Citations in New Mexico
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Mexico.
Statistics for New Mexico (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Mexico
A resident with multiple comorbidities and generalized muscle weakness had a care plan requiring two-person assistance for ADLs, including bathing and bed mobility. During a bed bath provided by one CNA, who reported being unaware of the two-person assist requirement, the CNA remained on one side of the bed while the resident rolled toward the opposite side and fell from the bed to the floor. The resident sustained a laceration to a finger, reported pain in the arm, leg, and hip, and was later found to have a displaced distal femur fracture and a displaced fracture of the fifth finger, requiring surgical repair.
The facility failed to follow and obtain physician orders for several residents, including providing O2 and a wrist brace without orders, missing multiple weekly Mounjaro injections due to pharmacy and pre-authorization issues without timely follow-up, and serving hot beverages in a regular cup instead of a prescribed sippy cup. Additional residents had care plans calling for built-up utensils or scoop plates, but there were no corresponding physician orders for these adaptive eating devices, despite the OT indicating that long-term use requires an order. These actions and omissions demonstrate a pattern of not ensuring that treatments, medications, and adaptive equipment were supported and implemented according to physician orders.
A resident at risk for skin breakdown did not receive a Braden Scale assessment on admission as required by facility policy, and turning/repositioning interventions were not added to the care plan until later despite multiple risk factors including decreased activity, impaired cognition, limited mobility, incontinence, and recent hip surgery. Braden assessments were only documented on later dates, and there was no documented off-loading of the coccyx. These failures in timely risk assessment and off-loading contributed to tissue necrosis and the development of a coccyx pressure injury, as confirmed by the ADON during interview.
A resident with multiple comorbidities, including a right femur fracture, DM2, SLE, osteoporosis, dementia, and generalized muscle weakness, developed an in-house acquired unstageable pressure injury to the coccyx. Nursing notes and weekly skin assessments documented the presence of this unstageable pressure injury, as well as an unstageable sacral wound, and family was present for wound care and teaching. However, the corresponding MDS assessment indicated there were no unhealed pressure ulcers or injuries, and the MDS Coordinator confirmed that the assessment did not accurately reflect the resident’s documented coccyx pressure injury.
Surveyors found that multiple residents were kept in cold rooms on one unit where thermostats in individual rooms did not function and temperatures were controlled from the nurse’s station, with staff acknowledging frequent complaints about the cold and the lack of temperature logs. In addition, a resident with atopic dermatitis, type 2 DM with neuropathy, varicose veins with inflammation, and dementia was observed multiple times lying directly on a bare plastic mattress without sheets or blankets, despite CNA, RN, and DON expectations that beds be remade immediately after linens are removed and that residents not remain on uncovered mattresses.
A resident with diabetes, prior TIA and stroke, cognitive communication deficit, and depression had multiple MDS assessments in which Section C (Cognitive Patterns) was repeatedly left incomplete. Across several assessments, items determining whether BIMS should be conducted, the BIMS questions themselves, the staff assessment for mental status, and short- and long-term memory fields were left unanswered or dashed, resulting in no BIMS score while some cognitive items were still coded (e.g., memory and decision-making). The MDS Coordinator confirmed responsibility for these assessments and acknowledged that Section C was expected to be fully completed but was not.
A resident with Type 2 DM, neuropathy, paraplegia, and reduced mobility had a physician order for daily diabetic foot checks, including skin assessment, shoe inspection, and pedal pulse checks, but this care was not documented as completed over an extended period. The resident’s care plan did not include diabetic foot care despite the order. A later podiatry consult identified thickened, painful toenails, nail dystrophy, localized edema, and slightly diminished foot and ankle ROM, and the podiatrist performed nail debridement and recommended ongoing daily foot checks. The DON acknowledged that it was expected for physician orders to be followed and confirmed the ordered foot care was not provided as required.
