**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure residents with a pressure injury or at risk for pressure injuries received necessary treatment and services consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R8) of 3 residents reviewed for pressure injuries. R8 admitted to the facility with pressure injuries (PIs) on her left heel and right lateral foot which later resolved. R8 was assessed as high risk for PIs. Despite being at high risk, R8's physician's order for an air mattress was not implemented, a care plan for actual skin impairment was not initiated timely, and her weekly skin assessments were not completed weekly as per facility policy. R8 developed pressure injuries to her right lower extremity that deteriorated to a stage 3 and a stage 4 with necrosis and muscle/fascia visible in addition to developing two stage 2 PIs to her buttocks. R8's care plan was never revised with interventions to promote healing. Surveyors had observations of orders including repositioning and heel offloading not being implemented as well as observations of R8 removing her dressings and scratching the open areas with dirty fingernails. The facility's failure to provide care to prevent the development of pressure injuries and promote the healing of R8's pressure injuries, the failure to assess and update resident's pressure injury care plan, monitor R8's dressings, and provide repositioning created a finding of immediate jeopardy (IJ) that began on 1/31/2024. Surveyor notified Nursing Home Administrator (NHA)-A, Interim Director of Nursing (Interim DON)-C and assistant DON (ADON)-D of the immediate jeopardy on 5/30/2024 at 11:41 AM. The immediate jeopardy was removed on 6/3/24. The deficient practice continues as a scope and severity of a D (potential for harm/isolated) as the facility continues to implement their action plan. Findings include: The facility policy titled, Pressure Injury Prevention and Managing Skin Integrity, reviewed on 8/10/2023, documents: I. Policy: Prevention measures are put in place to reduce the occurrence of pressure injuries. II. Procedure: 1. Risk Assessment. a. Upon admission: Braden Scale will be completed to evaluate individual's risk for developing a pressure injury at admission, and weekly for four weeks for all new admissions. c. Based on the individuals Braden Scale Score, pressure reduction interventions will be implemented by nursing and documented in the individual's medical record. 2. Identify Interventions and Care Plan, a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent any further advancement of the wound or additional skin breakdown . 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan. i. In developing a plan of care, the following will be considered: 1. Individual pressure injury history, 2. Cognitive changes or impairment of the individual. 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health . 5. Risk for pressure ulcer development (Braden Scale). 3. Skin Checks; a. Skin check will be done upon admission, readmission, or as clinically indicated. b. While providing routine care, a licensed nurse is to monitor the skin condition of each individual weekly and document the Skin Check in the medical record. 4. Weekly Wound Rounds, . b. Registered Nurse (RN) or designee will: i. Conduct weekly skin evaluation . iii. Update the Care Plan with any new interventions as applicable . R8 was admitted to the facility on [DATE] and has diagnoses that include (idiopathic) normal pressure hydrocephalus, delusional disorder, chronic kidney disease stage 3, neoplasm of unspecified behavior of brain, major depressive disorder, and dementia with other behavioral disturbance. R8's quarterly minimum data set (MDS) dated [DATE] indicates R8 has severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 4; requires maximal assistance with 1 staff member for repositioning and is dependent on 1 staff member for personal hygiene. R8 requires a Hoyer lift with 2 staff members for transferring and is incontinent of bowel and bladder and wears an adult brief. On 8/15/23, the facility assessed R8 to be high risk for the development of pressure injuries with a Braden score of 11. Surveyor notes R8 was admitted to the facility with pressure injuries to the left heel and right lateral foot, both resolved on 11/29/2023. R8 had a significant change MDS completed on 4/26/2024 and the facility assessed R8 to be dependent on staff with repositioning as well as all activities of daily living (ADLs) with assistance of 1 staff member. R8 has an activated POA (Power of Attorney.) Surveyor