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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 Compliance with Federal, State and Local Laws was out of compliance.

Based on document review and an interview, the facility failed to report occurrences to the Department as required by state statute. Specifically, the facility failed to report occurrences of physical abuse, sexual abuse, and a missing person.

Findings include:

Facility policy:

The Critical Incident/Unexpected Event Response policy read, a critical incident is any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals.

References:

The Health Facilities and Emergency Medical Services Division (HFEMSD) Occurrence Reporting Manual (2018) retrieved from https://drive.google.com/file/d/14h1U8zVP59HM9pusTeN08hjhRCGJsb63/view read, any occurrence involving physical abuse of a patient or resident, as described in Section 18-3-202, 18-3-203, and 18-3-204...C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124(2)(d), C.R.S. Two elements needed: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint.

Any occurrence involving sexual abuse of a patient or resident, as described in section...18-3-402, 18-3-403, 18-3-404, or 18-3-405 C.R.S., by another patient or resident, an employee of the facility, or a visitor to the facility." Section 25-1-124 (2)(d) C.R.S. Three elements needed: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts or, examiners or treats resident/patient for other than bona fide medical purposes or, observes or photographs another person ' s intimate parts or, physical force/threat.

Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident ' s health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient or resident has been missing for eight hours." Section 25-1-124(2)(c), C.R.S. Element (only 1 needed): At risk and missing after search conducted, or, missing more than eight hours, regardless of risk.

1. The facility failed to ensure occurrences were reported to the Department as required by state statute or regulation.

a. Review of the adverse event log revealed occurrences of physical abuse. Examples included:

i. Review of the adverse event log revealed, on 5/20/24 at 6:35 p.m., two peers began to fight and fell to the ground. One of the peers had a bloody nose and first aid was administered.

ii. Review of the adverse event log revealed, on 6/21/24 at 6:52 p.m., a patient bumped into another patient walking down the hall. Other peers became aggressive and began to attack the patient by hitting, kicking, and pulling hair. The patient was on the ground when other peers were attacking. Bruises were noted on the back of their neck, top of their left shoulder, there was minor missing hair on their scalp, with redness on top of their head where hair was pulled. The patient was sent to the emergency department for evaluation.

iii. Review of the adverse event log revealed, on 6/21/24 at 7:20 p.m., a patient was punched in the back of the head by a peer. The patient complained of double vision, flickering eye, and a headache. The patient was transferred to a hospital for medical clearance.

b. Review of the adverse event log revealed, on 6/5/24 at 4:30 p.m., an occurrence of sexual abuse occurred. The adverse event log revealed a patient was found in another patient's room having sexual intercourse. The patient had no recollection of events afterward. The other patient was documented as stating, "Why did you tell on us?" The patient was confirmed positive for trichomoniasis (a sexually transmitted disease) after the event and treatment was initiated.

c. Review of the adverse event log revealed, on 5/30/24 at 12:55 pm., a patient was in the cafeteria courtyard and climbed the fence. The police were notified. The patient had run to a grocery store but was unable to be found. On 6/1/24, the patient called the hospital to request their belongings.

d. Review of the state agency's occurrence reporting database on 8/6/24 revealed no occurrences had been reported since 7/3/23.

This was in contrast to the HFEMSD Occurrence Reporting Manual which read any occurrence involving physical abuse of a patient by another patient should be reported if two elements were met: Intent, or, knowingly or recklessly, and, bodily injury and/or serious bodily injury, and/or unreasonable confinement or restraint had occurred.

Any occurrence involving sexual abuse of a patient by another patient should be reported if three elements were met: Knowingly, and, consent not given, and sexual intrusion or penetration or, touching intimate parts or the clothing covering the intimate parts.

Any time a patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident ' s health, safety or welfare at risk or, regardless of whether such circumstances exist should be reported if one element was met: Missing more than eight hours, regardless of risk.

e. On 8/6/24 at 9:48 a.m., an interview was conducted with patient safety officer and director of risk management and performance improvement (Director) #4. Director #4 stated the Critical Incident/Unexpected Event Response policy did not include specific criteria for reporting to the Department. Director #4 also stated they reported occurrences to the behavioral health administration and were not aware occurrences were to also be reported to the Department.

