HospitalInspections.org

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

A-0118 - The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The facility failed to ensure patient or patient representatives were notified if dissatisfied with the investigation findings, the grievance may be referred in writing to the State Agency. This failure created the potential for patients to be unaware of their right to pursue a further grievance investigation.

A-0129 - Standard: Exercise of Rights. The facility failed to ensure patients received personal items delivered to the facility. This failure created the potential for negative patient outcomes related to personal patient items not being delivered to patients in accordance to their rights.

A-0130 - The patient has the right to participate in the development and implementation of his or her plan of care. The facility failed to ensure staff conducted initial psychosocial assessments with patients in a timely manner in order to determine psychological needs. This failure created the potential for patients to not be involved in their plan of care. In addition, this failure created a delay in the development of patient treatment plans.

A-0144 - The patient has the right to receive care in a safe setting. The facility failed to provide services in a safe environment in accordance with patients' rights. This failure created the potential for negative outcomes related to an increased risk for patient elopements. In addition, this failure resulted in a lack of immediate availability of emergency patient supplies.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.21 QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM was out of compliance.

A-0286 - The hospital must measure, analyze, and track adverse patient events. 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. The facility failed to implement preventative actions and process changes in response to trends of similar patient safety incidents which occurred in the facility. The failure resulted in the risk of negative patient outcomes and may have contributed to the recurrence of patient elopements or attempted elopements from the facility.

Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.23, NURSING SERVICES, was out of compliance.

A-0392 The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for bedside care of any patient. The facility failed to have a Registered Nurse (RN) present for immediate availability on each patient care unit. This failure created an environment where patients were placed in the care of staff unqualified to provide RN level of care.

A-0395 A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to provide ongoing nursing care based on facility policy. In addition, the nursing staff failed to ensure telephone verbal orders, physician orders and face to face evaluations were signed by physicians. These failures prevented reassessment of patients and alerting of staff and physicians in patient condition changes.

A-0405 Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under §482.12(c), and accepted standards of practice. Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. The facility failed to ensure control solution used for quality control checks of glucometers were not expired for 2 of 3 medication rooms toured. Further, the facility failed to ensure broken glucometers were taken out of service prior to use on patients. This failure created the potential for negative patient outcomes due to inaccurate blood glucose monitoring.

Based on interviews and document review the facility failed to ensure patient or patient representatives were notified if dissatisfied with the investigation findings, the grievance may be referred in writing to the State Agency.

This failure created the potential for patients to be unaware of their right to pursue a further grievance investigation for 2 of 2 grievances reviewed (Patients J and K).

FINDINGS

POLICY

According to the policy, Patient Grievances/Complaints, if the patient is not satisfied with response to the complaint they can file a grievance. The grievance process which addresses the following: Patients right to file a grievance with the Colorado Department of Public Health and Environment (CDPHE) directly, or The Joint Commission regardless of whether he/she first used the hospital's grievance process.

If the patient is not satisfied with the results of the report, the patient shall be informed upon request, the patient care advocate will refer the grievance and the findings in writing to the CDPHE, and the patient may register the grievance directly with CDPHE, DHS, or Joint Commission.

1. The facility failed to ensure the final resolution letter stated the patient or patient representative, if dissatisfied with the finding, could request the grievance be forwarded to the State Agency.

a) Document review revealed on 03/01/16, Chief Executive Officer, (CEO #1) mailed a letter explaining the investigation findings for the grievance filed by Patient J. The letter did not state the facility would, upon request, forward the grievance to the State Agency. This was in contrast to policy.

b) Document review revealed on 07/07/16, Patient Advocate #11 mailed a letter explaining the investigation findings for the grievance filed by Patient K. The letter did not state the facility would, upon request, forward the grievance to the State Agency.

c) On 02/10/17 at 2:19 p.m., a joint interview and grievance review for Patients J and K's packets was conducted with the Director of Quality (Director #5) and CEO #1, both of whom were in charge of the grievance process for the facility. CEO #1 stated the facility's policy was to include a second letter with the final resolution letter to the patient or patient representative, which included information for the State Agency.

After review of the grievance packet for Patients J and K, CEO #1 was unable to provide documentation that the facility provided the patient or patient representative information if dissatisfied with the investigation findings, the grievance could be referred in writing to the State Agency. CEO #1 stated s/he was unsure of why the letter providing that information was not attached and that usually the facility had a carbon copy included.

