ALBUQUERQUE, NM – AVAMERE REHABILITATION AT FIESTA PARK

Based on record review and interview the facility failed to ensure 1 (R#1) of 5 (R #1, 2, 3, 4 and 5) residents who were reviewed for receiving wound care and treatment was free from neglect, when the facility delayed providing wound care and treatment for 11 days, between which new multiple pressure wounds were identified by the hospice nurse and from when new orders for treatment were initiated. This deficient practice likely resulted in worsening pressure wounds for R #1.

Record review of Hospice Care Nurse (HCN) #1 narrative dated 04/03/20 reveals that HCN#1 arrived at the facility and found R#1 in bed: . Patient (R#1) was found to have significant breakdown on his body (referring to an unidentified pressure ulcer). Patient (R#1) brief (Adult diaper) was on so tight there was breakdown along the waist line. Patient has a very large Stage Two pressure ulcer (a shallow, partial thickness, skin rupture that does not penetrate to the fatty tissue below the surface) to sacrum/coccyx (lower back just above the buttocks). Patient has feces caked on his bottom. (Name of hospice aide) and myself cleansed area thoroughly. Seal barrier cream was placed. Patient has 3 stage 1 pressure ulcers to his back. R (right) fifth rib has an area where blood has pooled due to patient not being turned .I (HCN#1) notified (first name only of Facility Nurse) FN#1 of patients poor skin conditions.

DON stated that both the hospice nurses and the staff nurse should have reported the identified wound on 04/03/20 and treatment should have begun immediately. She also confirmed that any such order for care should have been entered by either the hospice nurse DON confirmed that no physician orders were entered until 04/14/20 and there appears to have been on treatment of [REDACTED].