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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the §485.635 Condition of Participation: Provision of Services was out of compliance.

A-0271- Standard: The CAH's health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. Based on document review and interviews the facility failed to ensure high-risk safety precaution patients, specifically those requiring fall precautions or suicide precautions, had interventions/monitoring in place and documented in the medical record. The failure was identified in 5 of 10 medical records reviewed (Patients #1, #2, #3, #4, and #9). Also, based on document review and interviews the facility failed to ensure patients had their vital signs obtained per physician orders or unit protocol. The failure was identified in 3 of 10 medical records reviewed (Patients #1, #2, and #4). Lastly, based on document review and interviews the facility failed to provide documented evidence patients were informed of their rights while in the facility under a 72-Hour Mental Health Hold. The failure was identified in 1 of 2 medical records reviewed of patients under a 72-Hour Mental Health Hold while receiving care at the facility (Patient #1).

Based on document review and interviews the facility failed to ensure the facility health care services were furnished in accordance with appropriate written policies that are consistent with applicable State law. Specifically, the facility failed to ensure safety precaution patients, specifically those requiring fall precautions or suicide precautions, had interventions/monitoring in place and documented in the medical record. The failure was identified in 5 of 10 medical records reviewed (Patients #1, #2, #3, #4, and #9). Also, based on document review and interviews the facility failed to ensure patients had their vital signs obtained per physician orders or unit protocol. The failure was identified in 3 of 10 medical records reviewed (Patients #1, #2, and #4). Lastly, based on document review and interviews the facility failed to provide documented evidence patients were informed of their rights while in the facility under a 72-Hour Mental Health Hold. The failure was identified in 1 of 2 medical records reviewed of patients under a 72-Hour Mental Health Hold while receiving care at the facility (Patient #1).

Facility policy:

According to Suicidal Ideation Precautions & Homicidal Ideation Precautions policy, the procedure applied to all clinical staff caring for patients presenting with suicidal and homicidal ideation. Patients are to be in constant supervision of a care provider. The Suicidal Patient Observation Flowsheet will be filled out, and checks would be documented every 15 minutes.

According to the Suicidal Patient Observation Flow Sheet policy, assessments included, but was not limited to; the patient's location, state of mind (cooperative, calm/quiet, restless, agitated, combative, and resting), toileting needs, vital signs, meals/snack needs

According to Fall Risks Assessment, Prevention & Management policy, stated all patients would be assessed using the EHR fall risk assessment, and interventions implemented based on category. Registered nurses were to assess the presence of fall risk factors and calculate fall risk score and category at least once a shift. "High Fall Risk" interventions included, but not limited to; keeping the bed in a low position, use of bed alarms as needed, keeping call light within reach at all times, maintain two upper side rails on the bed at all times, educate to call for assistance when getting out of the bed.

According to the Acute Care Unit Guidelines for Care policy, patients receiving acute care are to have their vital signs obtained at least every 4 hours.

According to Suicidal Ideation Precaution and Homicidal Precautions, read all patients on a [72-hour mental health hold] would be given a copy of their patient rights.

1. The facility failed to ensure high-risk safety precaution patients, specifically those requiring fall precautions or suicide precautions, had intervention and monitoring in place and documented in the medical record.

a. A medical record review was conducted for Patient #3 admitted on 4/14/19 with the diagnosis of alcoholism related dementia. Further review found the patient was documented as a high fall risk according to the Morse Fall Scale (fall scale) completed in the nursing shift assessments.

On 4/19/19 at 10:53 a.m. the patient was documented as a high fall risk, but no fall prevention interventions were implemented and documented in the medical record for the assessment. On 4/19/19 at 4:15 p.m. Patient #3 walked off the unit to the outside of the hospital unaccompanied and experienced a fall while outside of the facility. The patient was assessed, upon being returned to the unit, and was found to have skin abrasions identified.

b. A medical record review was conducted for Patient #9 with an admission order for acute care service as of 4/10/19 at 12:39 p.m. for the primary diagnosis of syncope, dementia, calculus of kidney and ureter, leukocytosis, and congestive heart failure.

According to the Fall Risks Assessment, Prevention & Management policy, fall scale assessments were to be completed by nursing each shift.

On 4/15/19 at 8:06 p.m., the emergency medical services (EMS) tech documented the patient was exhibiting behavior that was impulsive and non-cooperative.

On review of the record, there was no documentation on 4/15/19 the night shift nurse had completed the fall scale assessment during their shift.

