cms_NM: 64

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

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rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
64 SANDIA RIDGE CENTER 325032 2216 LESTER DRIVE NE ALBUQUERQUE NM 87112 2017-03-20 279 G 0 1 30NH11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and revise comprehensive care plans with individualized goals and interventions for 2 (R #s 57 and 128) of 2 (R #s 57 and 128) residents reviewed for care plan issues. After R #128 sustained a fall which resulted in a [MEDICAL CONDITION], the facility failed to update his care plan and did not create any new interventions to prevent future falls, which resulted in the resident falling 2 more times acquiring multiple skin tears and another [MEDICAL CONDITION]. This deficient practice resulted in staff failing to identify and create new interventions that were necessary to prevent avoidable falls which resulted in serious injury to R #128. The findings are: Findings related to R #57: [NAME] Record review of R #57's electronic record revealed he was admitted to the facility on [DATE]. B. Record review of R #57's current care plan dated [DATE] revealed only 2 entries: one related to pain inititated on [DATE] and one related to [MEDICAL CONDITION] drugs (drugs that change brain function and results in alterations in perception, mood, or consciousness) initiated on [DATE]. C. On [DATE] at 2:36 pm, during an interview with the MDS (Minimum Data Set) Coordinator, she stated that back on [DATE] an MDS (Minimum Data Set) Asssessment was accidentally submitted that indicated the resident had died . She stated the mistake was corrected the same day however the error caused R #57's care plan to be deleted from his eletronic record. The MDS Coordinator stated she would have to contact the IT (Information Technology) department to see if they can recover his full care plan. D. On [DATE] at 11:51 am, during an interview with the Administrator, she verified that R #57's care plan was accidentally deleted and that none of the staff had access to it from [DATE] up until today ([DATE]). Findings related to R #128: E. Record review of R #128's Nurse's Note dated [DATE] stated, This day an Agency nurse worked on hall 500. Reported that resident was found on the floor at 7am during breakfast, lying down and a pillow on the back of his head. Nurse stated that assessed resident and was in pain. (Name of Nurse Practitioner) was informed and assessed Resident and gave new orders to transport resident to the ER (emergency room ) for evaluation. Efforts to reach the nurse for pertinent details fruitless. F. Record review of R #128's Nurse's Note dated [DATE] stated, Resident was re-admitted [DATE] from the hospital due to a hip fx (fracture). [NAME] Record review of the facility's investigative report regarding R #128's incident on [DATE] concluded by saying, His care plan has been updated with new fall interventions. H. Record review of the Fall Risk Assessment portion of R #128's Nursing assessment dated [DATE] indicated he scored of 19.0 which was considered High Risk for falls. I. Record review of R #128's Nurse's Note dated [DATE] stated, Resident self-reported to me @ around 1500, that he had tripped in his room; time unknown. He sustained 2 skin tears; one to his left outer elbow and one to his left knee. [NAME] Record review of the facility's RMS (Risk Management System) Event Summary Report regarding R #128's fall on [DATE] stated Preventative measures in place prior to fall: n/a. The report also stated Interventions added immediately after fall and care plan updated: VS (vital signs) taken; woundcare. K. Record review of R #128's Nurse's Note dated [DATE] stated, Received call back from on call (Name of on call physician) for Radiology Report on (Name of R #128). Results is right intertrochanteric fracture ([MEDICAL CONDITION]) with minimal displacement. keep patient comfortable and let (Name of R #128's physician) know in the morning. message was left for family member during day shift. No call back. L. Record review of the facility Follow-up Summary of R #128's incident on [DATE] revealed The resident did have a surgical repair of his hip and has returned back to the center. Although the center could not conclude the causation of the fracture, it is possible the resident fell in his room and got himself back up. Per the hospital records, the ortho (orthopedic, the branch of medicine dealing with the correction of deformities of bones or muscles) notes stated his fracture was acute and was probably due to a fall as they found a laceration (a deep cut or tear in skin or flesh) to his scalp. M. Record review of R #128's History and Physical completed by his physician on [DATE] indicated his past medical history of [REDACTED]. It also indicated his subsequent surgeries related to those fractures: Left Hip ORIF (An Open Reduction Internal Fixation surgery which involves realigning the bone or joint and then using steel rods, screws and/or plates to keep the fracture stable.) (MONTH) (YEAR), Right Hip ORIF (MONTH) 16, (YEAR). N. Record review of R #128's care plan revealed he did not have a focus related to fall prevention or any fall related interventions prior to [DATE]. O. On [DATE] at 2:53 pm, during an interview with Licensed Practical Nurse (LPN) #4, she stated R #128 did not have a fall when he was on the 100 unit in (MONTH) (YEAR). She stated he complained of pain and was eventually sent out for an x-ray which confirmed a [MEDICAL CONDITION] however since nobody saw him fall she stated she did not consider that he fell . LPN #4 stated R #128 was unsteady on his feet but did not consider him to be a fall risk. She also stated she was not sure whether R #128 had any interventions in place related to fall prevention. P. On [DATE] at 3:33 pm, during an interview with the Director of Nurses (DON), he stated that a resident is considered a fall risk after they have their first fall. The DON verified that R #128's first fall at the facility occurred on [DATE] which resulted in his left hip being fractured. The DON stated that after a fall, the resident's care plan should be updated with new interventions added to prevent future falls. The DON failed to provide an updated care plan for R #128 after his fall on [DATE] and after his fall on [DATE] which resulted in 2 skin tears. Q. On [DATE] at 8:47 am, during an interview with the Administrator, she verified that R #128 did not have his care plan updated after his fall on [DATE] or after his fall on [DATE]. She verified that his care plan was not updated until [DATE] after his fall on [DATE]. The Administrator was unable to provide an answer as to what interventions were in place to prevent R #128's second and third falls. 2020-09-01