ALBUQUERQUE, NM - Federal inspectors documented multiple violations at Las Palomas Center following a complaint investigation that revealed a resident sustained a third-degree burn from a heating pad and experienced inadequate wound care before being discharged in critical condition.
Third-Degree Burn Incident Goes Unreported to Physicians
The most serious violation involved a cognitively intact resident with end-stage renal disease who developed a severe third-degree burn on her lower back while using a heating pad in November 2024. The wound evaluation documented the burn as "minutes old and acquired in-house" with measurements of 6.64 centimeters in length, 4.2 centimeters in width, and covering an area of 15.95 square centimeters.
Documentation revealed that nursing staff discovered "Resident's skin was hot to touch with a heating pad under her" and noted the resident's "skin was thin and fragile" before removing the heating pad. The resident reported experiencing pain at a 7 out of 10 level during wound dressing changes.
Despite the severity of this facility-acquired injury, inspectors found no evidence that physicians were notified of the burn. The facility's Medical Director confirmed during interviews that she was never informed of the incident and stated she "expected the staff to report the wound to her, but she did not recall staff notifying her." The physician noted that treatment should have begun immediately and the wound should have been reported before it deteriorated further.
Systematic Failures in Wound Care Treatment Administration
Beyond the burn incident, inspectors identified widespread failures in wound care for pressure ulcers present on the resident's heels and ankles upon admission. The facility failed to ensure ordered wound treatments were actually administered to residents, with documentation showing multiple instances where treatment orders existed but no evidence of actual care delivery.
The resident arrived at the facility with two Stage 1 pressure ulcers and one Stage 4 pressure ulcer, requiring specialized wound care protocols. However, medication and treatment administration records consistently lacked documentation that ordered wound care was provided. This pattern continued throughout the resident's stay, with orders dated November 13, November 28, and December 4 showing no corresponding evidence of treatment administration.
The Skin Health Team Lead explained the documentation gap occurred because wound care orders were incorrectly entered into an auxiliary system rather than the Treatment Administration Record, preventing nursing staff from knowing treatments were required. As a result, "there was not any evidence that staff completed wound treatments" between the weekly skin assessments.
Medical Consequences and Deteriorating Condition
The failure to provide adequate wound care had serious medical implications. The third-degree burn showed signs of infection by December 4, with documentation noting "increased drainage, increased pain" and "moderate serosanguineous exudate with faint odor." The wound had expanded to 18.24 square centimeters and developed 20 percent slough tissue, indicating deteriorating condition.
Third-degree burns require immediate and consistent medical intervention to prevent complications. These injuries destroy all layers of skin and underlying tissue, making patients vulnerable to infection, sepsis, and prolonged healing times. When burns develop signs of infection - including increased drainage, odor, and pain - immediate medical attention becomes critical to prevent systemic complications.
The resident's daughter described her mother's declining condition during the final days at the facility, noting her mother "looked horrible and was sweating" on discharge day and was "in an unusual amount of pain." The daughter reported her mother was "not mentally herself, and her back was covered with sweat" during the transfer process.
The resident was discharged to an assisted living facility on December 9 despite the deteriorating wound condition. Within 24 hours, she was sent to the emergency room with septic shock, characterized by racing heart rhythm, low blood pressure, and incoherence. She died in the hospital eight days later.
Industry Standards for Wound Care Management
Healthcare facilities are required to implement comprehensive wound care protocols that include regular assessment, appropriate treatment interventions, and physician notification for facility-acquired injuries. Standard practice requires immediate physician notification when residents develop burns or other injuries while in care, particularly for vulnerable populations with conditions like end-stage renal disease.
Proper wound care protocols mandate that treatment orders be accurately documented in medication administration systems to ensure nursing staff can access and implement required interventions. Regular wound assessments should track healing progress, and any signs of deterioration or infection require immediate medical evaluation and potential treatment modifications.
The Centers for Medicare & Medicaid Services requires facilities to provide necessary care and services to promote healing and prevent new pressure ulcers from developing. This includes ensuring all ordered treatments are administered and documented appropriately.
Missing Physician Documentation Affects Multiple Residents
The inspection also revealed systemic issues with physician documentation affecting eight residents whose care was managed by an outside senior service agency. Despite weekly physician visits, electronic medical records contained no progress notes documenting these encounters for any of the eight residents over a six-month period.
Federal regulations require physicians to provide written, signed, and dated progress notes after each resident visit to ensure continuity of care and proper medical oversight. The Director of Nursing acknowledged that the senior service agency "seldom provided written, signed, dated progress notes of these visits" despite conducting frequent resident evaluations.
This documentation gap affects the facility's ability to coordinate care and ensure residents receive appropriate medical oversight. Without proper physician documentation, nursing staff may lack critical information about treatment plans, medication changes, or evolving medical conditions.
Medication Safety Concerns
Inspectors documented a significant medication error involving a resident receiving end-of-life care. The facility administered 47 doses of morphine at five times the intended strength before discovering the error. The resident received 26 milligrams per dose instead of the prescribed 5.2 milligrams, resulting in dangerous vital signs including blood pressure of 80/51 and oxygen saturation of 61 percent.
The error occurred when the pharmacy supplied morphine in a different concentration than ordered, and facility staff failed to verify the medication matched the prescription. This represents a fundamental breakdown in medication safety protocols, which require verification of the correct drug, dose, route, time, and patient before each administration.
Additional Issues Identified
Inspectors found several other violations including kitchen staff preparing and serving food without required hairnets during lunch service, potentially affecting food safety for all residents. The facility also lacked systematic processes for ensuring timely physician communication and response.
The investigation revealed broader administrative challenges in ensuring effective use of resources and maintaining proper oversight of care delivery systems. These issues combined to create an environment where resident safety and quality care were compromised through multiple system failures.
The violations represent serious gaps in fundamental nursing home operations that directly impacted resident health and safety outcomes.
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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