During a flooring renovation project, several residents were removed from their rooms without prior notice and were left for extended periods in wheelchairs or crowded into another room, with one resident moved from a bariatric bed with rails to a smaller standard bed without rails. Residents reported having no access to their own bathrooms, belongings, or a place to lie down, and some observed others sleeping on couches in common areas while construction workers replaced flooring in their rooms. The Administrator acknowledged the facility-wide flooring replacement and stated no complaints had been received, without indicating that residents were given notice or options before being told to leave their rooms.
During a flooring renovation, the facility failed to follow its own safety plan and manufacturer guidance for flooring adhesive, leaving multiple uncovered buckets of industrial adhesive in resident areas and applying adhesive in an open resident room without fans, open windows, or open exit doors, resulting in strong odors throughout the hallway while residents remained in nearby rooms. A visitor reported a strong, unpleasant odor despite wearing a mask, and a resident with asthma expressed concern. Review of the adhesive’s MSDS showed the need for adequate ventilation and keeping containers closed when not in use, but facility leadership believed residents were not at risk and relied on existing mechanical ventilation. At the same time, surveyors observed extensive obstruction of multiple means of egress, including resident hallways, utility and kitchen dock corridors, and the Administration wing, where beds, carts, equipment, furniture, boxes, and other items blocked or encroached on exit paths and doors while residents in wheelchairs navigated around them. A resident reported being displaced from his room for flooring work and stated that hallway items had been present, moved, and then returned, and that the hallway had been in this condition for some time.
Surveyors found that two discharged residents did not have discharge summaries in their medical records. Review of facility documentation confirmed that both residents had been discharged, but no discharge summaries were completed or filed. In an interview, the ADON acknowledged that staff should have completed these discharge summaries and that they were expected to be present in the medical record.
Failure to Follow Two-Person Assist Care Plan During Bed Bath Resulting in Fall and Fractures
Penalty
Summary
The facility failed to ensure a resident’s environment was free from accident hazards and that adequate supervision and assistance were provided during personal care, resulting in a fall with injury. The resident was admitted with multiple diagnoses including chronic systolic heart failure, major depressive disorder, morbid obesity, type 2 diabetes mellitus, and generalized muscle weakness. Her care plan, revised on 06/03/25, specified that she required two-person assistance for bathing/showering, bed mobility, dressing, toilet use, and transfers with a Hoyer lift. On 12/27/25, progress notes documented that the resident was in her room with her husband and requested a bed bath. During this bed bath, she fell from her bed, sustained a laceration to her left pinky finger, and complained of pain to her left arm, leg, and hip. Interview with CNA #2 revealed that he responded to the resident’s request for a bed bath and provided care while positioned on one side of the bed. During the bath, the resident rolled toward the opposite side of the bed, and CNA #2 was unable to prevent her from rolling out of the bed, resulting in her fall to the floor. CNA #2 stated he assisted the resident without a second staff member because he was unaware that she required two-person assistance as outlined in her care plan. The DON stated that residents who require two-person assistance are expected to receive help from two staff members and that CNA #2 should have been informed of this requirement during shift report. Hospital records later documented that the resident was admitted with a displaced oblique fracture of the distal femur and a displaced fracture of the middle phalanx of the fifth finger and underwent surgery to repair these fractures.
