**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to provide care to prevent pressure ulcers for one (1) of three (3) sampled residents (Resident #1). Resident #1 sustained a pathological fracture to the left femur on 09/23/18, and was treated with a splint and ACE (brand name for an elastic bandage) wrap to the left leg. The facility failed to assess Resident #1’s skin under the splint/ACE wrap and failed to identify and treat a pressure ulcer to the area of the leg behind the left knee. The pressure ulcer was not identified until staff from an acute care hospital identified the pressure ulcer on 10/26/18, when the facility transferred the resident to the hospital due to blood in his/her emesis (vomit). The hospital assessed the pressure ulcer as a Stage IV (the ulcer extends into muscle and other structures, e.g. tendon, fascia, and bone) and the resident was admitted to the hospital for intravenous (IV) antibiotics and treatments to the infected pressure ulcer.

Interview with State Registered Nurse Aide (SRNA) #1 on 10/30/18 at 4:00 PM and SRNA #2 on 10/30/18 at 4:05 PM revealed they were frequently assigned to provide care for Resident #1 and were knowledgeable that the resident had a splint/ACE wrap to the left leg. The SRNAs stated they provided no care to the resident’s left leg and were never asked to help or assist with the splint/ACE wrap to the left leg. SRNA #2 further stated she had not observed staff removing/applying the ACE wrap.