The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

PRESBYTERIAN ESPANOLA HOSPITAL 1010 SPRUCE STREET ESPANOLA, NM 87532 March 28, 2016
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on record review and interview, the facility failed to supply complete disclosure of patient rights for 8 (#1, 2, 4, 6, 7, 8, 9 and 10) of 10 (#1-10) randomly sampled charts. This information is required to inform each patient, or when appropriate, the patient's representative, of patient's rights in advance of furnishing or discontinuing patient care whenever possible. The findings are:

A. Record review of the medical record for 8 (#1, 2, 4, 6, 7, 8, 9, and 10) charts indicated no specific patient rights notice(s) in the electronic record, only an abbreviated, general consent.

B. Record review of the facility's consent and patient rights notices lacked the following: grievances and a grievance process, participation in the plan of care, an explanation of informed consent, admission status, privacy and safety, care without abuse and neglect, confidentiality, and access to the medical record. None of these appear in the facility's "Hospital General Consent [facility name] Healthcare Service Facilities."

C. On 03/28/2016 at 2:00 pm during interview, the facility Quality Director confirmed the facility used the abbreviated general consent form and not a complete consent form for patient consents and rights information.
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on interview and record review, the facility failed to reassess discharges from the facility on an ongoing basis for their quality control program. As a result of this failure, the facility was potentially unaware of discharge plans that did not meet the needs of the patients. The findings are:

A. On 03/28/16 at 1:15 pm during interview, the Director of Quality indicated that the facility quality program did not monitor or review discharges as audits or in any other manner for meeting the needs of the patients.

B. Record review of the facility's quality program indicated no tracking, review or assessment of any kind for the discharges of all types from the facility.

C. Record review of the home health agency that admitted Patient #1 to its service on the same day (03/10/16) the patient was discharged from the hospital indicated a stage II skin decubitus wound on the left hip.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interviews and record review, the facility failed to assign nurses and aides who could manage the special skin care needs for Patient #1 while she was in the facility from 03/04/16 to 03//10/16. Patient #1 arrived at the facility with her skin intact and left the facility with a stage II decubitus wound on her left hip. The findings are:

A. On 03//28/16 at 3:15 pm during interview, Staff #8 and #11 who were reviewing the
electronic medical records of Patient #1 indicated the following: "I cannot find any notes that confirm that the skin assessment of [Patient #1] identified any skin breakdown."

B. On 03/28/16 at 11:00 pm during interview, Staff #3 and #4 confirmed that Patient #1 was a high risk for skin breakdown because of her immobility and recent femur (upper leg bone) fracture.

C. Record review of the electronic medical record of Patient #1 indicated no documentation of a wound anywhere on the skin of Patient #1 throughout the stay in the facility from 03/04/16 to 03/10/16. The medical record also confirmed Patient #1 had a high risk profile (Braden Score) for skin breakdown.

D. Record review of the admission clinical assessment on 03/11/16 Patient #1 by a local
home health agency specifically identified a stage II decubitus wound on the left hip of
Patient #1.

E. Review of the facility policy entitled "Pressure Ulcer Prevention and Wound Care," dated 02//01/2012, indicated the following:
"Assessment: Skin/Tissue Management. Nursing staff shall: 1. Perform Braden Score within 8 hours of admission, in conjunction with initial nursing assessment and at least twice daily. 2. Assess the skin every shift for signs and symptoms of skin and/or tissue breakdown. Pay particular attention to heels, sacrum, and bony prominences. Medical devices such as oxygen tubing, foley [indwelling urinary] catheters, and personal patient items can also cause pressure ulcers."