Failure to Follow and Obtain Physician Orders for Treatments, Medications, and Adaptive Devices
Penalty
Summary
The deficiency involves the facility’s failure to ensure services met professional standards by not following or obtaining physician orders for multiple residents. One resident with a right wrist fracture and respiratory illness was observed sitting in a wheelchair with a right wrist brace and receiving O2 at 2 L/min via nasal cannula. Record review showed there were no physician orders for either the oxygen therapy or the wrist brace. The DON confirmed that the resident had a wrist brace and was receiving oxygen without corresponding orders in the electronic medical record and stated that nurses should have addressed this and obtained provider orders, but this did not occur. Another resident with type 2 DM, morbid obesity, and long-term use of insulin and injectable non-insulin antidiabetic drugs had multiple sequential orders for weekly Mounjaro injections. Review of the MAR showed missed Mounjaro doses on three specific dates. The resident reported that the facility was not consistently administering the weekly injection and that some weeks the medication was not available and the dose was skipped. The ADON confirmed the missed doses, explaining that the medication was not available on two of the dates due to pharmacy/insurance pre-authorization issues, and that on another date the medication arrived several days late and the resident refused it because it was too close to the next scheduled dose; the ADON stated nurses should have requested the medication from the pharmacy as soon as they knew it was not available, but this did not happen. A resident with hemiplegia, vascular dementia with behavioral disturbance, aphasia, and dysphagia had a dietary order for a scoop plate and a sippy cup for hot beverages. During a meal observation, this resident was served hot coffee in a regular cup despite the meal slip indicating a sippy cup for hot beverages. The admissions coordinator confirmed that the hot coffee was served in a regular cup and acknowledged that, per the dietary order, all hot beverages should have been served in a sippy cup, which did not occur. Additional deficiencies involved adaptive eating devices and the lack of corresponding physician orders. One resident with multiple sclerosis, type 2 DM, generalized muscle weakness, and a right rotator cuff tear had a care plan specifying built-up utensils for all meals, but record review did not show a physician order for built-up utensils. Another resident with Alzheimer’s disease, vascular dementia, psychophysiologic insomnia, and hearing loss had a care plan for rehab eating devices, including a scoop plate during meals, but there was no physician order for a scoop plate. A further resident with a left hand contracture, orthostatic hypotension, restless legs syndrome, and a neurostimulator had a care plan for built-up utensils for all meals, yet no physician order for built-up utensils was found. In interviews, the OT stated that he evaluates residents for built-up utensils, notifies the dietitian and dietary so the devices are placed on meal tickets, and that if a resident needs built-up utensils for a long period of time, a physician order is needed, which was not present in these cases.
Failure to Complete Admission Braden Assessment and Off-Loading Leading to Coccyx Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for pressure ulcer prevention for one resident identified as being at risk for skin breakdown. Record review showed that the facility’s Braden Scale policy required completion of a Braden assessment on resident move-in, but no Braden Scale assessment was completed on this resident’s admission date. Subsequent Braden assessments were documented only on 04/01/23, 04/08/23, and 04/14/23. The resident’s care plan, dated 04/28/23, identified the resident as being at risk for skin breakdown related to decreased activity, impaired cognition, limited mobility, poor safety awareness, incontinence, shear or friction, informed refusals of care, and recent right hip surgery noted on 03/28/23. The care plan intervention for turning and repositioning every 1 to 2 hours was not added until 04/01/23, despite the identified risk factors. The report also notes a lack of documented off-loading of the coccyx area, which directly contributed to tissue necrosis and the development of a pressure injury to the coccyx. During an interview, the ADON confirmed that Braden Scale assessments are supposed to be done on admission and acknowledged that this did not occur for this resident.
Inaccurate MDS Assessment for Resident With Unstageable Pressure Injury
Penalty
Summary
The facility failed to complete an accurate MDS assessment for one resident by not documenting an existing unstageable pressure injury. The resident was admitted with multiple diagnoses, including an intracapsular right femur fracture, type 2 diabetes mellitus, systemic lupus erythematosus, age-related osteoporosis, unspecified dementia without behavioral disturbance, and generalized muscle weakness. Nursing progress notes documented ongoing skin checks, including right hip and right lower extremity assessments, and on one date a new in-house acquired unstageable pressure wound to the coccyx was identified. Subsequent nursing documentation noted family presence for wound care and teaching related to this unstageable coccyx pressure injury. Weekly skin assessments for the resident showed that on one date there was no pressure injury, but later entries documented an unstageable pressure injury to the sacrum due to slough and then an unstageable in-house acquired pressure injury to the coccyx area. Despite these documented findings in the clinical record, the MDS assessment for the resident, dated within the same time frame, indicated in section M0210 that there were no unhealed pressure ulcers or injuries. During an interview, the MDS Coordinator confirmed that this MDS assessment did not accurately reflect the resident’s unstageable coccyx pressure injury.
