RIO RANCHO, NM- RIO RANCHO CENTER

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, observation, and interview, the facility failed to ensure that residents receive the necessary treatment and services to promote healing of pressure ulcers (skin damage which results from unrelieved pressure on the body) for 2 ( R #42 and #113) of 2 (R #42 and #113) residents reviewed, by not identifying and beginning treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice is likely to result in residents’ pressure ulcers not healing and/or getting worse.

The findings are: Resident #42 A. Record review of R #42’s face sheet revealed she was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .
B. Record review of R #42’s daily care notes revealed the following:
09/17/21 A skin check was performed. No skin injury/wounds were noted.
09/22/21 Has a small open skin area to the left side of her buttock, tender to touch.
09/26/21 Wound dressing changed to left buttock/sacral area, wound has increased in size since noted by this nurse on 09/23/21, Tx (treatment) per order.
C. Record review of R #42’s physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .
D. Record review of R #42’s Treatment Administration Record dated 09/28/21 revealed that no wound care had been documented on or before 09/28/21.

On 09/29/21 at 1:30 pm during interview with Registered Nurse (RN) #2, he stated that he was the nurse assigned to monitor wound care for the facility. He stated that he was aware of R #42’s sacral wound. He stated that he had observed the wound and stated that it was small in size, was skin deep with minimal fluid accumulation. RN #2 reviewed the daily care notes and confirmed that the notes were correct and that R #42’s wound had been identified on 09/22/21 and that treatment should have commenced (start) immediately. He also stated the providing physician should have been notified of the new wound immediately. He stated that initial treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . He confirmed there was no indication this had occurred prior to 09/26/21.

Findings for R #113:
F. Record review of R #113’s care plan dated 05/24/21 revealed, Focus- Resident is at risk for skin
breakdown: d/t (due to) hx (history) of vascular ulcers to right foot and left heel. Interventions Observe skin condition daily with ADL (Activities of Daily Living) care and report abnormalities, and Weekly skin check by license nurse.

On 09/28/21 at 10:30 am during an interview with the Nurse Practitioner (NP), she stated, Their [facility] staffing is terrible and the person that does wound care is often pulled to the [nursing] floor. They [nursing] should be doing a weekly skin assessment. They [nursing] should be doing a weekly skin assessment at the bare minimum.

On 09/28/21 at 2:48 pm during an interview with the Director of Nursing (DON), she stated, He [R #113] should have regular skin checks. DON confirmed R #113 did receive weekly skin assessments between 08/21/21 and 09/18/21, and should have been been receiving weekly skin assessments.