This was in contrast to the Critical Incident/Unexpected Event Response policy which read, a critical incident was any significant event or condition that must be reported within twenty-four (24) hours to the Department that is of public concern and/or has jeopardized the health, safety and/or welfare of individuals.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.21 QAPI was out of compliance.

A0286 §482.21 (a),(c)(2),(e)(3) PATIENT SAFETY (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will identify and reduce medical errors. (2) The hospital must measure, analyze, and track adverse patient events (c) Program Activities (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities. The hospital's governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: (3) That clear expectations for safety are established. Based on document review and interviews, the quality assessment and performance improvement (QAPI) program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred in two of two patients reviewed who repeatedly physically assaulted peers.

Based on document review and interviews, the quality assessment and performance improvement (QAPI) program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred in two of two patients reviewed who repeatedly physically assaulted peers.

Findings include:

Facility policies:

The Assault/Homicide Precautions policy read, precautions require an MD order. All precautions should be clearly indicated on the rounds sheet and in all hand off communication.

The Incident Reporting Process policy read, the purpose of an incident reporting process is to ensure immediate actions are taken to prevent potential for further incident/injury or incident reoccurrence. Investigate incidents in a timely manner to identify and implement patient safety improvement and prevention strategies. An incident is an event, outcome, or situation that is not consistent with routine care of patients and/or the desired operations of the facility and results in or could have resulted in unexpected medical intervention, unexpected intensity of care, or unexpected physical or mental impairment. The facility Risk Manager assumes overall responsibility for the incident reporting process to conduct follow up and investigation to ensure appropriate actions are taken to prevent further incident and/or reoccurrence.

References:

The QAPI 2024 Plan read, the plan is used as a guide to design, measure, assess and improve organizational performance; identify, minimize and prevent organizational risks and ensure delivery of safe patient care. The objectives are to enhance, maintain and continually improve the quality and safety of patient care through departmental/service measurement and assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care; to provide a culture where care is delivered in a safe environment; to facilitate a proactive approach toward continuous performance improvement and evaluate actions taken to assure desired results are achieved and maintained; to promote safety and prevent untoward occurrences through systematic monitoring of the treatment environment to reduce facility and medical liability. Organization-wide QAPI activities include safety and risk management. Safe, is defined as avoiding harm to the patients by reducing risks in the care environment and in the application of patient interventions.

The Performance Improvement Committee is the steering committee for the QAPI program. As the steering committee for the QAPI program, the committee is responsible to oversee and accomplish the following: to assure appropriate actions are implemented to effectively resolve identified problems or improve existing processes.

1. The QAPI program failed to ensure preventive measures were implemented and effective to prevent recurrence after adverse events occurred.

a. Review of the adverse event log provided by the facility revealed, on 5/21/24 at 7:51 p.m., Patient #2 ran down the hallway toward a peer, grabbed the peer's hair, threw them to the ground, and hit the peer. The adverse event log indicated interventions implemented included separating the patients and placing Patient #2 on aggression (assaultive/homicidal) precautions.

Review of the adverse event log also revealed, on 5/27/24 at 8:15 p.m, Patient #2 physically assaulted another peer. The adverse event log indicated interventions implemented for Patient #2 were aggression precautions, separating the patients, and that the treatment team discussed managing Patient #2's behavior.

Review of the adverse event log further revealed, on 5/30/24 at 8:30 p.m., Patient #2 jumped over the nursing counter to attack another peer who was in a restraint. Patient #2 was able to hit the peer several times as staff intervened to pull them off. The adverse event log indicated camera footage review had been completed and coaching had been provided with staff.

These interventions were in contrast to Patient #2's medical record review which revealed no evidence of a provider's order for aggression precautions. Also, aggression precautions were not selected on Patient #2's patient observation rounds sheets throughout their admission.

