Inspection Findings Report

Aztec Healthcare

Aztec, NM • CMS ID: 325071

Report Summary

34 Findings Documented

Jan 2022 - Jan 2026 Date Range

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, record review, and interview the facility failed to have the Interdisciplinary Team (IDT) (a facility team composed of various professionals who review and determine resident needs and abilities) determine if residents could self-administer medication for one (R #73) of one (R #73) random residents sampled. This deficient practice is likely to result in residents self-administering medication inappropriately or incorrectly causing harm. The findings are:
A.
On 01/04/22 at 11:36 am during observation and interview of R #73, he was observed lying in bed in his room. Next to his bed was a side table with drawers. R #73 asked that he be given his inhalers (prescribed medical devices used to relieve difficulty breathing). Upon opening the drawer, three inhalers were observed in the drawer-both were labeled with the name of the medication on the inhaler and R #73's name.
B.
Record review of R #73's face sheet printed 01/06/22 revealed he was admitted to the facility on [DATE] with multiple diagnoses including but not limited to Chronic Respiratory Failure (difficulty breathing) with hypoxia (a drop in the measured oxygen content of the blood), unspecified dementia (decline and change in mental capacity and memory).
C.
Record review of R #73's Minimum Data Set (a thorough assessment of resident skills and abilities) (MDS) Section C (measurement of resident mental status) dated 12/20/21 revealed a Brief Interview for Mental Status (a brief assessment of a resident memory retention) (BIMS) score of 13 (0-15 with 15 being normal memory recall)
D.
Record review of R #73's physician orders dated 12/18/21 revealed orders to administer inhalers as needed. The orders did not include R #73 having his inhalers at bedside or self administering the medications.
E.
Record review of R #73's care plan initiated 12/19/21 did not indicate any plan for R #73 to self administer any medications or inhalers.
F.
On 01/05/22 at 9:55 am during interview with Licensed Practical Nurse (LPN) #1, she confirmed that some residents were keeping inhalers at their bedside. She stated that she was told that, per the prescribing physician, residents who utilized inhalers were allowed to keep their inhalers with them and self administer as needed.
G.
On 01/05/22 at 11:20 am during interview with the Director of Nursing (DON) she reviewed R#73's medical record including physician orders, daily care notes and IDT meetings and confirmed that there was no physician order or IDT team assessment that would allow R #73 to self administer medications. She further stated that the process would be a review and assessment of the self administration of medications which would be included in the nursing assessment to determine if the resident would be allowed to self administer his/her own medications.

Event ID: 5XE111

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Source: All findings sourced from official CMS Nursing Home Inspect records via ProPublica. This report presents factual government inspection data without ratings or recommendations.