Based on interviews and document review the facility failed to ensure patients received personal items delivered to the facility.

This failure created the potential for negative patient outcomes related to personal patient items not being delivered to patients in accordance with their rights.

FINDINGS

REFERENCE

According to Patient Bill of Rights, you have a right to personal privacy, comfort and security to the extent possible during your stay.

According to Rights of Patients, you have the right to receive and send sealed letters. No incoming or outgoing letters shall be opened, delayed, held or censored by the personnel of the facility.

1. The facility failed to ensure Patient #2 received mail addressed to him/her and provided at the front entrance of the facility.

a) Review of Patient #2's medical record revealed a document titled Patient Belongings Inventory dated, 11/24/16 at 3:46 p.m. The document included a list of items intended to be left for Patient #2's use with a visitor's signature at the bottom of the document attesting that all items on the list were accurate. The third item on the list was entered as a letter with never received by patient written next to the entry.

Review of the Belongings Inventory List, dated 11/24/16 at 4:30 p.m., revealed the receipt of 4 magazines listed as contraband and several clothing items listed as items kept by the patient. There was no documentation on the Belongings Inventory List indicating the patient received the letter that was listed on the Patient Belongings Inventory. No further documentation was noted on the document or in the medical record regarding why the patient never received the letter.

b) On 02/09/17 at 9:34 a.m., an interview with Receptionist #9 was conducted, who described the process of receiving items from visitors intended to be given to patients. Receptionist #9 verified the Patient Belongings Inventory as the document s/he used with visitors to list the items brought in for patients. Receptionist #9 then stated the document would be sent back to the nurse's station with the items. Receptionist #9 further stated s/he was not involved with Patient #2's document and s/he did not know why the letter was documented as never received by the patient or who wrote the comment.

c) On 02/09/17 at 12:28 p.m., an interview with Mental Health Technician (MHT) #10 was conducted who described the process of receiving items from visitors intended to be given to patients. MHT #10 stated s/he would receive the items and the Patient Belongings Inventory document from the receptionist. MHT #10 would then conduct another inventory of the items received and document them on another document, titled the Belongings Inventory List. MHT #10 stated s/he was not involved with Patient #2's Belongings Inventory List and did not know why the letter did not appear on the Belongings Inventory List. MHT #10 further stated s/he did not think the patient would have access to the Patient Belongings Inventory document to write the comment regarding never receiving the letter, but s/he did not know who would have written the comment.

d) On 02/08/17 p.m., an interview was conducted with the Director of Quality and Risk Management (Director #5). After reviewing the documentation involving Patient #2's belongings, Director #5 verified the letter received at the front desk did not appear on the inventory list used by staff on the unit. Director #5 stated s/he was unaware of the incident but s/he could investigate to see why the patient did not receive the letter as they have a right to receive mail. Director #5 further stated an incident report would not be triggered with this event unless the patient contacted him/her about not receiving the letter.

On 02/10/17 at 2:19 p.m., Director #5 was interviewed to follow up on any additional information about the missing letter. Director #5 stated s/he did not know what happened with the patient's letter and was never notified of an incident regarding a missing letter.

Based on interviews and document review the facility failed to ensure staff conducted initial psychosocial assessments with patients in a timely manner in order to determine psychological needs in 4 of 11 records reviewed (Patients #1, #2, #5, and #7) .

This failure created the potential for patients to not be involved in their plan of care. In addition, this failure created a delay in the development of patient treatment plans.

FINDINGS

POLICY

According to the policy, Psychosocial Assessment, a Psychosocial Assessment will be completed on every patient and will be started at admission. If a patient is admitted the Psychosocial Assessment will be reviewed and completed by the Therapist within 24 hours of admission.

According to the policy, Plan for Provision of Care, the Psychosocial Assessment, the assessment is performed within 48 hours of admission with the patient and, when possible, family members/significant others by the admission department upon admission. It is reviewed and updated by Therapy Services staff within 24 hours of admission.

REFERENCE

According to Rights of Patients, you will be examined to determine your mental condition. The staff has a responsibility to give you the best care and treatment possible and available and to respect your rights.