Additionally, there was no evidence in the medical record a treatment team discussion had occurred to discuss how to manage Patient #2's aggression although this was indicated as an intervention from the adverse event log for the event that occurred on 5/27/24.

b. Review of the adverse event log revealed, on 5/18/24 at 8:15 p.m., Patient #4 slapped a peer across the face. The adverse event log indicated interventions included separating the patients and aggression precautions for Patient #4.

Review of the adverse event log also revealed, on 5/20/24 at 8:19 p.m., Patient #4 initiated a physical altercation with a peer. The adverse event log indicated interventions included aggression precautions, additional attention for de-escalation was recommended by the milieu manager, and there was an emergency treatment team meeting initiated to discuss Patient #4's behavioral plan.

Review of the adverse event log further revealed, on 5/21/24 at 7:53 p.m., Patient #4 hit a staff member in the face and was arrested for assault.

These interventions were in contrast to Patient #4's medical record review which revealed aggression precautions had been implemented for Patient #4 since 5/16/24 at 5:11 p.m., almost 48 hours before the first event occurred. There was no evidence in the medical record of additional recommendations for de-escalation, of an emergency treatment team meeting to discuss Patient #4's behavioral plan, and no evidence of a behavioral plan.

These examples were in contrast to the Incident Reporting Process policy which read, the purpose of the incident reporting process was to ensure immediate actions were taken to prevent potential for further incident/injury or incident reoccurrence.

These examples were also in contrast to the QAPI 2024 Plan which read, the purpose of the plan was to identify, minimize and prevent risks and ensure delivery of safe patient care. The objectives were to enhance, maintain and continually improve the quality and safety of patient care through assessment of patient care, resolution of problems and on-going pursuit of opportunities to improve patient care; provided a culture where care was delivered in a safe environment; facilitated a proactive approach toward continuous performance improvement and evaluated actions taken to assure desired results were achieved and maintained; promoted safety and prevented untoward occurrences through systematic monitoring of the treatment environment to reduce liability. Organization-wide QAPI activities included safety and risk management. Safe, was defined as avoiding harm to the patients by reducing risks in the care environment and in the application of patient interventions.

The Performance Improvement Committee was responsible to oversee and accomplish assuring appropriate actions were implemented to effectively resolve identified problems or improve existing processes.

c. On 8/7/24 at 8:30 a.m., an interview was conducted with behavioral health technician (Tech) #1. Tech #1 stated aggression precautions made staff aware the patient was assaultive and to be more careful, and there was no difference in interventions between patients who were on aggression precautions and those who were not on aggression precautions.

d. On 8/8/24 at 1:01 p.m., an interview was conducted with nurse manager (Manager) #3. During the interview, Manager #3 reviewed the medical record for Patient #4. Manager #4 verified after the adverse event which occurred on 5/18/24, no additional interventions were implemented for Patient #4 other than separating the patients. Manager #3 also stated there was no evidence in the record an emergency treatment team meeting occurred after the 5/20/24 adverse event, and the behavior plan was not documented in Patient #4's medical record. Additionally, Manager #3 stated after the physical assault events occurred, they would have expected Patient #4 to have increased monitoring, but Manager #3 stated this did not occur.

e. On 8/8/24 at 10:33 a.m., an interview was conducted with chief nursing officer (CNO) #2. CNO #2 stated when an adverse event occurred, she followed up with staff and reviewed camera footage to assess what happened. CNO #2 stated she would then follow up with staff to provide education. During the interview, CNO #2 reviewed the medical record for Patient #2. CNO #2 stated they were unable to locate evidence of aggression precautions or a treatment team discussion for how to manage Patient #2's aggression, which were listed as interventions in the adverse event log. CNO #2 stated after a physical assault event occurred, they would have expected Patient #2 to be on line of sight monitoring, however, CNO #2 stated monitoring was not increased after the events occurred. CNO #2 stated it was important to ensure interventions were implemented to keep patients safe. CNO #2 stated it was wrong for staff to continue the same interventions after repeated adverse events occurred. Furthermore, CNO #2 stated they had only begun to review the medical records of patients who experienced an adverse event within the last two weeks, after the last survey when the facility was cited for deficient practice.

f. On 8/8/24 at 2:45 p.m., an interview was conducted with patient safety officer and director of risk management and performance improvement (Director) #4. Director #4 stated when an adverse event occurred, they reviewed camera footage with nurse leaders and noted opportunities for improvement. Director #4 stated the nurse leader would verify if interventions and precautions were put into place. Director #4 stated they did not verify the implementation of interventions for each adverse event as they trusted the follow up of nurse leaders.

