: Decreased bone stock of the distal coccyx which is of uncertain age. This could reflect sequelae from prior or active osteomyelitis. Assessment: After debridement, the wound is nearly all granular. Will plan to start NPWT (negative pressure wound therapy) (wound vac) at next appointment .Reviewed X-ray results, will plan to proceed with MRI (magnetic resonance imaging) (a diagnostic test that can create detailed images of nearly every structure and organ inside the body) versus CT (computed tomography) (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body). Discussed advanced imaging options with Radiology. Due to prior shunt and underlying hardware, CT without contrast was recommended. Order placed. ~On 2/28/24 at 10:31 AM, Surveyor observed R32 in the lobby in R32's wheelchair. Per Registered Nurse (RN)-D, R32 just returned from a wound care appointment. Surveyor observed a blue sling underneath R32 in the wheelchair. On 2/28/24 at 11:34 AM, Surveyor interviewed Assistant Director of Nursing (ADON)-I who was also the wound care nurse. When asked about the missing orders between 12/18/23 and 1/13/24, ADON-I indicated on 12/18/23, a fax was sent to MD-L and the nurse indicated staff were going to apply foam to the wound. ADON-I said MD-L said okay and to have R32 see the wound MD (who was off over the holidays). ADON-I indicated ADON-I saw R32 on wound rounds and placed a call to the wound MD who agreed to see R32 on 1/24/24. There was an order to cover the wound with Mepilex which ADON-I continued on wound rounds, however, ADON-I confirmed the order was not entered in R32's medical record and there was no documentation the treatment was completed. ADON-I indicated the treatment was provided in report so staff knew to complete it. ADON-I verified ADON-I did not check R32's medical record to see if the order was transcribed, but should have. ADON-I indicated staff noticed the order was not in R32's medial record on 1/13/24. The MD was notified and the order was entered. ADON-I verified orders should to be transcribed in the medical record and documented as completed. Surveyor asked if there was documentation that the MD was notified when R32's wound deteriorated as noted on the 12/25/23, 1/8/24, and 1/18/24 weekly wound assessments. ADON-I did not provide notification that the MD was notified of the deterioration or that there was a delay in having R32 seen by the wound doctor. When Surveyor asked about weekly wound assessments and noted more than one week between in-house wound assessments, dated 12/25/23 to 1/8/24 (2 weeks) and 1/8/24 and 1/18/24, ADON-I verified wound assessments should be completed weekly. ADON-I indicated ADON-I had issues with the camera during the 12/31/23 assessment and thought the assessment uploaded. When Surveyor informed ADON-I that Surveyor observed R32 sitting on a sling in R32's wheelchair which was not on R32's care plan, ADON-I confirmed residents should have a care plan intervention to leave a sling underneath them when in a wheelchair. When Surveyor asked ADON-I about the delay in R32 seeing a wound doctor, ADON-I verified APNP-J responded to the 12/18/23 fax on 12/29/23 and indicated R32 should see the wound doctor, but R32 did not see a wound doctor until 1/24/23 (26 days later). ADON-I indicated the facility's wound doctor was out of the office over the holidays and when ADON-I contacted the wound doctor, ADON-I was under the impression the wound doctor would see R32 the following week. The facility realized the contracted wound doctor was inconsistent with facility visits and worked on getting a new contract. In the meantime, ADON-I stated R32 was scheduled to see wound care at the local hospital. ADON-I confirmed a resident should be seen by a wound doctor as soon as possible if ordered by a physician. When asked if the facility had a backup wound doctor if the regular wound doctor was on vacation or couldn't see a resident, ADON-I indicated that's when the facility should refer a resident to the outpatient clinic. ADON-I reviewed ADON-I's cell phone history and stated ADON-I contacted the wound MD around 12/31/23 to inform the wound MD the facility had a new resident ADON-I contacted the wound MD again on 1/8/24 and expected a 1/10/24 visit that did not happen. ADON-I confirmed contact with the wound MD was not documented in R32's medical record. ADON-I acknowledged that was a long period of time and indicated the backup for the wound doctor should get the resident seen at an outpatient clinic. When Surveyor asked why R32's care plan not was not updated after the MASD area was discovered on 12/18/24 or until after R32 saw