reviewed R8's physician orders and noted an air mattress was ordered on 9/14/2023 and was never implemented. Surveyor observed R8's current mattress is a foam mattress. Surveyor reviewed the Manufacturer's Owner's Manual and noted a description for the memory foam flip mattress, and it was designed to provide different levels of comfort on the two opposing sides of the mattress. The memory foam side of the mattress features a soft viscoelastic foam top layer with three support layers underneath. The traditional foam side of the mattress has a firmer feel while still providing comfort and pressure redistribution. A super-soft heel section is featured on both sides of the mattress . On 5/29/2024 at 3:46 PM, Surveyor interviewed Interim Director of Nursing (DON)-C who stated they are not sure why R8's air mattress was never implemented when ordered on 9/14/2023. Interim DON-C stated there may be a story there but would have to look into it. Surveyor never received further information regarding why R8's air mattress was never implemented. R8's care plan for actual skin impairment was not initiated until 9/27/2023 (6 weeks after admission with pressure injuries) and included the following interventions: - Encourage good nutrition and hydration in order to promote healthier skin. - Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal s/sx of infection, maceration, etc . - Nursing collaborate with [Name of Wound Care company] wound care consultants on changes to or worsening of the wound. R8's current Certified Nursing Assistant (CNA) [NAME] has the following interventions as of 5/29/2024: - Check positioning in chair and when alone in room, tilt chair back with feet elevated for safety and proper lower extremity position. Surveyor reviewed R8's [Wound Care Company] wound care assessments and noted on 1/31/2024 R8 was assessed to have two unstageable deep tissue injuries (DTIs): - Right lateral foot measuring 0.5 cm (centimeters) x 1.0 cm (length x width x depth) - Right ankle measuring 0.5 cm x 0.5 cm New orders included: - Skin prep ordered - Offload wound, reposition, pressure off loading boots Surveyor noted R8's care plan and CNA [NAME] were not revised with the new interventions for offloading, pressure off loading boots, or repositioning. On 3/6/2024, the facility's assessment of R8's right ankle wound is documented as an unstageable PI with necrosis, 1 x 1 x 0.2, 20% necrotic (dead,) 80% granulation tissue. On 3/13/2024, the facility's assessment of R8's right lateral foot wound is noted to be a stage 3 PI measuring 0.2 x 0.2 x 0.2, 100% granulation tissue. Wound Medical Doctor (Wound MD)-P also indicated a possible concern for bone infection in right ankle due to it not healing and an x-ray was ordered. The x-ray was found to be negative for a bone infection. On 3/20/2024, the facility's assessment of R8's right ankle wound is documented as a Stage 4 measuring, 1 x 1 x 0.4, 20% necrotic, 80% granulation, muscle/fascia visible. On 3/29/2024, Wound MD-P ordered an ace wrap be applied around the right foot to keep the bandages in place. Surveyor noted the new order was not added to R8's care plan or added to R8's MAR (Medication Administration Record)/TAR (Treatment Administration Record). Surveyor did not observe an ace wrap around R8's right foot during the survey. On 5/14/2024, the facility's assessment of R8's right lateral foot wound documents a deterioration from a stage 3 to stage 4, measuring 2 x 2 x 0.3, 100% granulation tissue. On 5/21/2024, R8's wound measurements are documented as: -Right lateral foot, stage 4, 2.0 x 1.8 x 0.2, 90% granulation tissue, 10% muscle -Right ankle, stage 4, 2.0 x 2 x 0.3, 100% granulation tissue On 5/21/2024, Wound MD-P's assessment notes state it was stressed to R8's POA and facility nursing staff the need to ensure the patient offloads site as [R8] favors laying on the right side which is a concern for ongoing source of pressure. Wound MD-P's assessment notes discussed that [R8] has palpable pulse and with improvement seen since last week's assessment, R8 should have the ability to heal, but that will not occur unless R8 continues to have pressure relief to the wound site. Re-reviewed wound orders with nursing to complete as ordered and additionally discussed ways to ensure improved offloading and prevent [R8] from continuing to favor the right side and leading to worsening of [R8's] right foot wound. Discussed with R8's POA additional treatment or adjustment to the GOC (goal of care) for hospice versus aggressive therapies should wound worsen such as amputation. R8's