ALBUQUERQUE, NM-SKIES HEALTHCARE AND REHABILIATION CENTER

Immediately tell the resident, the resident’s doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39822

Based on record review and interview, the facility failed to notify the physician and family for 1 (R #17) of 1 (R #17) resident reviewed for falls. This deficient practice likely resulted in a delay in identification of a hip fracture and unnecessary pain. The findings are:

A. Record review of the face sheet revealed R #17 was admitted to the facility from a local hospital on 03/03/22 with a primary diagnosis of left femur [long bone in upper leg extending from the hip to the knee] fracture and a secondary diagnosis of dementia [a group of symptoms that affects memory, thinking and interferes with daily life] without behavioral disturbance [a pattern of disruptive behaviors].

B. On 11/01/22 at 2:40 pm, during an interview with R #17’s husband and Power of Attorney for Health Care [legal document that empowers a specific individual to make decisions on your behalf concerning your medical condition, treatment, and care] (HCPA) decisions, he revealed, on Tuesday [09/27/22] [first name of hospice nurse for R #17] called and said his wife had a fractured ]broken] left hip the upper part of the upper bone of the thigh that extends from hip to knee] and pelvis [a break of the bony structure of the pelvis (to include sacrum, hip bones and tailbone]. I go to the nurses station and said, ‘Did my wife fall?’ It was one of the traveling nurses [he addressed] and after she looked in the computer [looking for information about R #17 falling], she said, no. The nurse next to her [at the nursing desk], [first name of Registered Nurse (RN) #10], then told him his wife had fallen out of bed on Friday [09/23/22] and she [RN #10] didn’t write it up [did not write an incident report – a document that describes an incident that occurred in which a resident might be harmed and where you document calling the provider and the family to notify of the incident].

C. On 11/01/22 at 4:30 pm, during an interview with R #17’s hospice nurse, she revealed, she saw R #17 on 09/26/22, that she [R #17] had a dramatic change in status, tremendous pain and could not bear weight on her left leg. She asked for X-rays [to be obtained] and when the results were given to her [on 09/27/22] she called the nurse at the facility [RN #10] and was told [by RN #10] that R #17 had been found on the floor by her bed around dinner time [4:30 pm] on Friday evening [09/23/22] they [facility staff] found her on the floor by her bed, they thought she had just tried to get into her wheelchair (w/c) by herself to go to dinner, she assessed her and thought she was fine [was not injured] so they put her in to her w/c and gave her dinner.

D. On 11/03/22 at 11:20 am, during an interview with Registered Nurse (RN) #10 [nurse who was
caring for R #17 when she fell on [DATE]] she revealed, I just got too busy and let it slip my mind [to report the incident]. No, I didn’t call the husband or the doctor that day. [She confirmed the husband and medical provider were not informed of R #17’s fall on 09/23/22 until 09/27/22].

E. On 11/03/22 at 1:35 pm, during an interview with the Nurse Practioner caring for R #17 at the
facility she revealed that the residents fall on 09/23/22 had resulted in an acute [new] hip and a
pelvic fracture. She had been informed about the hip fracture after the resident had X-rays done on
09/27/22 and she had read the report from the radiologist for the first time today [11/03/22] and
it was then she realized the resident also had a pelvic fracture.

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 39822

Based on record review and interview the facility failed to provide quality care for 1 (R #17) of 1 (R #17) resident reviewed by delaying in identifying a hip fracture [the upper part of the upper bone of the thigh that extends from hip to knee] and pelvis [a break of the bony structure of the pelvis {to include sacrum, hip bones and tailbone}] for 3 days following an unwitnessed fall and then not communicating with staff about the new fracture for consideration when transferring/repositioning the resident which likely resulted in unnecessary pain and further limiting R #17s range of motion.

The findings are:
Findings R #17

A. Record review of the face sheet revealed R #17 was admitted to the facility from a local hospital on 03/03/22 with a primary diagnosis of left femur [long bone in upper leg that extends from the hip to the knee] fracture and a secondary diagnosis of dementia [a group of symptoms that affects memory, thinking and interferes with daily life] without behavioral disturbance [a pattern of disruptive behaviors].

B. Record review of census revealed R #17 was admitted to hospice [end of life care] services on 04/20/22

C. On 11/01/22 at 2:40 pm, during an interview with R #17’s husband and Power of Attorney for Health Care [legal document that empowers a specific individual to make decisions on your behalf concerning your medical condition, treatment, and care] (HCPA) decisions, he revealed, on Saturday [09/24/22] he came to visit R #17 as he does each day. A hospice guy [Home Health Aide [HHA]] comes by and gives her a shower Saturday and touched her side [left] and it hurt. Then [on] Monday here comes the hospice guy [HHA] again to give her a shower and he [the hospice HHA] text me and says she is in a lot of pain and he called [first name of the hospice nurse who cares for R #17] and she [the hospice nurse] ordered an X-ray [test that produces images of the structures inside your body, particularly your bones] [On] Tuesday [09/27/22] [first name of hospice nurse for R #17] called and said she [R #17] had a fractured left hip and pelvis. He [R #17’s husband] revealed he used to get her up in her wheelchair [prior to the fall on 09/23/22] when he came to
see her, almost daily, she enjoyed being taken around the facility and talking to other residents, now she mostly just yells whenever you disturb [turn her in bed, bathe] her. He stated, She will never get out of bed again.

