ALBUQUERQUE, NM - Las Palomas Center faces multiple federal violations following an inspection that revealed a third-degree burn incident caused by improper heating pad use, along with failures in medical communication and reporting procedures that may have contributed to a resident's death.
Heating Pad Burn Results in Third-Degree Injury
The most serious violation centered on a resident who sustained a significant third-degree burn on November 28, 2024, while using a heating pad at the facility. The burn, measuring 6.64 centimeters in length and 4.2 centimeters in width, was located on the resident's sacrum and was classified as "acquired in-house," meaning it occurred at the facility.
According to wound evaluation records, nursing staff found "the resident's skin was hot to touch with a heating pad under her" and noted that "the resident's skin was thin and fragile." The heating pad was immediately removed, and the resident was educated about the risks involved in using such devices. However, the resident reported experiencing pain at a level of 7 out of 10 during wound dressing changes.
Third-degree burns represent the most severe type of thermal injury, affecting all layers of skin including the dermis and potentially extending into underlying tissues. These burns typically require specialized medical treatment and close monitoring for complications such as infection. The fact that this injury occurred from a heating pad highlights significant safety protocol failures, as medical facilities typically restrict or carefully monitor the use of heating devices due to the risk of thermal injury, particularly among elderly residents with fragile skin conditions.
Communication Breakdown Delays Critical Medical Response
Perhaps more concerning than the burn itself was the facility's failure to promptly notify the resident's physician about the serious injury. Medical records revealed no documentation that staff informed the resident's doctor of the third-degree burn, despite facility protocols requiring physician notification for significant changes in resident condition.
When the facility's Medical Director reviewed the case during the inspection, she emphasized the critical nature of this communication failure. "She stated she would expect staff to notify her of the wound," the Medical Director told inspectors, adding that "she still wanted to be notified of the wound" even though wound care nurses typically handled treatment decisions.
This breakdown in communication became more critical as the wound showed signs of deterioration. By December 4, 2024, wound evaluations documented evidence of infection with increased drainage and pain, along with moderate discharge that developed a faint odor. The wound area had also expanded to 18.24 square centimeters, indicating worsening of the condition.
Professional medical standards require immediate physician notification for serious injuries like third-degree burns. These injuries carry significant risks of infection, sepsis, and other life-threatening complications that require prompt medical intervention and close monitoring. The delay in notifying the attending physician potentially compromised the resident's treatment options and recovery prospects.
Progression to Septic Shock and Death
The situation deteriorated rapidly in early December 2024. The resident's daughter, who visited daily, noticed concerning changes in her mother's condition. On December 4, the wound care nurse expressed concerns about the wound's appearance, describing it as "turning green" and sending photographs to the family.
"The wound nurse took a picture and sent it to her and told her she would send the picture to the doctor," the daughter reported. "She stated it had been four days since she saw her mother and it looked a lot worse than the last time she saw the wound."
By December 9, when the resident was scheduled for discharge, family members observed alarming symptoms. The daughter described her mother as appearing "horrible and was sweating" with staff unable to explain the profuse sweating. The resident experienced severe pain during transfers and displayed confusion and agitation - potential early signs of systemic infection.
The resident was transported to an assisted living facility but was sent to dialysis the following day. The dialysis center immediately transferred her to the emergency room due to an extremely low heart rate. She was subsequently diagnosed with septic shock - a life-threatening condition characterized by severe infection leading to dangerously low blood pressure and organ dysfunction.
Septic shock represents the most severe stage of sepsis, with mortality rates ranging from 28-50% even with aggressive treatment. The condition occurs when bacterial infections spread throughout the bloodstream, triggering widespread inflammation that can rapidly lead to multiple organ failure. Early recognition and treatment are crucial for survival, making the communication delays and oversight failures particularly significant in this case.
Medical Provider Fails to Properly Examine Wound
Adding to the concerning pattern of care was the failure of the nurse practitioner to physically examine the infected wound before prescribing treatment. On December 6, the nurse practitioner was notified by wound care staff about the burn's deteriorating condition, including odor and greenish discharge - classic signs of bacterial infection.
However, the nurse practitioner documented being "unable to reposition the resident at the time of the encounter in order to examine the resident's back" due to the resident's dementia and positioning difficulties. Despite this limitation, the practitioner prescribed silver sulfadiazine cream, an antibiotic treatment typically used for serious burn infections.
The facility's Medical Director strongly criticized this approach during the inspection, stating "she expected the NP to give the resident some pain medication and look at the wound" and emphasizing that "the NP should not have prescribed a treatment without looking at the wound." She concluded that "it was not acceptable to treat the wound without looking at it."
Standard medical practice requires direct visualization and assessment of wounds, particularly infected ones, before prescribing treatment. Visual inspection allows healthcare providers to assess the extent of infection, determine appropriate treatment intensity, and identify signs of deeper tissue involvement or systemic complications. Prescribing antibiotics without proper examination can lead to inadequate treatment of serious infections.
Additional Issues Identified
The inspection revealed several other concerning violations:
Inadequate Reporting Systems: The facility failed to submit required 5-day follow-up investigation reports to the State Survey Agency for 26 separate incidents, including allegations of abuse, neglect, and injuries. Some reports were delayed by months, with one incident from October 2024 not submitted until January 2025.
Environmental Safety Concerns: Inspectors found bags of soiled linens left on the floor outside resident rooms, creating unsanitary conditions and potential infection control hazards. Staff confirmed that soiled linens should be properly disposed of in designated biohazard areas, not left in resident living areas.
Assessment Documentation Issues: The facility demonstrated failures in maintaining accurate resident assessments, which are crucial for developing appropriate care plans and identifying potential health risks.
Following identification of immediate jeopardy conditions, the facility implemented corrective measures including comprehensive audits of electrical devices, enhanced staff education on wound care protocols, and improved communication procedures for medical condition changes. However, the tragic outcome in this case underscores the critical importance of proper safety protocols, timely medical communication, and thorough wound assessment in nursing home care.
The case highlights how multiple system failures - from inadequate device safety protocols to poor medical communication - can combine to create life-threatening situations for vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Palomas Center from 2025-04-03 including all violations, facility responses, and corrective action plans.
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