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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.11 Condition of Participation: Compliance with Federal, State and Local Laws, was out of compliance.

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(A-0020) -§482.11 Condition of Participation: Compliance with Federal, State and Local Laws. Based on document review and interviews, the facility failed to ensure state law requirements were met. Specifically, the facility failed to ensure state regulations for nurse staffing requirements and patient event reporting were met.

Based on document review and interviews, the facility failed to ensure state law requirements were met. Specifically, the facility failed to ensure state regulations for nurse staffing requirements and patient event reporting were met.

Findings include:

References:

The HFEMSD Occurrence Reporting Manual read, any occurrence that results in the death of a patient or resident of the facility and is required to be reported to the coroner pursuant to Section 30-10-606, C.R.S., as arising from an unexplained cause or under suspicious circumstances." Section 25-1-124 (2)(a), C.R.S. Two elements needed: the occurrence (event) resulting in death AND reportable to the coroner as unexplained or suspicious event - unexpected, unplanned action or avoidable action that results in the serious injuries. Unexpected, unplanned or avoidable action is defined by community or professional standards of practice.

According to the Colorado Code of Regulations Chapter Four Part 14.10, Each hospital shall establish and maintain a nurse staffing oversight process. The nurse staffing oversight process shall, at a minimum: develop the master nurse staffing plan, including a specific plan for each inpatient care unit and emergency department and describe the process for addressing concerns brought forth by staff. The nurse staffing oversight process shall have at least 50% or greater participation by clinical staff nurses, in addition to auxiliary personnel and nurse management. The hospital shall develop, document, and implement a nurse staffing oversight charter or guideline that shall address, at a minimum, the following: the process for how complaints and feedback from hospital staff related to nurse staffing are received and processed; how decisions are made; and how the staffing plans will be monitored, evaluated, and modified over time.

1. The facility failed to ensure an unexpected death reported to the coroner was reported to the state agency as an occurrence.

a. Patient #1's medical record was reviewed. Patient #1 was declared deceased on 6/5/22 at 8:48 p.m. by emergency personnel who had arrived at the facility. The police department and coroner were notified of the death and Patient #1's body was released to the coroner at 10:15 p.m.

b. Review of the state agency's occurrence manual, referenced above, revealed a death required to be reported to the coroner was considered an occurrence and was to be reported to the state agency.

c. Review of the state agency's occurrence reporting database on 8/3/22 (two months after Patient #1 expired) revealed no occurrences were reported in regards to the death of Patient #1.

d. On 8/3/22 at 1:06 p.m., an interview was conducted with the Director of Performance Improvement and Risk Management (Director) #1. Director #1 stated events listed in the state agency occurrence manual were required to be reported to the state agency.

2. The facility failed to ensure clinical staff nurses were involved in the nurse staffing oversight process.

a. On 8/3/22 the facility's nursing staff matrix and staffing plan were reviewed. Upon review, there was no evidence at least 50% of clinical staff nurses were involved in the oversight process.

b. 8/3/22 at 2:15 p.m., an interview was conducted with the Director of Nursing (DON) #2. DON #2 stated the facility was in the process of implementing a staffing committee in order for clinical staff nurses to have oversight of the staffing process.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.13, PATIENT RIGHTS, was out of compliance.

A-0144 The patient has the right to receive care in a safe setting. Based on interviews and document review, the facility failed to ensure all patients received care in a safe setting. Specifically the facility failed to ensure safety concerns expressed by patients were addressed prior to physical harm occurring in one of one medical records reviewed where a patient expressed concerns of harm. (Patient #2).

Based on interviews and document review, the facility failed to ensure all patients received care in a safe setting. Specifically the facility failed to ensure safety concerns expressed by patients were addressed prior to physical harm occurring in one of one medical records reviewed where a patient expressed concerns of harm. (Patient #2).

Findings include:

Facility policies:

According to the facility policy, Managing Aggressive Patient Behavior/Assault Precautions, patient risk factors may include: past history of assaultive behavior or verbal/physical threats towards others. Staff responsibilities include: if the patient's aggression or threats are focused on a particular peer or staff, separate the two to avoid the trigger and alleviate the risk (this may be temporary or something more permanent like a move to another unit if deemed appropriate). Offer alternative solutions to address the patient's perceived fears, concerns or stressors; follow all observation expectations to maintain the safety of all patients; be cognizant of all precautions a patient is on to assure awareness of a patient's risk factors and assure these are noted on the patient's observation record and updated as indicated; understand that precautions and observations are a key tool to always maintain a safe and therapeutic milieu.

