Rehabilitation Hospital of Southern New Mexico,inc

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 53401 Based on record review and interview the facility failed to meet the Condition of Participation to ensure that nursing services were provided per facility procedure. This deficient practice can lead to compromised patient safety, inconsistent delivery of care, increased risk for patient harm, and non-compliance with federal regulatory requirements. The findings are: A. Refer to Tag A-0398 B. Refer to Tag A-0405”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 53401 Based on record review and interviews, the facility failed to ensure patients feel comfortable filing a complaint for 1(P[patient] P3) out of 4 (P1, P3, P6, P7) patients interviewed. This deficient practice could possibly lead to patients receiving care without adequate knowledge and understanding of their right to file a complaint or grievance, placing the facility out of compliance with patient rights regulations. The findings are: A. Record review of the facility’s document titled “Patients’ Rights” dated 02/2025 stated in the third paragraph “ ...patients and families are provided information on admission regarding the facility’s complaints/grievance process, including who to contact within the facility to file a complaint/grievance.” B. During an interview on 01/15/26 with S(Staff)4, Clinical, when asked how she would handle a patient complaint, S4 verbalized appropriate steps to resolve a complaint and escalating if not promptly resolved. However, no mention was made that the nurse would provide the patient with additional information on how the patient can file a grievance and no reassurance to the patient to make them feel comfortable filing a grievance. C. During an interview on 01/14/26 at 3:10 pm with P3 stated he did not know who to contact if he decided to file a complaint as he felt his concerns about his diabetes were still not adequately addressed. However, P3 stated he was hesitant to file a complaint as he did not want to be treated differently by staff.”

“PATIENT RIGHTS: GRIEVANCE PROCEDURES CFR(s): 482.13(a)(2)(i) [At a minimum:] The hospital must establish a clearly explained procedure for the submission of a patient’s written or verbal grievance to the hospital. This Standard is not met as evidenced by: 53401 Based on record review and interviews, the facility failed to ensure patients are informed about the procedure of filing a complaint or grievance for 1(P[patient] P3) out of 4 (P1, P3, P6, and P7) patients interviewed. The patient interviewed reported not knowing how to file a complaint. This deficient practice could possibly lead to patients receiving care without adequate understanding of the procedure to file a complaint or grievance, placing the facility out of compliance with patient rights regulations. The findings are: A. Record review of the facility’s document titled “Patient’s Rights” dated 02/25, stated in the third paragraph that “ ...patients and families are provided information on admission regarding the facility’s complaints/grievance process, including who to contact within the facility to file a complaint/grievance” B. During an interview on 01/14/2026 at 3:10 pm with P3 stated he did not know who to contact if he decided to file a grievance. Furthermore, P3 stated he was hesitant to file a grievance as he did not want to be treated differently by staff.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 53401 Based on record reviews and interviews, the facility failed to ensure medication reconciliation was completed by the facility as per policy for 1(P[patient]3) out of 1(P3) patient reviewed for medication reconciliation. This deficient practice has the potential to affect patient safety and lead to preventable patient harm. The findings are: A. Record review of P3’s medical record for admission date of 01/12/26, with admitting diagnosis of SCI (Spinal Cord Injury) incomplete. Past medical history of Type 1 Diabetes with use of insulin pump. Document dated 1/15/26, titled, “order listing report” no physician’s orders are present for capillary glucose checks or insulin for day of admission of 1/12/2026. B. Record review of P3’s medical record for admission date of 01/12/26, titled, “Scheduled: Medication/ History” dated 01/15/26 Insulin is not listed for 01/12/26. C. Record review of P3’s medical record for admission date of 01/12/26, document dated 1/12/26, titled “Notes- Consultation Note (General)” under Impression/Plan section of the consultation note, written by a physician, it reads, “type 1 diabetes mellitus patient on insulin pump at home ...I will monitor blood sugars and adjust insulin accordingly.” D. Record review of the facility’s policy titled “Medication reconciliation” dated 02/2023, stated under section II (1). “At the time of admission, a complete list of medications that the patient was taking at home prior to hospitalization and at the time of transfer is obtained and documented ... The most complete and accurate list is created utilizing a variety sources that may include, but not be limited to the patient, family ...” E. During an interview on 01/15/26 at 1:05 pm with S1(staff) confirmed an order for capillary glucose checks should have been obtained upon the patient’s admission. F. During an interview on 01/14/26 at 3:10 pm with P3 stated he explained to his nurse he is a type one diabetic and management for his diabetes is different. P3 also stated he asked his nurse multiple times about checking his blood sugars, but the nurse replied, they didn’t have an order.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 53401 Based on record reviews, observation and interviews, the facility failed to ensure medications, specifically insulin (a medication that is essential for type 1 diabetics because their pancreas does not produce it) were ordered in a timely fashion as per the facility’s medication reconciliation policy for 1(P[patient]3) out of 1(P3) patient reviewed for medication reconciliation. This deficient practice has the potential to lead to delays in obtaining medication orders and places patients at risk for poor outcomes. The findings are: A. Record review of the facility’s policy titled “Medication reconciliation” dated 02/2023 stated under section II (1). “At the time of admission, a complete list of medications that the patient was taking at home prior to hospitalization and at the time of transfer is obtained and documented ... The most complete and accurate list is created utilizing a variety sources that may include, but not be limited to the patient, family ...” B. Record review of P3’s medical record for admission date of 01/12/26, document dated 01/12/26, titled “Notes- Consultation Note (General)” under Impression/Plan section of note it reads, “type 1 diabetes mellitus patient on insulin pump at home ...I will monitor blood sugars and adjust insulin accordingly.” C. Record review of P3’s medical record for admission date of 01/12/26, under document titled “Physician’s Order” Insulin orders are first documented on 01/13/26. The insulin order with date of 01/13/26, reads,”Insulin regular 1 unit/ 0.01ml (HumuLin R/ NovoLin R) Inject 16 unit (0.16 mL) subcutaneously Before Meals.” Insulin order for 01/13/26, reads, “Insulin Glargine-Yfgn 1 unit/0.01mL (Semglee) Inject 15 unit (0.15 mL) subcutaneously Every Evening.” Insulin order for 01/13/26 reads, “Insulin Glargine-Yfgn 1 unit/0.01mL (Semglee) Inject35 unit (0.35 mL) subcutaneously Every Morning.” D. Record review of P3’s medical record for admission date of 01/12/26, Medication Administration document dated 01/12/26, lists all medications administered to P3 on 01/12/26. No evidence that insulin was administered on 01/12/26, to P3 is present. E. During an observation on 01/14/26 at 3:10 pm the patient is placing his own insulin pump after stating he is tired of not being managed well for his type 1 diabetes. F. During an interview with S (staff)1 on 01/15/26 at 1:05 pm when asked if the expectation to have physicians write orders for diabetic management on admission and she replied yes. Additionally, when S1 was asked if the expectation from nurses is to request orders for diabetic management when the patient does not have any and she replied, yes. Lastly, when S1 was asked if the facility had specific policy or standards of practice for diabetic management she replied, no, just the Lippincott (an online resource that provides facilities with evidence-based practice content and virtual learning solutions) references.”