Failure to Maintain Comfortable Temperatures and Provide Bed Linens
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not maintaining appropriate room temperatures for several residents and not providing bed linens for one resident. Surveyors observed that one resident was sleeping in a room that was noticeably colder than the common area, with the room thermostat set to 59°F and a wall furnace present but not functioning when the thermostat was adjusted. Another resident reported that his room was often cold despite the thermostat being set to 78°F. A third resident, sharing the cold room, was heard moaning in discomfort; a CNA stated this resident was moaning because she was cold and did not like being cold. Staff interviews revealed that CNAs and the Maintenance Supervisor believed the room thermostats did not work and that the 300-unit was often colder than other areas. The Maintenance Supervisor confirmed that room temperatures on the 300-unit were controlled by a thermostat at the nurse’s station, that he was aware of recent complaints, and that he did not keep logs of temperature readings. The RN and DON both acknowledged ongoing complaints about cold temperatures on the 300-unit, with the RN noting the nursing station vent constantly blew cold air and that residents had recently complained about cold rooms. The deficiency also includes the facility’s failure to provide bed linens for a resident with multiple chronic conditions, including atopic dermatitis, type 2 diabetes mellitus with diabetic neuropathy, varicose veins with inflammation, and unspecified dementia. This resident was repeatedly observed lying directly on a bare mattress without linens at multiple times throughout the same day. CNA staff reported that all CNAs are responsible for making resident beds and that beds should be re-made immediately after linens are removed. The RN stated that resident beds should be made without unnecessary delay, that residents should not lie directly on the plastic mattress surface because prolonged contact could disrupt the skin, and that residents can be cold without a blanket. The DON stated it was her expectation that all residents’ beds be made immediately after linens are removed and acknowledged that residents cannot rest comfortably without linens and that delays in making beds could contribute to worsening skin issues.
Incomplete MDS Cognitive Assessments for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate and complete completion of the Minimum Data Set (MDS) cognitive assessment (Section C) for one resident. The resident was admitted with multiple diagnoses, including type 2 diabetes mellitus with diabetic autonomic neuropathy, a personal history of TIA and cerebral infarction without residual deficits, a cognitive communication deficit, and depression. These conditions were documented on the resident’s face sheet and establish that the resident had relevant cognitive and neurological history at the time the MDS assessments were due. Multiple MDS assessments for this resident, each with different assessment dates, showed repeated omissions and unanswered items in Section C (Cognitive Patterns). On one MDS, the item asking whether the Brief Interview for Mental Status (BIMS) should be conducted (C0100) was left unanswered, and all BIMS items (C0200–C0500) were unanswered, resulting in no BIMS score, while the staff assessment for mental status (C0600) was also dashed. Despite these omissions, short-term memory (C0700) and cognitive skills for daily decision making (C1000) were coded as “memory ok” and “modified independence.” On subsequent MDS assessments, C0100 was sometimes coded “yes,” but the BIMS items (C0200–C0500) were dashed, C0600 remained dashed, and short-term and long-term memory items (C0700, C0800) were also dashed, again resulting in the absence of a BIMS score. Across several MDS assessments, this pattern of incomplete coding persisted: key cognitive assessment items were either left unanswered or dashed, including the decision to conduct BIMS, the BIMS questions themselves, the staff assessment for mental status, and memory items. During an interview, the MDS Coordinator stated she was responsible for completing these MDS assessments for the resident and acknowledged that it was her expectation that the assessments, including Section C, be fully completed and not dashed or left unanswered. The documented record review and the MDS Coordinator’s statements together show that the facility did not ensure an accurate and fully completed MDS cognitive assessment for this resident.