POA wishes to continue with aggressive wound care given seeming improvement possible with offloading measures discussed. Surveyor noted there were no changes to R8's care plan or the CNA [NAME] to include interventions discussed in Wound MD-P's progress notes. Surveyor also noted that the above information was not noted in the progress notes for nursing to see and that the need to make sure R8 is offloading R8's right ankle and pressure injury was not indicated. Surveyor noted the following concerns: - R8's care plan and CNA [NAME] were never revised to include new interventions recommended by Wound MD-P for off-loading, repositioning, and pillow boots. - Multiple notes from Wound MD-P stating patient noncompliance with offloading and repositioning, and behaviors, and this was never addressed in care plan. - Quarterly MDS completed on 11/22/2023 and current MDS done 4/26/2023 do not document R8 refuses cares or is non compliant. Surveyor noted R8's current wound measurements as of 5/28/2024 are: - Right lateral foot, Stage 4, 2.2 x 1.5 x 0.2, 100% granulation tissue - Right ankle, Stage 4, 2 x 1.5 x 0.2 100% granulation tissue Buttock Pressure Injury On 2/7/2024 at 22:46 (10:46 PM) in progress notes, nursing documented, skin only evaluation indicating R8 has an open area on the buttock. Seen by Wound Doctor. Treatment in TAR. No other concerns. Surveyor noted there was no comprehensive assessment of the buttock pressure injury including measurements, description, or location of the open area on R8's buttock. Surveyor also noted there is no documentation by Wound MD-P regarding the open area on buttock from 2/7/2024. Surveyor reviewed R8's February 2024 MAR/TAR and noted a new treatment was not initiated on 2/7/2024 for the newly identified pressure injury. R8 had the following orders in place from 8/15/23 which documented: -[NAME] Buttocks External Ointment (Diaper Rash Products)-Apply to buttocks topically two times a day for skin protection (Start date: 8/15/2023). -Duoderm to right buttock, change every 3 days and PRN (as needed) (Start date: 9/17/2023.) Surveyor noted staff initialed the treatment as being completed 6 out of the 9 scheduled days in February. Surveyor also did not see any progress notes or assessments to indicate why R8's treatment to right buttock was changed from [NAME] Buttock Ointment to a Duoderm dressing three times a day on 9/17/23. Surveyor noted that there are no further assessments or progress notes regarding R8's open area on the buttocks which was noted on 2/7/2024. On 4/9/2024, Wound MD-P submitted a supplemental progress note which indicated R8 has buttock wounds which appear to be pressure related (stage 2) given patient frequently spends long periods of the day in [R8's] recliner. Will use Zinc TID (three times a day) for treatment in addition to upgrading patient cushion and mattress, reposition per protocol. Measurements were provided to Wound MD-P by facility staff: - Right buttock wound 2.1 x 0.49 x 0.1 - Left buttock wound 2.1 x 0.49 x 0.1 (per telephone from facility-did not assess) - Zinc ordered for 3x (times)/day in addition to upgrade patient cushion and mattress, reposition. Surveyor noted R8's mattress was not upgraded on 4/9/2024 as ordered by Wound MD-P. On 4/16/2024, Wound MD assesses R8's buttocks wounds: - Right buttock wound, stage 2, 2.5 x 3.0 x 0.1, open area with exposed dermis - Left buttock wound, stage 2, 5.0 x 1.0 x 0.2, open area with exposed dermis - TX (treatment) changed to leptospermum honey once daily and cover with bordered gauze. R8's current measurements right and left buttocks wounds as of 5/28/2024 are: - Right buttock wound, stage 2, 0.5 x 0.5 x 0.1. - Left buttock wound, stage 2, 3 x 3 x 0.1. On 5/28/2024 at 8:27 AM, Surveyor observed R8 lying on her right side in bed sleeping. Surveyor noted there was not an air mattress on R8's bed and there were 2 blue pillow boots in R8's wheelchair. Surveyor was unable to visualize R8's legs at this time. On 5/28/2024 at 11:03 AM, Surveyor observed R8 lying in bed on her back slightly leaning on R8's right side and R8's legs were turned to the right and R8's right foot/ankle were against the mattress. Surveyor observed two bandages on the sheets next to R8 that were dated 5/28/2024 with [initials] on the bandage. R8 was observed scratching R8's lower extremity. Surveyor asked R8 if Surveyor could look at R8's hands. Surveyor noted R8's fingernails on her right and left hands to be long and dirty. Surveyor also observed R8 throwing a blue type dressing on her bedroom floor where another blue dressing