This was in contrast to the Incident Reporting Process policy which read, the purpose of the incident reporting process was to ensure immediate actions were taken to prevent potential for further incident/injury or incident reoccurrence. The facility Risk Manager assumed overall responsibility for the incident reporting process to conduct follow up and investigation to ensure appropriate actions were taken to prevent further incident and/or reoccurrence.

Furthermore, Director #4 stated it was important to ensure patient specific interventions were implemented to ensure effectiveness. Director #4 stated if the interventions were not effective or not validated, there was potential for the same adverse events to occur.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23, Nursing Services, was out of compliance.

A-0396 The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. Based on interviews and document review, the facility failed to ensure nursing staff revised and kept current a nursing care plan for each patient in three of four medical records reviewed (Patient #1, #2, and #4).

Based on interviews and document review, the facility failed to ensure nursing staff revised and kept current a nursing care plan for each patient in three of four medical records reviewed (Patient #1, #2, and #4).

Findings include:

References:

The Interdisciplinary Patient-Centered Care Planning policy read, the treatment team works to identify the patient's assessed needs to be addressed during treatment and develop appropriate goals and interventions. The treatment team will complete a review of the treatment plan as clinically indicated, or at minimum every seven days. Identified problems will be summarized, progress toward goals will be reviewed, and new goals and interventions will be identified. The following would be cause for conducting a review of the plan and developing a revision: A new impairment/problem is identified, a major change occurs in the patient's clinical condition, such as the use of restraint or seclusion, or the treatment team determines the patient's current treatment plan would more appropriately by delivered on an individual basis rather than group interventions.

The Patient Assessment and Reassessment Process policy read, assessment shall continue throughout the course of treatment and shall be reviewed and updated when there is a change in the person's level of care of functioning. Treatment planning meeting are held at least weekly. During this meeting, the patient's condition is reassessed and the treatment plan and progress goals are evaluated. Patient's requiring more frequent reassessment are as follows: patients on a one to one, for suicide, assault, fall, elopement, or other precautions.

The Staff Nurse job description read, the staff nurse will prioritize and formulate a plan of care based on patient assessment and according to policy; participate in the development of an interdisciplinary treatment plan with specific and measurable goals, objections, and inventions defining actions unique to each patient's needs; update and revise the plan as goals/objectives are met or when the patient's condition changes; and document both the nursing interventions on the treatment plan and the patient's response to the intervention.

The Licensed Practical Nurse (LPN) job description read, the LPN will maintain awareness of patient's individualized plan of care including goals and interventions; provide information to the charge nurse that assists in the development and revision of the treatment plan; document the treatment plan, nursing interventions and the patient's response to the intervention.

1. The facility failed to ensure nursing care plans were updated to reflect changes in patient condition and nursing concerns related to adverse patient safety events, health outcomes, and treatment progress.

A. Document review

i. A review of Patient #1's medical record revealed Patient #1 was admitted for a diagnosis of schizophrenic form disorder (a mental health condition that causes hallucinations, delusions, paranoia, and disorganized speech) and suicidal ideations (thinking about or formulating a plan for suicide) on 5/28/24.

On 5/29/24, a provider increased the frequency of patient observations from every 15 minutes to every five minutes. On 5/30/24 the provider note read that Patient #1 was exhibiting hypersexuality, and the provider ordered Patient #1 to be under sexual aggression precautions and sexual victimization precautions. The nursing note on 5/30/24 read that Patient #1 got into an altercation with another patient, punched the patient, and required emergency medication.

Staff created a treatment plan on 5/31/24. The treatment plan on 5/31/24 did not include any interventions or goals to address the increased frequency of observations, incidents of aggression, or the change in order for sexual aggression and sexual victimization precautions.