On 4/16/19 at 2:39 a.m., the nurse documented the patient was "found on the floor" with "no obvious signs of trauma noted."

c. A medical record review was conducted for Patient #2 with an admission order for acute care services and "Observation" level of care on 3/3/19 at 5:48 p.m. Patient #2 had a primary diagnosis of dementia and uncontrolled behavior.

On 3/3/19 at 8:08 p.m., the patient's provider ordered "Fall Precautions" for Patient #2. Review of the nursing shift assessments found the patient's fall scale assessment was only performed once, on 3/4/19 at 7:18 p.m., during their stay. The patients fall scale score was documented as a 95.

Per interviews with the clinical nurse manager- registered nurse (RN #2) and the chief nursing officer (CNO #1), any patient who scored above 45 on the fall scale were considered high fall risk.

Per the Fall Risks Assessment, Prevention & Management policy, interventions for high risk fall patients included; keeping the bed in a low position, use of bed alarms as needed, keeping call light within reach at all times, maintain two upper side rails on the bed at all times, and educating the patient to call for assistance when getting out of the bed.

Further review of the record also found no documented evidence high risk fall prevention interventions were put into place during the patient's stay.

d. On 7/10/19 at 1:59 p.m., an interview was conducted with RN #2. RN #2 stated patients with a score higher than 45 on the fall scale were considered high risk for falls. RN #2 stated those patients required a yellow "fall" wristband, a yellow star magnet outside of the room, non-slip socks/shoes, bed alarm engaged, bed maintained in the lowest position, and call light within reach. RN #2 stated the interventions were in place to help staff identify patients considered a high fall risk, and to help prevent situations where the patient could experience a fall.

RN #2 stated fall prevention interventions utilized should be reflected in the patient's medical record.

e. On 7/11/19 at 2:10 p.m., an interview was conducted with CNO #1. CNO #1 was able to review the medical records for Patients #2 and #3 and confirmed there were gaps in the nursing fall scale assessment frequencies and fall prevention interventions.

CNO #1 stated the patients had fall scale scores higher than 45 which would indicate the patients were high risk for fall, therefore staff were expected to follow fall prevention measures according to the policy.

CNO #1 stated it was important for staff to follow the fall prevention policy in order to prevent patient falls and to ensure the appropriate interventions were in place.

f. A medical record review was conducted for Patient #1 who arrived at the emergency department (ED) by law enforcement on 1/10/19 with reports of suicidal ideation (SI). On 1/10/19 at 3:00 p.m., the patient was placed on a 72-hour mental health hold while receiving care at the facility.

According to the policy "Suicidal Ideation Precautions & Homicidal Ideation Precautions", patients presenting with suicidal and homicidal ideation (HI) were to be in constant supervision by a care provider. The policy also read, The Suicidal Patient Observation Flowsheet will be filled out, and checks would be documented every 15 minutes.

However, further review of the medical record found no documented evidence the Suicidal Patient Observation Flowsheet was completed while receiving care at the facility, or that patient checks were documented every 15 minutes per protocol.

g. A medical record review was conducted for Patient #4 who arrived to the ED on 4/3/19 via ambulance due to a reported suicide attempt. On 4/5/19 at 2:15 p.m. the patient was placed on a 72-hour mental health hold by the facility's ED provider.

Review of the medical record identified similar findings where there was no documented evidence the clinical staff completed the Suicidal Patient Observation Flowsheet while Patient #4 was receiving care at the facility, or that 15 minute checks were completed per protocol.

h. On 7/11/19 at 8:56 a.m., an interview was conducted with an emergency medical technician (EMT #3). EMT #3 stated patients who arrived to the ED with SI symptoms are placed in the most visible room in the emergency room, the patient's belongings are removed from the room, they are placed in a dark green hospital gown, all safety hazards are removed from the patient's room, and the patient's room door was to remain open at all times. EMT #3 stated that process was completed to help prevent the patient from harming themselves or others while in the room. EMT #3 stated the staff had not required a physician's order to implement the safety precautions, and that it was based on the patients presenting symptoms related to SI or HI.

EMT #3 stated the staff were expected to check on the patient regularly, but was unable to specify timeframes for patient checks per the protocol. EMT #3 stated he was familiar with the Suicidal Patient Observation Flowsheet used for SI/HI patients, but also stated the form was not always used when caring for SI/HI patients in the ED.

i. On 7/11/19 at 2:10 p.m., an interview was conducted with the chief nursing officer (CNO #1). CNO #1 stated the Suicidal Patient Observation Flow Sheet (observation form) was to be completed while all SI/HI presenting patients were receiving care at the facility. CNO #1 stated the observation form was important to ensure SI/HI patients were monitored, safe, and had their basic necessities assessed for while receiving care.

