GALLUP, NM – MCKINLEY CENTER

This is a repeat deficiency from a survey completed on [DATE].

The facility failed to provide the necessary treatment to residents with pressure ulcers (an injury to skin and underlying tissue resulting from prolonged pressure on the skin) to promote wound healing and the prevention of infection for 4 (R #1, 2, 3, and 6) of 6 (R #1, 2, 3, 4, 5 and 6) residents who were reviewed for receiving wound care for pressure ulcers, in which one of the resident was hospitalized [MEDICAL CONDITION] (infection in the blood stream), expiring in the hospital. This was indicated by:

Nursing staff not following physician’s orders [REDACTED].

Nursing staff were unable to complete the wound care treatments on their shift;

Nursing staff not notifying the physician of the resident’s symptoms that included: an increased temperature, a low blood pressure and having a wound odor; providing the physician with the resident’s assessment, to make a medical decision of possibly ordering an antibiotic (medication used to treat an infection).

Nursing staff providing the same wound care treatment for [REDACTED].

Wounds not being evaluated to identify progress or decline and appropriate communications with the physician(s);

Nursing staff not following standards of practice for wound care by not documenting on the dressings as to the time, date and initials as to when the dressing was changed last;

Nursing staff not providing wound treatments completed as ordered and wound care treatments not being documented in the Treatment Administration Record (TAR) and validated wound treatments thru observations or visualization of the wound and wound dressings.

The facility failed to provide the necessary treatment and services to prevent the development of pressure ulcers for residents in which a resident was not recognized as having an infection, likely resulted in for an unknown period of time, resulting in the resident becoming septic (having an infection in the blood), being hospitalized , and eventually contributing to the resident’s death. This deficient practice resulted in an

Immediate Jeopardy (IJ) at a scope and severity of K being identified on [DATE]. The facility was notified on [DATE] at 5:55 pm.

Record review of R #1’s the physician’s Discharge Summary from the local hospital, dated [DATE], revealed the following: .R #1 having an infection for an unknown period of time, causing R #1 to become septic (having an infection in the blood), resulting in being hospitalized , and eventually contributing to (name of R #1) death.

On [DATE] at 3:04 pm, during an interview, the Interim CNE (Certified Nursing Executive, a Graduate Nurse (GN)) stated, the wound care could have been better, and that the wound care was not getting done as often as it should have. He further stated that the nursing staff depend on the treatment nurses too much and she isn’t always here to do it. The CNE confirmed that there was a smell in the room, that was either coming from R #1 or R #2. He did remember while he was walking down the hall and you could smell something, he wasn’t sure if it was every day or every other day. He stated that this was a concern. The CNE stated that he was not sure why if the room smelled for days and days and no one knew exactly which resident the smell was coming from, or if it was a wound or the wound vac (vacuum) for R #2; why nothing was done sooner. The CNE stated that it was likely due to the smell, that the wound for R #1 was cultured. He stated that he did remember speaking with R #1’s daughter and that she was not happy with the care her mother received.