the wound doctor on 1/24/24, ADON-I indicated residents' care plans should be reviewed if there is a new issue to ensure all new approaches are added and discontinued approaches are removed. On 2/27/24 at 4:35 PM, Surveyor interviewed APNP-J via phone who confirmed APNP-J was initially notified of R32's wound. APNP-J indicated generally APNP-J does not write wound orders and refers residents to a wound doctor. APNP-J indicated R32 had loose stools for awhile and the biggest problem was getting R32's bowels regulated. APNP-J reviewed R32's medical record, but could not locate an order or treatment request until 1/13/24. APNP-J indicated R32 was not seen by a wound specialist until 2/15/24 (the outpatient wound clinic). APNP-J confirmed there was a delay and would have wanted R32 seen sooner. APNP-J also indicated APNP-J wanted to be notified when R32's wound deteriorated. APNP-J checked APNP-J's documentation and confirmed the facility notified APNP-J of the wound, but did not request APNP-J care for the wound if the wound doctor was unavailable. APNP-J could not find documentation that indicated R32's physician was notified when a wound doctor was not available. APNP-J indicated communication was difficult because sometimes there were verbal discussions, sometimes there were faxes, and sometimes there were phone calls. APNP-J stated APNP-J is not sure what happens to a fax on the facility's end after APNP-J responds. The above example was cited at a severity/scope level G (Actual Harm/Isolated). 2. R18 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes, pressure ulcer of left buttock, and pressure ulcer of left heel. R18's MDS assessment, dated 2/23/24, contained a BIMS score of 11 out of which indicated R18 had moderate cognitive impairment. R18 had a skin integrity care plan (initiated 4/13/22) related to R18's current pressure ulcers and bilateral leg edema (swelling). Interventions included: Use wedge under right shoulder and along right side to keep straight in bed. On 2/26/24 at 10:52 AM, Surveyor observed R18 in bed without a wedge underneath R18's right side. On 2/27/24 at 10:20 AM, Surveyor observed R18 asleep in bed without a wedge underneath R18's right side and noted R18's head leaned to the right. On 2/27/24 at 10:58 AM, Surveyor interviewed R18 and asked if the green wedge cushion on R18's chair should be under R18's right shoulder. R18 was unsure what Surveyor was referring to. On 2/28/24 at 12:56 PM, ADON-I indicated ADON-I placed the wedge underneath R18's right shoulder. ADON-I verified the wedge should have been in place per R18's skin integrity care plan. Between 2/26/24 and 2/28/24, Surveyor reviewed R18's medical record and noted the following: ~An order, dated 10/2/23, indicated: Left buttock: Cleanse with soap and water, cover with skin prep, allow to dry and apply Allevyn Life foam dressing in the evening until healed. The order was discontinued on 12/4/23. Surveyor noted in October 2023, documentation indicated the treatment was not completed on 4 out of 31 opportunities. In November 2023, documentation indicated the treatment was not completed on 5 out of 30 opportunities. ~An order, dated 10/17/23, indicated: Left heel: Cleanse with NS, apply Santyl to wound bed followed by border gauze daily. Apply tubigrip and heel protector boots (to be worn at all times) every evening shift. The order was discontinued on 10/30/23. In October 2023, documentation indicated the treatment was not completed on 4 out of 14 opportunities. ~An order, dated 11/15/23, indicated: Left foot (bottom): Cleanse with NS and apply foam dressing daily. Apply tubigrip and heel protector boots (to be worn at all times.) every evening shift. The order was discontinued on 2/21/24. In December 2023, documentation indicated the treatment was not completed on 3 out of 31 opportunities. In January 2024, documentation indicated the treatment was not completed on 2 out of 31 opportunities. ~An order, dated 12/12/23, indicated: Wound to ischium, left buttocks: Cleanse with saline, apply Dakins 0.25%, soak for 5 minutes, apply Aquacel AG to wound, cover with Mepilex border, and seal with Tegaderm 3 times per week and PRN every evening shift. The order was discontinued on 2/15/24. In December 2023, documentation indicated the treatment was not completed on 3 out of 19 opportunities. In January 2024, documentation indicated the treatment was not completed on 2 out of 31 opportunities. On 2/28/24 at 1:59 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated DON-B expected staff to document all treatments. DON-B indicated if the treatment was not completed, there should be a note.