Failure to Provide Ordered Diabetic Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered diabetic foot care for one resident with multiple high-risk conditions. The resident was admitted with Type 2 diabetes mellitus with diabetic autonomic neuropathy, paraplegia, cognitive communication deficit, reduced mobility, and unsteadiness on feet. Review of the resident’s care plan dated 08/05/25 showed that diabetic foot care was not included. A physician order dated 09/11/25 directed daily diabetic foot care and checks, including observation of the feet, toes, ankles, and soles for alterations in skin integrity, color, temperature, and cleanliness, inspection of shoes for proper fit and excessive wear, and checking pedal pulses every night shift. Review of the Treatment Administration Record from 09/11/25 through 01/14/26 revealed that the ordered diabetic foot care was not completed by nursing staff for the entire period reviewed. A podiatry consultation on 01/14/26 documented diagnoses of Type 2 diabetes mellitus with hyperglycemia, onychogryphosis, nail dystrophy, pain in both toes, localized edema, and slightly diminished range of motion in the foot and ankle joints without pain. The podiatrist performed debridement and trimming of thickened, painful toenails and recommended daily foot checks, supportive shoes, and moisturizing lotions with precautions. During an interview on 01/22/26, the DON stated it was her expectation that physician orders, including diabetic foot care, be followed and confirmed that the ordered foot care for this resident was not followed as prescribed.
Failure to Provide Notice and Appropriate Accommodations During Room Renovations
Penalty
Summary
Surveyors found that during a flooring renovation on the 400 hallway, multiple resident rooms were emptied of furniture and flooring while construction workers were present, yet several residents remained on the hallway and were displaced from their rooms without prior notice. One resident reported being told by staff to leave his room so carpet could be removed and flooring installed, with no advance notice, and then having to sit in his wheelchair from 7:40 a.m. to 6:00 p.m. without access to his own bathroom, belongings, or a place to lie down. Another observation showed three residents together in a single resident room, with two in wheelchairs and one lying in a standard hospital bed without rails. A resident who normally used a bariatric bed with rails stated she was moved out of her room without notice to a smaller standard bed without rails and was not told how long she would be out of her room or how staff would assist her with restroom needs, given that her required equipment remained in her original room. Another resident stated she was removed from her room at 8:00 a.m. and not allowed to return until after 7:00 p.m., with no prior notice and no place to nap, remaining in her wheelchair all day and observing other residents sleeping on couches in common areas. A third resident reported being moved out of her room without notice for flooring replacement and not being informed when she could return or where she could use the restroom privately with her wheelchair. The Administrator stated the facility was replacing flooring throughout the building and that the 400 hallway was the last area to be completed, and reported not receiving any complaints from residents during the construction, without indicating that residents had been given notice or options before being told to leave their rooms.
Inadequate Ventilation of Flooring Adhesive Fumes and Blocked Egress During Renovation
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe and comfortable environment during a flooring renovation project, specifically related to inadequate ventilation of construction adhesive fumes and obstruction of the means of egress. The facility’s Safety Plan for the floor renovation, dated 09/16/2025, identified affected resident units and noted potential issues such as unpleasant odors from materials in use. The plan instructed staff to contain aerosol dust and debris with ventilation as needed, close doors where applicable to provide barriers, and remove patient activity and exposure in areas being worked on as allowable. Despite these written instructions, surveyors observed that these measures were not implemented as required during active construction. During observations on the 400 hallway, surveyors found multiple five-gallon buckets of industrial flooring adhesive uncovered and accessible in resident areas, including three buckets in an electrical closet with the door open, one bucket on a hallway table, and another on the floor. Adhesive was visible on the sides and bottoms of the buckets, and residents were moving throughout the unit around these open containers. In resident room 427, flooring adhesive had been applied to the floor with the door left open while a construction worker, who was wearing a face mask, installed flooring. There was a strong adhesive odor throughout the 400 hallway, with no fans present, windows in room 427 closed, and the exit door at the end of the hallway also closed. Residents were present in nearby rooms 423, 424, 425, and 426 with their doors open. A visitor reported smelling a strong, unpleasant adhesive odor through a face mask and suggested that closing resident room doors would help protect them from the odor. Another resident with asthma stated she