D. On 11/01/22 at 3:30 pm during an interview with the Certified Nursing Aide (CNA) #11 caring for R #17 she revealed, she cares for R #17 often and turns her in bed every two hours when she it there. She stated, she is turned just side to side like everyone. CNA #11 revealed, there have been no new instruction for how to turn R #17 since the new hip and pelvic fractures were diagnosed on [DATE].

E. On 11/01/22 at 4:30 pm, during an interview with R #17’s hospice nurse, she revealed, she saw R
#17 on 09/26/22, that she [R #17] had a dramatic change in status, tremendous pain and could not bear weight on her left leg as she had previously been able to do. She [the hospice RN] asked for X-rays [to be obtained] and when the results were given to her [on 09/27/22] they revealed R #17 had a left hip fracture and a pelvic fracture. She called the nurse at the facility [RN #10] and was told [by RN #10] that R #17 had been found on the floor by her bed around dinner time [4:30 pm] on Friday evening [09/23/22] they [facility staff] found her on the floor by her bed, they thought she had just tried to get into her wheelchair (w/c) by herself to go to dinner, she assessed her and thought she was fine [was not injured] so they put her in to her w/c and gave her dinner. The hospice RN revealed for R #17’s comfort they would keep her in bed as moving her contributed to her pain. She confirmed she had not updated a plan of care to help alleviate R #17’s pain related to fractures [with interventions such as specific ways to turn resident, ice or heat packs] but had spoken with R #17’s husband to educate him about the need for more pain control with medication.

F. On 11/03/22 at 10:30 am, during an interview with the Medical Director, she revealed that because R #17 is a hospice patient, the focus is on her comfort only. She reported that she would think that she [R #17] might not be comfortable lying on the left side.

G. On 11/03/22 at 1:20 pm, during an interview with the Hospice Home Health Aide (HHA) he revealed that he was never given any instructions on how to move R #17 after her fall, but from his past work experience with trauma patients he knew how to handle turns so that the resident remains comfortable and the fracture does not become displaced [change the alignment of the fractured bone].

H. On 11/03/22 at 1:35 pm, during an interview with the Nurse Practitioner (NP) caring for R #17
she revealed On Saturday [09/24/22] they [staff at the facility] had told me she [R #17] was agitated (feeling or appearing troubled or nervous) the night before and they [the facility staff caring for R #17] were wondering if she needed more of, I think Ativan [medication for anxiety] and I think morphine [medication for pain] [the NP was not aware of the fractures at that time]. She confirmed that, after becoming aware of the hip fracture on she believes Tuesday [09/27/22] when called about R #17’s X-ray report and notified of the hip fracture she had not written any new orders in terms of how to position the resident or other interventions [examples, ice or heat] to promote comfort. She revealed she had just learned of the pelvic fracture when she reviewed the X-ray report on this day [11/03/22].

I. On 11/03/22 at 2:12 pm, during an interview with CNA #15 she revealed, I was there [working on 09/23/22] but I was in the dining room [when R #17 fell ]. They had her [R #17] on the wheelchair when I went back [to the unit] after [the meal] she [R #17] was complaining about pain and she was saying she hurt. CNA #15 confirmed that R #17 was not able to identify the location of the pain.

J. On 11/03/22 at 11:20 am, during an interview with Registered Nurse (RN) #10 [nurse who was
caring for R# 17 when she fell on [DATE]] she revealed, I was working by myself [no other nurse or Certified Medication Aide (CMA) to assist her with medication passes] on the floor that day and I never had to work that floor alone before. I want to say that first, because that had a lot to do with it [not following up with an incident report and calling the physician and the POA after R #17’s fall]. I was just passing medications, and it took forever because they [the residents] had all these needs whenever I went into the room. I don’t remember if it was 4:00 or 4:30 [pm] when they [the Certified Nursing Assistants (CNA’s)] called me to [first name of R #17] room and she was on the floor, the aides [CNA’s] said they found her there. She was on the bare floor. She had those soft socks on, no not with the little pads [tread stop/anti slip pads to help prevent falls]. The wheelchair was there [by her bed where she fell ] she might have been trying to move into it or from it. When I did my assessment, any place you touched her she was yelling and moving you couldn’t touch anything, but she didn’t say she hurt. I moved her arms and legs and there was no difference in her yelling. We got her up in the chair [w/c] and she settled [became more calm] I asked the CNA’s [who had worked with R #17 more often than the nurse had] and they said it was kind of normal behavior for her [R #17] she yelled and did not answer questions [as part of her usual behaviors]. I just got too busy and let it slip my mind [to report the incident]. No, I didn’t call the husband or the doctor that day. I did the CIC [Change in Condition/Incident report] when I came back the following Tuesday [09/27/22] and that is when I notified the Nurse Practitioner and the husband.

K. On 11/04/22 at 9:51 am, during an interview with RN (Registered Nurse) #12, the nurse who cared for R #17 on the weekend after fall [09/24/22 and 09/25/22] she reported I didn’t really know her [R #17] [and didn’t know she had new fractures] well, she was combative [ready or eager to fight] with the CNA’s that Saturday morning and we couldn’t get her changed for quite a while. At the time her husband came in around 8:00 [am], she was just confused and she was kicking and thrashing (moving in a violent way) about. She had difficulty moving out of the bed and yelled more when we did try to get her up.