SANTE FE, NM- CASA REAL

The Department of Health & Human Services conducted an inspection of the facility. The following decencies listed below were found in a public survey.

Based on record review, observation, and interview, the facility failed to ensure that 3 (R #42, 96 and 98) of 3 (R #s 42, 96 and 98) residents reviewed for pressure ulcers received monitoring and care to prevent the development and worsening of pressure ulcers by:

1. Not accurately assessing residents skin upon admission/re-admission or immediately implementing treatment and monitoring for skin issues once identified for R #42, 96 and 98.
2. Not implementing effective interventions to prevent new skin wounds from developing and worsening for R #96 and R #98.

These deficient practices likely resulted in the development and worsening of resident pressure wounds, including a Stage 3 (full thickness tissue loss) pressure ulcer and Stage 4 (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) pressure ulcer. The findings are: 

E. Record review of R #98’s skin checks revealed the following:
1. 04/10/23 identified no wounds on heels or sacrum (a triangular bone in the lower back formed from fused backbones and situated between the two hipbones of the pelvis).
2. 04/27/23 identified 3 new injuries:
a) left heel deep tissue injury (DTI) measuring 8 centimeters (cm) by 4.5 centimeters (cm),
b) a right lateral dorsum (shown in picture to be located on the side and bottom of the outer right foot) measuring 1 cm x 1 cm, and,
c) a right foot dorsum (dorsum of foot, the top of the foot) fifth digit (pinky toe) deep tissue injury were identified.

F. Record review of R #98’s medical record did not identify that an admission skin assessment was
completed by the admitting nurse upon re-admission [04/18/23].

H. Record review of the Medication Administration Records/Treatment Administration Record (MAR/TAR) for April 2023 for R #98 revealed the following:

1. No treatment orders or interventions documented for the red and macerated skin of the coccyx/sacral area for the month of April 2023 for the damaged skin identified on 04/18/23. No orders or interventions were documented for the reddened areas of the left and right heels.

2.  An order to Apply Optifoam Heel (a brand of dressing applied to the heels of the feet that provides an ideal healing environment because of its well-known property of handling high fluid, provides strong protection against outside contaminants and is highly absorptive and is considered ideal for partial and full-thickness wounds, lacerations, abrasions, pressure ulcers, and foot ulcers) to bilateral (both heels of feet) heels every day shift every 3 day(s) for wound care starting 04/27/23.

A nursing progress note by Wound Care Nurse (WCN #1) dated 05/16/23 indicated that a change of condition was created after a skin check was performed following notification that CNAs were changing R #98’s brief on 05/16/23 and reported R #98 had a hole in his bottom. As a result of the assessment, the following new and worsening skin injuries/wounds were identified: a stage 4 pressure injury (full thickness skin loss with extensive destruction; tissue necrosis {death}; or damage to muscle, bone, or supporting structure {such as tendon, or joint capsule}) to the coccyx, with tunneling (a wound that’s progressed to form passageways underneath the surface of the skin) a stage 3 (full thickness tissue loss) pressure injury to the right buttock, and a stage 3 pressure injury to R #98’s right ankle. 

An observation of a photo taken as part of the of R #98’s coccyx wound assessment was observed to show a coccyx wound located at the 12:00 o’clock position, directly above the anus (the opening where bowel movement passes from the body), consisting of 3 holes (open wounds) clustered closely together, with sinewy (stringy) yellow appearance border around all three. One of the three wounds had bubbly clear fluid in it. The largest open wound appeared to be cavernous with a tunnel-like appearance going into the resident’s lower backside; outside of the sinewy border is another border around all 3 wounds that is a rectangular border surrounding all three wounds and the skin there is yellow-white in color and appears to look like raw skin with the top layer of skin missing. There were red bumps throughout the rectangular border of white skin. The next border around the periphery of the rectangular shaped wound was a thin, red border (edge) of skin. Above the rectangular shaped wound was another small open wound that was separate from the large rectangular wound. It was pink with a small depression, and it had a red and pink edge. This wound was located on the right buttock at the 2:00 o’clock position above the 3 clustered, open wounds.

On 05/18/23 at 12:16 pm during an interview with RN #2, she stated R #98 had started Doxycycline (an antibiotic) yesterday on 05/17/23 for the wound on his coccyx. It had a discharge and a foul odor. Currently the wound was being treated with wound cleanser, Aquacel Ag for packing the wound, and Allevyn. She reported that R #98 was not able to be seen at the wound clinic this morning due to being late and that he was now being sent out to the emergency department because his appointment was rescheduled to Tuesday [05/23/23] of the following week. RN #2 stated, she last saw R #98’s sacral area last Thursday [05/11/23] and that it was red and macerated. She first became aware of the maceration on 05/03/23 and that it was being treated with a barrier cream.

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.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

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