could not smell the odor due to difficulty smelling but was concerned about it. Record review of the flooring adhesive’s Material Safety Data Sheet showed instructions that, if inhaled, individuals should be moved to fresh air, and that adequate ventilation and respiratory protection were recommended when using the product. The MSDS also directed that accidental releases be managed by ventilating the area and that containers be kept closed when not in use. Despite this, the Administrator stated she did not believe residents were at risk from inhalation of the adhesive vapors and reported no complaints during the renovation. The Plant Operations Manager stated that the hallway’s mechanical ventilation was considered sufficient and that exit doors on certain units should be opened if residents were uncomfortable, but these doors were not open at the time of observation. The deficiency also includes extensive obstruction of the means of egress throughout the facility during the renovation. NFPA 101, Life Safety Code, requires that means of egress be continuously maintained free of obstructions or impediments. On observation, the 400 hallway, where residents were living during renovation, had its egress path blocked by two trash cans, four beds, an armchair, three tables, a chair, three 4-gallon buckets, an industrial tile cutter, and piled boxes of wood flooring strips, while residents in wheelchairs navigated around these items. Additional egress routes were blocked in multiple areas: the Utility hallway by boxes containing wheelchairs and other items; the kitchen dock hallway by a tall food tray cart, cleaning supplies, and boxes, with double exit doors further blocked by a wood pallet and a cardboard box; and the Administration wing by numerous items including vacuums, furniture, housekeeping and floor machines, a hoyer lift, medical equipment, and stacked boxes, with an emergency exit door blocked by an oxygen cylinder, printers, and boxes. Other hallways outside resident rooms had egress paths blocked or encroached upon by unused utility carts, treatment carts, a mattress, a wheelchair, a medication cart, and service carts. A resident reported being told to leave his room for most of a day so flooring could be replaced and stated that the hallway items were present when he left his room, were moved out, and then brought back, and that the hallway had been like that for a while. The Administrator acknowledged that the Maintenance Department was responsible for maintaining the facility according to the Life Safety Code, and the Plant Operations Manager stated that means of egress should be maintained throughout the remodeling period and that staff should remove items stored within the egress paths.
Failure to Complete and Maintain Discharge Summaries for Discharged Residents
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to provide required discharge summaries for two of three sampled residents who were discharged. Record review of the admission/discharge report showed that Resident #1 was discharged on 01/07/26, but the resident’s medical record did not contain a discharge summary. Similarly, nursing progress notes for Resident #2 documented that this resident was discharged on 01/07/26, yet the resident’s medical record also lacked a discharge summary. During an interview on 01/14/26 at 10:12 a.m., the ADON confirmed that both residents did not have discharge summaries and stated that staff should have completed these summaries and that they should be present in the medical record. The deficiency centers on the inaction of facility staff in completing and placing discharge summaries into the medical records for these discharged residents, despite the facility’s expectation, as confirmed by the ADON, that such documentation be completed and maintained.
Some of the Latest Corrective Actions taken by Facilities in New Mexico
- Re-educated all licensed nurses on the wound care policy (K - F0686 - NM)
- Re-educated all licensed nurses on identification of wound progression (wound assessment/monitoring techniques) to recognize signs of wound decline or lack of progression (K - F0686 - NM)
- Re-educated all licensed nurses on correct documentation of completed wound care (K - F0686 - NM)
- Re-educated all licensed nurses on when/how to notify the provider for worsening wound status to ensure new orders were obtained as needed (K - F0686 - NM)
- Re-educated all licensed nurses on completing wound treatments exactly as ordered (K - F0686 - NM)
- Re-educated all licensed nurses on the zero-tolerance policy for falsifying documentation (K - F0686 - NM)
- Required nurses to complete wound-dressing competency related to completing wound dressings correctly (K - F0686 - NM)
- Implemented interim DON/designee competency observation prior to nurses performing wound care (K - F0686 - NM)
- Implemented interim DON/designee pre-shift education for agency nurses (K - F0686 - NM)
- Implemented ongoing weekly random reviews of five residents after the initial two-week audit period (K - F0686 - NM)
Failure to Follow Wound Care Orders and Monitor Pressure Ulcers Resulting in Worsening Wounds
