LAS CRUCES, NM – CASA DE ORO CENTER

Based on observation, interview, and record review, the facility failed to ensure that a resident with Pressure Ulcers (an injury to the skin and underlying tissue, caused by prolonged pressure on the skin) received the necessary treatment and services, consistent with professional standards of practice for 1 (R #1) of 3 (R #1,

R #2, and R #3) residents reviewed for Pressure Ulcers, when they failed to:

1) Initiate wound care order for R #1’s pressure wound upon admission to the facility,

2) Start antibiotic treatment (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER]

3) Provide documentation consistently in accordance with wound care orders for R #1’s pressure wound ,

4) Initiate a wound vac (vacuum-assisted closure of a wound, a type of therapy to help wound heal) for R#1’s pressure wound per Physician request,

5) Obtain weekly wound assessment and measurements for R #1’s pressure wound, and

6) Place the R #1 under contact precautions for [CONDITION(S)] ([CONDITION(S)] infection caused by bacteria that are resistant to commonly used antibiotics. Very infectious organism that requires contact precautions) .

This deficient practice has likely caused R #1 wound to became infected and not healed and ultimately result in amputation (limb loss) at level between knee and ankle to the right lower leg.

On 09/22/21 at 2:55 pm, during an interview with the DON, she stated I was not here during that time, I did not look at the wound, but I believe if resident would start the antibiotic and wound vac sooner, she could benefit from that. The DON confirmed that the wound was not measured weekly per care plan and facility policy. The DON also confirmed facility should have placed R #1 under contact precautions per culture results of [CONDITION(S)] and they failed to to that. The DON also confirmed they failed to document wound care regularly per order.