cms_NM: 5641
Data source: Big Local News · About: big-local-datasette
rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
5641 | CASA REAL | 325038 | 1650 GALISTEO STREET | SANTA FE | NM | 87505 | 2010-11-16 | 225 | G | 8PRQ11 | Based on record review and interviews, the facility failed to investigate, immediately report and do a follow-up investigation for 1 of 6 sampled residents (#1) who sustained a dislocated hip (injury of unknown origin). This injury resulted in Resident #1 having to go to the emergency room (ER) for treatment. This deficient practice had the potential to affect 117 residents who resided at the facility. The findings are: A. On 11/16/10 at 9:45 am, during an interview, Resident #1's granddaughter stated that when she visited the resident on 07/10/10, she could hear her grandfather yelling as she walked down the hallway. When she entered his room she stated, "He was in bed and his left foot was turned out." She asked the staff if he had fallen and they told her no. She asked for her grandfather to be transported to the emergency room (ER) to be evaluated. She stated at the ER, hospital staff told her that Resident #1 had a dislocated hip and "it had to be popped back into place." B. On 11/16/10, review of Resident #1's chart revealed a nurse's note dated 07/10/10 at 2:30 pm. The note indicated, "Resident's son and granddaughter into visit with him. Per son 'he's C/O (complaining of) pain to his hip & it looks twisted.' Went to assess resident's L (left) leg/hip appears out of place. Touched leg/foot, resident states 'it hurts too much don't move it.'" The signature on the note belonged to Licensed Practical Nurse #1, who no longer works at the facility. C. On 11/16/10 at 1:10 pm, during an interview, the Director of Nursing (DON) stated, "I don't remember being told anything about this incident." D. On 11/16/10 at 2:05 pm, during an interview, the Administrator stated, "I'm the abuse coordinator for the building and this is a reportable incident but it was not reported to me." The Administrator confirmed that they failed to investigate, report, and do a follow-up investigation. E. On 11/16/10 at 3:05 pm, during an interview, Certified Nursing Assistant #1 stated, "The resident was on a low bed, had a tabs alarm with a fall mat and was always on the floor and never wanted to be in the bed, and that is all I know." F. On 11/16/10 at 4:30 pm, during an interview, Physical Therapist #1 stated, "When the resident first came into the facility we were walking him and after he went to the ER he was placed on bedrest." | 2014-03-01 |