was already lying. Surveyor did not observe R8's feet offloaded, and 2 blue pillow boots were still located on R8's wheelchair. On 5/28/2024 at 11:29 AM, Surveyor observed R8 lying in bed scratching at her lower right leg. 2 bandages were still located on R8 bed, and 2 blue pillow boots were located on R8's wheelchair. Surveyor noted R8's right lower leg was exposed and asked R8 if Surveyor could look at R8's right foot. Surveyor noted an open area on the right lateral side by R8's pinky toe and R8's ankle had open areas that did not have dressing on them and R8 was scratching around the open areas. On 5/28/2024 at 12:36 PM, Surveyor observed CNA-M going into R8's bedroom. CNA-M stated CNA-M was getting R8 up for the day. Surveyor asked CNA-M what interventions R8 has in place for R8's wounds. CNA-M stated R8 gets repositioning at least every two hours and treatments to R8's wounds. Surveyor asked CNA-M if R8 has been getting repositioned. CNA-M stated R8 has been getting repositioned because R8 is unable to do it without help. Surveyor asked CNA-M if R8 is supposed to have dressings on R8's right foot pressure injuries. CNA-M stated CNA-M noticed they were off earlier and told the Nurse. Surveyor asked CNA-M how long ago that was, and CNA-M replied at least a couple hours ago. Surveyor asked CNA-M if R8 had any pressure injuries on R8's buttocks. CNA-M stated that R8 has some areas and gets a barrier cream applied. CNA-M provided cares on R8 and applied a barrier cream to R8's buttocks. On 5/28/2024 at 12:58 PM, Licensed Practical Nurse (LPN)-N entered R8's bedroom. LPN-N stated LPN-N redressed R8's dressings earlier and was not aware they had come off again. LPN-N redressed R8's right foot dressings to R8's right lateral and right ankle pressure injuries and wrapped R8's foot with a Coban dressing so the dressings stay on. LPN-N then cleaned and applied the ordered treatments to R8's right and left buttock pressure injuries. Surveyor asked LPN-N what interventions are in place for R8's wound management. LPN-N stated R8 should be repositioned, receives treatments to the areas, and should have pillow boots on but R8 rubs her legs, and they fall off all the time. On 5/29/2024 at 8:02 AM, Surveyor observed R8 lying slightly on R8's right side, her knees were propped on a pillow and her right ankle was directly against the mattress. R8 did not have pillow boots on and had a Coban wrap around the right foot. Surveyor noted R8's blue pillow boots were sitting on R8's wheelchair. On 5/29/2024 at 11:04 AM, Surveyor observed CNA-M and CNA-O putting R8 into R8's wheelchair. Surveyor asked CNA-M and CNA-O how the pressure injuries developed on R8's right foot and buttocks. CNA-M and CNA-O both stated they were most likely due to pressure. CNA-M stated R8 favors her right side and tends to want to lay on that side. Surveyor asked if CNA-M and CNA-O were ever instructed to keep R8 off her right side or put interventions in place for offloading R8's right foot so there is no pressure in that area. CNA-M stated the pillow boots are put on to keep pressure off. Surveyor shared with CNA-M and CNA-O that Surveyor had observations that the pillow boots were not in place and sitting in R8's wheelchair. CNA-M stated the staff tries to keep the pillow boots on when able. CNA-M and CNA-O stated they were not sure what else to do. On 5/29/2024 at 3:46 PM, Surveyor interviewed Interim Director of Nursing (DON)-C who stated they are not sure why R8's air mattress was never implemented when ordered on 9/14/2023. Interim DON-C stated there may be a story there but would have to look into it. Surveyor never received further information regarding why R8's air mattress was never implemented. During the interview, Surveyor shared concerns with Interim DON-C. Interim DON-C stated they are wound care certified and has been in the Interim DON position for almost 3 weeks. Interim DON-C stated the facility is aware some things were not being completed as the staff should such as care plan and CNA [NAME]'s. Surveyor shared concerns with Interim DON-C that R8's impaired skin integrity care plan was never revised after R8 developed the pressure injuries in the right lateral foot and right ankle, and it was not revised again after R8 developed two stage 2 pressure injuries on R8's buttocks. Surveyor also shared concern R8's CNA [NAME] does not identify the recommendations to offload and keep R8 off her right side for wound care. Interim DON-C agreed with Surveyor R8's care plan and CNA [NAME] were lacking and needed to be revised and the facility is