According to the Investigating Serious Incidents, Allegations and Near Misses policy, the purpose of the policy is to provide for a structured response to serious patient related incidents.
A serious incident is defined as any major injury or impairment in which the patient or visitor is altered long term; or permanently. Sentinel Events is composed of a special class of serious incidents with extreme consequences, as involving the following: an event that results in death or major permanent loss of function, not related to the natural course of the patient's underlying condition; suicide of a patient in a setting where the patient receives around the clock care, or the report of rape/sexual assault of patients by either other patients or staff.

For serious incidents, the facility's risk manager or designee will be notified and will initiate an internal investigation of the occurrence. Upon gathering available data related to the event, the Risk manager will analyze the incident and identify any underlying causes that may reflect process or systems issues in need of further review. When incident investigations reveal the need for process improvements, the findings will be communicated to the Patient Safety Council. The Patient Safety Council is to address the issue identified and ensure actions are taken for improvement where appropriate.

According to the policy, Response to Patient Threats to Harm Others (Duty to Warn), the purpose was to communicate when a patient makes a violent threat against a specific person. Any staff member who is aware of a patient making a threat of violence towards other persons shall immediately notify their immediate supervisor or the superior of that person. Supervisors or managers who are made aware of patient threats of violence will assure that a responsible professional is notified of the situation. The appropriate responsible professional for various situations is the attending physician in the acute care area. Clinicians who have been notified of patient threats or who have been informed directly of such threats are responsible for assessing the seriousness and credibility of the threats. A patient's attending physician or other supervising clinician who is not physically present at the facility when notified of threats may delegate assessment to another professional such as an RN or therapist, who will call them back for consultation regarding the results of their assessment. When a responsible professional has determined that a patient has made a serious threat of imminent physical violence against other persons, the results of this assessment will be immediately communicated to the Administrator on Call. Notifications will be made to the person threatened and to a law enforcement agency, based upon the location of the person threatened and the person making the threat.

1. The facility failed to intervene and prevent injury to patients who felt unsafe or received threats from peers.

a. A review of Patient #2's medical record revealed the patient had expressed concerns to staff members that another patient had made threats to harm him and he felt unsafe.

Examples included:

i. A Daily Nursing Note, documented on 6/12/22 at 2:28 a.m., revealed Patient #2 reported to staff his roommate had threatened to hit him if he continued to be hostile and rude to staff.

ii. A Physician's Order, obtained on 6/12/22 at 5:50 a.m., read Patient #2 was allowed to sleep out in the milieu area of the unit if he felt unsafe sleeping in his room with his roommate.

iii. A Daily Nursing Note, documented on 6/12/22 at 4:00 p.m., revealed Patient #2 again reported he did not feel safe in his room with his roommate and asked to sleep out of the room in the common area of the unit.

iv. A Daily Nursing Note, documented on 6/12/22 at 9:55 p.m., revealed Patient #2 had asked the staff for permission earlier in the evening to sleep out of the room for safety because another peer was verbally threatening him.

Review of the medial record revealed no evidence staff intervened and ensured Patient #2 was safe; to include, physically separating Patient #3 from Patient #2 on separate units.

b. An interview was conducted with the Director of Nursing (DON) #2 on 8/3/22 at 1:58 p.m. DON #2 stated if a patient reported to facility staff they did not feel safe, she expected staff separate the patient from the peer expressing threatening behavior in order to prioritize patient safety and prevent injury.

The facility was unable to provide any policy or training for staff for immediate actions to take when a patient reports feeling unsafe due to threats by a peer.

c. Documentation review for Patient #2 revealed on 6/12/22 at 9:16 p.m., 7 hours after Patient #2 notified staff he felt unsafe, Patient #2 was assaulted by Patient #3 while sleeping in the milieu. Patient #3 approached Patient #2 and began to punch the left side of Patient #2's head and the left side of his upper body. Patient #2 was transferred to an acute care hospital where the patient received treatment for a closed head injury, a non-displaced distal radius fracture, and contusion of his ribs. Once Patient #2 returned to the facility, the patient was placed on a separate unit than Patient #3.

The facility was unable to provide evidence of follow-up for the 6/12/22 event to ensure preventative measures were in place to prevent future occurrences.