Evaluations highlight concerns, harm at state health centers

SANTA FE, N.M. (AP) — A new evaluation of state-operated hospitals for veterans, the mentally ill and the elderly describes inadequate oversight that threatens the ability to provide quality care, including harmful conditions at a care facility for military veterans in Truth or Consequences.

Presented Thursday to legislators, the evaluation from the Legislature’s accountability and budget office describes improvements in management of finances, marketing and tracking of clinical outcomes for patients.

But the quality of patient care and oversight at the New Mexico State Veterans’ Home in Truth or Consequences in particular continues to be a point of concern.

Problems there were highlighted recently by the federal Centers for Medicare and Medicaid Services, which found substandard care and examples of patients who were harmed.

That review found the State Veterans’ Home failed to properly intervene to care for a patient who had fallen eight times and died after being found unresponsive after a fall. A diabetic patient was sent home with insulin but no glucose meter, and another patient was intubated despite a do-not-resuscitate order.

The home failed to ensure compliance with infection-control protocols and training, such as the use of face masks by staff and proper procedures for antibiotics — placing residents in jeopardy.

The facility risks losing funding agreements with Medicaid and Medicare programs if deficiencies are still unresolved in December. A medical director at the facility lost privileges as a result of the June federal inspection and resigned.

Gov. Michelle Lujan Grisham said state officials are confident that the facility will be back in compliance within the time allotted through reinspection.

In a statement Thursday, the governor recounted an impromptu visit to the veterans’ home earlier in the week to personally check in on progress and meet with residents and staff.

“I reassured them all that I will continue to hold accountable those in charge of our veterans’ care until every metric is met and every deficiency is corrected,” Lujan Grisham said in the statement. “I also made several commitments to them based on their feedback, including increasing transportation options, improving their access to medical specialists and more flexibility for meal options and times.”

The governor indicated that employment was recently terminated for five individuals at the veterans’ home, while two nurses were reported for discipline and eight other staff were reprimanded or counseled. An expert team assessed the facility, and staff are now being trained in critical areas.

New Mexico has assigned at least $60 million to the Department of Health to build a new veteran’s home buildings at Truth or Consequences that are scheduled for completion next year.

In all, New Mexico currently operates seven facilities that provide court-ordered psychiatric care, detox services for drugs and alcohol, nursing care for honorable-discharged military veterans, teenage boys with mental-health or violence problems, supportive living arrangements for people disabled since youth and more.

A 2021 evaluation of the facilities found a need for better governance, planning and oversight. Out of dozen recommendations, four have been met and solutions to eight more are underway.

The release of the new report coincided with a visit by Gov. Michelle Lujan Grisham to a new senior center in Wagon Mound.

The Department of Health has begun tracking daily occupancy at all its facilities. The results showed that only about half of licensed beds were occupied from March to July 2022.

Evaluators also found that the Turquoise Lodge detox center in Albuquerque doesn’t allow walk-in admissions, requiring a multi-step admissions process over the phone. Federal guidelines say that makes it less likely that patients will seek treatment.