LOCATED: 1650 GALISTEO STREET, SANTA FE, NM 87505
CASA REAL was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:
PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.
FACILITY FAILED TO GIVE RESIDENTS PROPER TREATMENT TO PREVENT NEW (PRESSURE) SORES OR HEAL EXISTING BED SORES
LEVEL OF HARM –IMMEDIATE JEOPARDY
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the facility failed to ensure that 1 (R #3) of 5 (R #3, 31, 43, 81 & 87) residents reviewed for pressure ulcers received the necessary services to prevent the development of new pressure ulcers by:
This deficient pact likely resulted in the resident developing multiple avoidable pressure ulcers.
Record review of the wound and skin status report dated 01/20/16 revealed the resident was noted to have two unstageable pressure ulcers; one located on the left ankle and the other located on the left side of her foot. Both of these pressure ulcers were noted to have been identified on 11/19/15 and were not present upon the resident’s admission to the facility. The resident was also noted to have two other unstageable pressure ulcers to her right foot; one located on the lateral (outside) aspect of the heel and the other on the lateral aspect of the foot. Both of these pressure ulcers were noted to have been identified on 01/13/16 and were not present upon the resident’s admission to the facility.
On 01/21/16 from 9:19 am to 10:28 R #3 was reclined in the Geri chair in the common area next to the nurses’ station. The resident did not have waffle boots placed on either feet and both of the resident’s heels were set directly on the foot rest of the Geri-chair. During the observation the resident was not offered to re-position or a cushion/pillow to relieve the pressure off of her feet/heels.
On 01/21/16 at 3:46 pm, during an interview with the resident she was asked if she had the strength to re-position herself on her own and stated, No, I can’t do anything thing on my own, I’m helpless, they (staff members) have to do everything for me.
On 01/21/16 at 3:47 pm, during an interview and observation with the wound care nurse Registered Nurse, (RN) #11 she was asked if the resident should be wearing waffle boots on both of her feet while she rests in the Geri-chair and stated, Yes. RN #11 confirmed that even though the resident cannot re-position herself, she frequently shifts while in the chair and the waffle boot often get removed. During an observation, RN #11 began performing wound care to the resident’s pressure ulcers on her feet. When RN #11 removed the resident’s right sock, no wound dressing was present over the resident’s pressure ulcer located closest to the ankle. RN #11 confirmed the resident should have had a dressing covering the pressure ulcer to protect it.
Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.
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