SANTA FE, NM - State health inspectors discovered that Casa Real nursing home failed to properly monitor, document and notify medical providers about a resident's pressure wound on his tailbone, leading to worsening of the condition that caused significant pain when the resident was later hospitalized.
Critical Pressure Wound Management Failures
During a March 2025 investigation, inspectors found that facility staff at Casa Real on Galisteo Street failed to provide appropriate wound care for a resident identified as R #3, who developed a stage two pressure ulcer on his coccyx (tailbone) area. The wound was first documented on July 3, 2024, but staff never measured the wound and failed to track its progression over the following month.
Despite nursing staff applying barrier cream to the wound 58 times out of 62 scheduled treatments between July 3 and July 31, indicating clear awareness of the pressure injury, the facility's Skin Health Lead failed to document the wound in weekly evaluations. Only one initial notation appeared in records, with no follow-up measurements or monitoring documented in the subsequent five weekly assessments.
The severity of this oversight became apparent when the resident was transferred to the hospital on August 5, 2024. Hospital staff discovered what they described as a "large" stage two pressure ulcer on the resident's coccyx. The resident's brother told investigators that his brother "would cry out in pain" from the wound while hospitalized, and that he had never been informed by the facility about the pressure injury's existence.
Medical Implications of Inadequate Wound Monitoring
Pressure ulcers develop when sustained pressure restricts blood flow to skin and underlying tissues, causing tissue damage and death. Stage two ulcers involve partial-thickness skin loss with exposed dermis - essentially an open wound that requires careful monitoring and treatment to prevent progression to deeper, more dangerous stages.
Proper wound care protocol requires precise measurement and weekly documentation of all pressure injuries to track whether wounds are healing, remaining stable, or deteriorating. Without measurements, healthcare providers cannot determine if treatment interventions are effective or if more aggressive care is needed. This monitoring becomes especially critical for tailbone wounds, as this area experiences constant pressure when residents are seated or lying on their backs.
The failure to document wound dimensions meant that neither the facility's nurse practitioner nor the resident's family could make informed decisions about care. The nurse practitioner confirmed to investigators she was never notified about the coccyx pressure ulcer and "did not know that R #3 had a pressure ulcer on his coccyx."
Communication Breakdowns Compound Care Failures
Beyond the documentation failures, the investigation revealed significant lapses in required notifications. Federal regulations mandate that facilities immediately notify both medical providers and family members or legal representatives when new pressure wounds develop.
The facility's Skin Health Lead admitted she "could not remember" if she contacted the resident's power of attorney about the new wound discovered on July 3. She also couldn't recall notifying any medical provider. Both the facility's Unit Manager and Director of Nursing confirmed these notifications should have occurred immediately but did not.
This communication failure persisted even after the resident's hospitalization. When the resident's brother contacted the facility administrator after learning about the large pressure wound from hospital staff, the administrator incorrectly told him that his brother did not have a coccyx pressure ulcer prior to hospitalization - contradicting the facility's own documentation and staff testimony.
Additional Issues Identified
Inspectors also documented failures in maintaining accurate shower and hygiene records for another resident. Review of shower documentation for resident R #1 revealed:
- January 2025: Only 7 of 21 scheduled showers documented with no refusals recorded - February 2025: Only 5 of 23 scheduled showers documented - March 2025: Only 9 of 31 scheduled showers documented
Accurate hygiene documentation is essential for monitoring skin integrity, as regular bathing helps prevent skin breakdown and allows staff to identify developing skin issues early. The Director of Nursing confirmed shower documentation "should be completed and documented at all times."
The facility's quality control systems failed to identify these documentation gaps despite their potential impact on resident care and regulatory compliance.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa Real from 2025-03-27 including all violations, facility responses, and corrective action plans.
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