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary treatment and services to prevent the development and worsening of pressure ulcers for two residents with wounds. One resident was admitted with a stage 2 coccyx pressure ulcer measuring 2.3 x 4.2 cm and had multiple risk factors, including type 2 diabetes mellitus, an unstageable pressure ulcer diagnosis, muscle wasting and atrophy, and severe protein-calorie malnutrition. The admission evaluation documented a sacral pressure sore and functional limitations requiring assistance with mobility and ADLs. The care plan identified a pressure ulcer and risk for further breakdown but did not include interventions such as a pressure-relieving mattress, wheelchair cushion, or specific repositioning requirements. Weekly wound reports for this resident showed inconsistent documentation, with missing weekly assessments and progression from deep tissue injury to unstageable status, along with changes in wound size and tissue characteristics. Physician orders for this resident’s coccyx wound changed over time, including orders for collagen dressings, calcium alginate, moisture barrier cream, and later Medihoney with calcium alginate, but the Treatment Administration Records showed missed wound care on multiple ordered days. Moisture barrier cream ordered every shift was only documented twice daily. Staff interviews revealed that a previous wound treatment nurse had been providing wound care treatments without provider orders and that on one occasion a nurse applied a dressing that was not in accordance with the physician’s order, changing to a dressing intended to be changed every three days. A corrective action memo documented that during wound rounds, the dressing found on the resident was not the ordered dressing, bore the initials and date of the nurse who changed it, and the wound was observed to have worsened. The family reported that the wound, initially the size of a quarter on admission, became larger, with blue discoloration around the sore and eventually the size of a business card, and that they were told the dressing orders had been changed so it would be changed less often to reduce pain. Further documentation for this resident showed that the NP expected orders to be followed and to be notified of wound changes but confirmed she had not been informed of the worsening wound. A nursing note recorded that the resident was discharged to the hospital due to the unstageable wound, and the hospital admission assessment described a large sacral decubitus ulcer, stage III or IV, and noted worsening from the previously documented stage II, quarter-sized wound at the prior hospital discharge. For the second resident, the care plan identified a pressure ulcer or risk related to a history of ulcers but contained no updated wound or treatment interventions. Progress notes documented coccyx redness and later a stage 3 coccyx pressure ulcer measuring 1 x 1 x 0.1 cm. Provider orders directed daily dressing changes with collagen and dry dressing, but the TAR showed wound care documented on only some days, and an observation of wound care revealed a dressing dated six days earlier, indicating that daily wound care had not been performed as ordered. The DON confirmed the dressing age and stated that the TAR entries for several days represented false documentation. The medical director stated he had not been notified that the wound was not improving and that he expected nursing staff, including the wound care nurse, to keep him informed of changes so he could monitor and direct wound care. The surveyors determined that these failures—missing and inconsistent wound assessments, failure to follow physician wound care orders, provision of wound treatments without orders, lack of appropriate care plan interventions, missed treatments, and inaccurate documentation—resulted in the worsening of pressure wounds for both residents. The facility was notified of a finding of Immediate Jeopardy related to these practices.
Removal Plan
- Assess and treat Resident #4 wound; ensure wound is improving.
- Notify the physician of inaccurate documentation.
- Suspend the charge nurse alleged to have falsified documentation pending investigation.
- Complete an audit of all residents with wounds to ensure all orders are carried out correctly; verify dressings are dated correctly and ordered treatments are in place.
- Re-educate all licensed nurses on the wound care policy.
- Re-educate all licensed nurses on identification of wound progression, including proper wound assessment and monitoring techniques to recognize signs of wound decline or lack of progression.
- Re-educate all licensed nurses on correct documentation of completed wound care.
- Re-educate all licensed nurses on when and how to notify the provider regarding worsening wound status to ensure new orders are obtained as needed.
- Re-educate all licensed nurses on completing wound treatments exactly as ordered.
- Re-educate all licensed nurses on the zero-tolerance policy for falsifying documentation.
- Require nurses to complete competency related to completing wound dressings correctly.
- Complete nurse re-education and competency observation by the interim DON or designee prior to nurses completing any wound care for residents.
- Educate agency nurses prior to their shift beginning by the interim DON or designee.
- Consult with the wound provider for consenting residents.
- Conduct weekly wound audits of current residents with wounds for two weeks, including wound assessment, documentation, notifications, and treatments.
- After the initial two weeks, select 5 random residents weekly for review.
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