aware there is a problem and they are working on it. Surveyor shared observations made of R8 not having her right foot offloaded, not having a dressing in place for several hours, her weekly skin assessments were not completed, and there were observations of R8 not wearing pillow boots. Interim DON-C stated it would be looked into. Interim DON-C stated Interim DON-C did wound rounds with Wound MD-P the last several weeks and is worried R8's right foot wound will not heal because the bone is exposed for whatever reason and afraid that it will get infected. Interim DON-C stated R8's family is thinking of hospice services for R8. On 5/30/2024 at 10:01 AM, Surveyor interviewed Wound MD-P who stated the primary issue with R8's wounds are not offloading them. Wound MD-P stated staff have been educated and reeducated to keep R8 off that right side, possibly using wedges to prevent rolling onto right side. Wound MD-P stated when they come to facility weekly (primarily on Tuesdays) R8 is usually lying on the right side and the pillow boots are not applied. Wound MD-P stated the wound will get better and then decline, it is like a roller coaster. Wound MD-P stated every week while I'm in the facility the staff is re-educated to make sure R8's right side is offloaded. Surveyor asked Wound MD-P if R8's pressure injury has a chance of healing. Wound MD-P stated R8's wound would heal if R8's right side stayed offloaded due to R8 having good pulses, no arterial issues, and the bone and wound tissue appear healthy, but facility staff have to keep R8 offloaded. Wound MD-P stated maintenance staff were also instructed if they observe R8 on R8's right side, they are to get someone to get R8 off that side. Surveyor asked Wound MD-P if R8 should have an air mattress in place. Wound MD-P stated R8 would benefit from an air mattress but it is not required to heal R8's right lateral foot and right ankle pressure injuries. Wound MD-P stated the facility needs to ensure R8's pillow boots remain in place and R8 stays off her right side. Wound MD-P stated if the pressure injuries on R8's buttocks worsen then she will require an air mattress for wound healing. Surveyor asked Wound MD-P to clarify notes written about R8's noncompliance with wound care. Wound MD-P stated R8 does not refuse treatment or interventions but R8 has severe dementia and has to be talked through and assure pain medication is given before treatments so R8 is comfortable with what is happening. Wound MD-P also stated the noncompliance is with R8 always going to that right side and not being offloaded. On 5/30/2024 at 11:41 AM, Nursing Home Administrator (NHA)-A, DON-B, and Assistant Director of Nursing (ADON)-D were informed of the facility's failure to implement changes/revisions to R8's care plan/CNA [NAME], complete skin assessments on R8, and current observations of interventions not in place for R8 to promote wound healing and prevent worsening. The immediate jeopardy was removed on 6/3/24 when the facility completed the following: *All nurses and CNAs have been educated on the facility's skin prevention policy. *All nurses and CNAs have been educated on the notification process of skin changes. Detailing that changes be communicated to resident provider and clinical leadership who then coordinates with wound NP, dietician, and provider as needed. *Facility skin sweep completed on 5/31/24. *Facility residents care plans reviewed for at risk skin and updated as needed. *Facility residents with skin alterations have had a review of their care plan, RN comprehensive skin evaluations, interventions, and treatment plans in place. *Daily the DON or designee will review progress notes, risk assessments and 24-hour boards for any resident alteration of skin integrity. *Competencies and education will be conducted by nursing management and/or a nurse who has passed the competency education and has been designated to provide the education. *Staff education will occur prior to the next shift and new agency staff will be educated upon their first shift. *Pressure Injury Prevention and Managing Skin Integrity policy reviewed and reviewed with Medical Director. *Interdisciplinary Team to have weekly wound meetings to review status to include: pressure injury Policy and Procedure compliance. All findings will be reported to QAPI committee. *DON or designee will audit 5 medical records to ensure the skin policy and procedure are being followed weekly x 4 weeks then monthly times 3 months. Findings will be reported to the QAPI committee. *Root cause analysis completed on 5/13/24.