The provider note dated 6/2/24 read that Patient #1 threatened the provider. The provider note dated 6/3/24 read that Patient #1 was aggressive and altercating with peers, and the provider ordered aggression/homicidal precautions.

The treatment plan was not updated until 6/7/24, and the updated treatment plan did not address the change in condition requiring aggression precautions.

This was in contrast to the Patient Assessment and Reassessment Process policy which read, treatment planning meetings would be held at least weekly to reassess the patient's condition and evaluate the treatment plan and progress goals. Patients requiring more frequent reassessment included patients on a one to one, for suicide, assault, fall, elopement, or other precautions.

ii. A review of Patient #2's medical record revealed Patient #2 was admitted for a diagnosis of major depressive disorder and suicidal ideations on 5/13/24.

On 5/16/24 staff created a treatment plan.

The provider note dated 5/19/24 read that Patient #2 was allegedly assaulted by a peer and filed a police report. The provider increased observation from every fifteen minutes to every five minutes on 5/19/24.

The nursing note dated 5/22/24 read that Patient #2 assaulted another patient and had to be restrained and given emergency medications.

The treatment plan was updated on 5/23/24 and there was no evidence that the treatment plan was revised to address physical aggression or the need for restraint.

This was in contrast to the Interdisciplinary Patient-Centered Care Planning PC 101 policy which read, a major change in the patient's condition, such as the use of restraint would have been a cause for developing a revision of the treatment plan.

The nursing note on 5/27/24 read that Patient #2 was aggressive and physically attacked another patient, requiring a physical hold and emergency medications.

The treatment plan was updated on 5/30/24. There was no evidence that new goals or interventions were added to the treatment plan regarding the incidents of physical aggression.

The nursing note on 5/30/24 read that Patient #2 was physically aggressive and attacked another patient.

iii. A review of Patient #3's medical record revealed Patient #4 was admitted with a diagnosis of major depressive disorder with suicidal ideations on 5/15/24.

On 5/16/24 a provider ordered that Patient #4 be placed on aggression/homicidal precautions.

On 5/17/24 staff created a treatment plan. There was no mention of aggression/homicidal behavioral concerns on the treatment plan. The provider note read Patient #4 was disrupting in groups. The nursing note read Patient #4 was physically aggressive with other patients.

On 5/19/24 the provider note read that Patient #4 was accused of slapping another patient. The nursing note read that Patient #4 was aggressive verbally and physically slapped another patient in the face.

On 5/20/24 the provider ordered Patient #4 to be placed under sexual aggression precautions.

On 5/21/24, the provider note read that Patient #4 was in a physical altercation with another patient. The provider ordered restraints and emergency medication.

There was no evidence that the treatment plan was updated after 5/17/24 despite changes in patient behavior, sexual aggression precautions, and physical altercations with other patients.

B. Interviews

i. An interview was conducted on 8/8/24 at 8:22 a.m. with registered nurse (RN) #5. RN #5 stated interdisciplinary treatment plans (treatment plans) were defined as the master plan for patients. RN #5 stated they were not sure how often treatment plans were updated, but treatment plans should have been updated with any changes in patient status. RN #5 stated treatment plans were important for patient safety. RN #5 stated it was important to update treatment plans to ensure that the care team was on the same page and following a plan to keep patients safe until released from the facility.

ii. An interview was conducted on 8/8/24 at 1:01 p.m. with nurse manager (Manager) #3. Manager #3 stated treatment plans were used in patient care and should be updated weekly or when an event occurred, like a change in condition. Manager#3 stated events that would have triggered an update in treatment plans included physical aggression, increased symptoms, increased psychosis, or self-injurious behavior. Manager #3 stated treatment plans helped to set goals for patients, and addressed why the patient was admitted and what staff were doing to help the patients. Manager #3 stated the treatment plans for Patients #1, #2, and #4 should have been updated to reflect changes in patient condition and behavior, including the need for new goals and interventions.

iii. An interview was conducted on 8/8/24 at 2:49 p.m. with the director of risk management (Director) #4. Director #4 stated treatment plans were important and should have been updated when changes in condition, such as aggression events occurred. Director #4 stated updated treatment plans should have included how to address aggression to prevent additional occurrences.