ALBUQUERQUE, NM – CANYON TRANSITIONAL REHABILITATION CENTER Multiple residents with bedsores due to lack of proper care.

Based on record review and interview the facility failed to ensure quality care for 2 (R #2 and #3) of 2 (R #2 and #3) residents looked at for abuse and/or neglect by:

Not following physician’s orders [REDACTED].

Not taking action on R #3’s lab work when it indicated that he had an infection,

This deficient practice caused R #3 to have an infection that went without treatment before being sent out to the hospital; and R #2 not having her heel and her two amputated toes treated, monitored and booted consistently, causing an unstageable pressure ulcer on her right heel. The findings are:

R #2

[NAME] Record review of the medical chart indicated that resident was admitted on [DATE] R #2 did have two toes amputated at the hospital, but did not have any pressure wounds at the time of admission to the facility.

Record review of the physician orders [REDACTED].

Record review of the physician orders [REDACTED].

Record review of the physician orders [REDACTED]. Elevate L (left) heel off the bed.

Record review of the physician orders [REDACTED].

Record review of the TAR (treatment administration record) dated Septemeber 2019 indicated that none of the above four physician orders [REDACTED]. The above orders were not being completed.

On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she saw (R #2) on 09/26/19, shedid an H (history) and P (physical). She agreed that she wrote the orders for the measurements, the wound care, and the boot. She was not aware that they are not on the TAR and were not being done. She stated that yes,  they were having problems with wounds. She stated that the agency nurses are lacking competence or lacking caring and concern. She stated that sometimes she can’t even get the nurses to report issues to her.

R #3

Record review of a wound care progress note dated 08/16/19, indicated the following: St 4 (stage 4) to L (left) hip measures 7.8 cm (centimeter) x 8 cm x 1.4 cm, Tunneling (tunneling wounds snake through the layers of tissue, creating horizontal S-shaped curves) at 1 o’clock 4 cm, tunneling at 11 o’clock is 2.5 cm and undermining (are wounds that extend in all directions into the subcutaneous tissue under the skin) from 3 o’clock to 5 o’clock is 1.5 cm. 100% granulation tissue (is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) moderate SS drainage (serosanguineous drainage is a sign of healing, and it is not usually a cause for concern when it appears in normal amounts), no odor. St 4 to L buttock measures 1.5 cm x 1.5 cm x 3 cm with tunneling at 9 o’clock measuring 2.8 cm and tunneling at 3 o’clock measuring 3.6 cm. 100% granulation tissue, moderate SS drainage and no odor. St 4 R buttock measures 3 cm x 1.5 cm x 2 cm, moderate SS drainage and no odor. St 3 to coccyx measures 2 cm x 1.5 cm x <0.1 cm. 50% [MEDICATION NAME] and 50% granulation tissue. Moderate SS drainage and no odor . Patient states no pain during treatment, tolerated well.

On 01/22/20 at 10:06 am, during an interview with the Unit Manger, she stated that his (R #3) wounds were doing well and then started to decline. The last time 09/27/19 she helped (wound care nurse) change the wound vac, there was an extreme amount of drainage and odor on the wounds. Because of the drainage the wounds were no longer appropriate for the wound vac. Yes, she stated there were concerns of infection in the wound because it was so odorous.

On 01/22/20 at 3:40 pm, during an interview with the wound care nurse, she stated that she left the facility to go workelse where. This was mid to late August, after some changes had been made at the facility they asked her to come back every Friday to due wound care because they were struggling a bit. So she agreed to do that and probably cameback in on the Friday of (MONTH) 27th. She stated that for R #3, his wounds did not look as good as they had previously. She stated that the odor coming from R #3’s wound was, she stated that she couldn’t even describe it. She stated that she had concerns that it was infected but without a wound culture, you can’t be sure, but an odor can indicate that a wound is infected. She stated that she did remember pulling out the foam that was stuck down into the wound, she stated there is no way to know if that foam was stuck in there from a previous wound vac change or not.

On 01/23/20 at 8:40 am during an interview with the CED (Center Executive Director), she stated that there was a period of time when the wound care SIRS (skin integrity report) sheets were not getting done. A[NAME] On 01/23/20 at 8:57 am, during an interview with the Medical Director, she stated that she did have concerns about R #3 wounds and that they were infected. That is why she ordered the lab work to get done when she saw R #3 on 10/01/19. She stated that she doesn’t ever remember viewing the lab results. She asked for two results during the interview, she asked for the SED rate which was 107 and reference range was 0-20. The CRP result was 188.2 and the reference range was 0.0-10.0. She agreed this would likely indicate an infection. She stated that nursing (wound care nurse) had said that the wounds were worsening. That there was slough in the wounds, the MD stated that she was concerned that the [DIAGNOSES REDACTED] had returned.