CNO #1 reviewed the medical records for Patients #1 and #4 and confirmed there was no documented evidence the 15-minute checks or the observation form was completed per protocol.

2. The facility failed to ensure patients had their vital signs obtained per physician orders or unit protocol.

a. A medical record review was conducted for Patient #1 who arrived to the Emergency Department (ED) on 1/10/19 presenting with suicidal ideation. The patient received "Observation" level of care within the facility until 1/12/19 when they were transferred to a behavioral health facility.

On 1/11/19 at 3:09 pm the patient's provider ordered "vital signs every 2 hours while awake" and "vital signs every 4 hour while sleeping".

Review of the record from 1/11/19 3:24 p.m. to 1/12/19 8:29 a.m., vitals were not obtained for approximately 16 hours.

b. A medical record review was conducted for Patient # 2 who arrived to the ED on 3/3/19 due to uncontrolled combative behavior. Review of the record also identified a lack of vital signs completed per physician orders.

On 3/3/19 at 8:08 p.m., the patient's provider ordered vital signs to be completed every 2 hours while awake, and every 4 hours when the patient was asleep.

Review of the record found no evidence the patient's vital signs were obtained from 3/4/19 3:39 a.m. to 3/4/19 7:38 p.m., approximately 16 hours.

c. A medical record review was conducted for Patient #4 admitted for "Observation" related to the diagnosis of suicidal ideation, depression, hypokalemia, and chronic renal failure.

Review of the Nursing Order section found the patient's provider ordered "vital signs every 30 minutes now". The order was entered by the provider on 4/3/19 at 5:19 p.m.

Review of the Flowsheet Vitals from 4/3/19 5:15 p.m. to 4/3/19 8:35 p.m., revealed vital signs were not completed every 30 minutes as ordered. Vital signs during that time frame were only obtained at 5:17 p.m., 6:38 p.m., and 8:35 p.m..

On 4/3/19 at 10:18 p.m. the provider then placed an order changing the vital sign frequency from every 30 minutes to every 1 hour.

d. On 7/10/19 at 1:59 p.m., an interview was conducted with a registered nurse also functioning as the facility's clinical operations manager (RN #2).

RN #2 stated patients were to have vital signs obtained according to the unit protocol, and always according to the physician's order. RN #2 stated vital signs were to be obtained and documented in the medical record, including documentation if the patient refused to have their vital signs taken.

e. On 7/11/19 2:10 p.m., an interview was conducted with the chief nursing officer (CNO #1).

CNO #1 reviewed the medical records for Patients #1, #2, and #4 and confirmed vital signs were not consistently completed per the physician orders. CNO #1 was unsure why the vital signs were not completed, and stated leadership at that time was not specifically monitoring for vital sign compliance among the staff.

CNO #1 stated staff were to obtain the patients' vital signs per the provider's orders and unit protocol. CNO #1 stated it was important for staff to monitor vital signs in order to ensure the patient was hemodynamically stable, and to identify any abnormal changes in vital signs.

3. The facility failed to provide documented evidence patients were informed of their rights while in the facility under a 72-Hour Mental Health Hold.

a. A medical record review was conducted for Patient #1 who arrived to the Emergency Department on 1/10/19 with law enforcement due to concerns for suicidal ideation. On 1/10/19 at 3:00 p.m. the patient was placed on a 72-Hour Mental Health Hold.

Further review of the medical record found no documented evidence, while the patient was under the 72-hour mental health within the facility, the patient was also informed and provided a copy of their rights listed on the "State of Colorado, CDHS, DBH Form M-2" form (M-2 Form).

b. On 7/11/19 at 2:10 p.m., an interview was conducted with the chief nursing officer (CNO #1). According to the interview, patients were to be informed and provided a physical copy of their rights listed on the M-2 Form. CNO #1 stated patients placed under a 72-hour mental health hold (M-1 Hold) are required to know the rights available to them, and the responsible clinical staff were expected to provide the patient with their rights listed on the M-2 form.

CNO #1 confirmed the facility was unable to provide documented evidence the patient was informed, or provided a copy of their rights while under the M-1 Hold within the facility.