1. The facility failed to ensure patients received timely therapy services in accordance with the approved policy.

a) Medical Record reviews revealed patients did not receive a complete Comprehensive Psychosocial Assessment within 24 hours of admission in 4 of 11 records reviewed. This was in contrast to the policy which stated the Psychosocial Assessment would be reviewed and completed by the therapist within 24 hours of admission.

i) According to the Adult Admission Orders, Patient #7 was admitted to the facility with an admission diagnosis of suicidal ideations with psychosis on 01/29/17 at 6:00 a.m. The Psychosocial Assessment was reviewed by therapy services on 02/07/17 at 1:25 (9 days after admission) and completed on 01/29/17 at 10:10 p.m. In addition, the Therapy Initial Contact Note was documented as occurring on 02/01/17 at 1:58 p.m. (approximately 80 hours after admission) and signed and dated by a therapist on 02/02/17 at 12:15 p.m. (approximately 102 hours after admission).

There was no documentation why the psychosocial assessment was delayed and not completed within 24 hours, which resulted in the patient not being able to participate in his/her care plan in a timely manner.

ii) According to the Chemical Dependency Admit Orders, Patient #1 was admitted to the facility with an admission diagnosis of major depressive disorder on 01/31/17 at 2:30 a.m. The Psychosocial Assessment was reviewed by therapy services on 02/02/17 at 7:32 a.m. (approximately 53 hours after admission) and completed by therapy services on 02/02/17 at 1:15 p.m. (approximately 58 hours after admission). In addition, the Therapy Initial Contact Note was signed and dated by a therapist on 02/02/17 at 1:19 p.m.

iii) According to the Adult Admission Orders, Patient #2 was admitted to the facility with an admission diagnosis of bipolar with mania and suicide ideations on 11/23/16 at 9:40 p.m. The Psychosocial Assessment was reviewed and completed by therapy services on 11/26/16 at 1:40 p.m. (approximately 64 hours after admission). In addition, the Therapy Initial Contact Note was documented as occurring on 11/26/16 at 12:00 p.m. and had no signature by a therapist documented on the Note.

iv) According to the Geriatric Admission Orders, Patient #5 was admitted to the facility with an admission diagnosis of major depressive disorder with a suicide attempt on 12/23/16 at 2:00 p.m. The Psychosocial Assessment was reviewed by therapy services on 12/26/16 at 3:57 p.m. (approximately 74 hours after admission) and completed on 12/26/16 at 4:14 p.m. In addition, the Therapy Initial Contact Note was signed and dated by a therapist on 12/26/16 at 4:55 p.m.

b) On 02/09/17 at 4:29 p.m., an interview was conducted with a Certified Clinician (Therapist #7) who revealed s/he worked as a therapist on the geriatric unit. Therapist #7 stated the expectation was for therapists to see patients and to review and complete the Psychosocial Assessment within 24 hours of admission. Therapist #7 then stated the therapists were having some trouble meeting that goal because Therapist #7 did not think there was enough therapy staff available.

c) On 02/10/17 at 1:12 p.m., an interview with the Director of Clinical Services (Director #8) was conducted. Director #8 stated his/her responsibilities as a Director included managing, supporting and guiding the team and acting as a consultant for difficult cases and issues that came up in the patient care units. Director #8 stated therapists were expected to conduct the Psychosocial Assessment within 24 hours of patient's admission. Director #8 further stated s/he did not know why therapists were not meeting the expectation of conducting the psychosocial assessment within the required 24 hour time frame. Director #8 explained the Clinical Services Department was short staffed and s/he was currently carrying a 10 patient case load in addition to his/her responsibilities as Director. Director #8 stated s/he had not been able to conduct medical record audits, or attend morning meetings because of the patients s/he was assigned to provide services for.

d) On 02/13/17 at 4:20 p.m., an interview was conducted with CEO #1 who stated the facility's expectation was for patients to be seen by a therapist within 24 hours of admission. CEO #1 stated the facility had been dealing with inconsistent staffing and performance issues with therapists. CEO #1 further stated there had been coaching provided to therapy staff over the past 3 months regarding time management and expectations.

Based on observations, interviews, and document review the facility failed to provide services in a safe environment in accordance with patients' rights.

This failure created the potential for negative outcomes related to an increased risk for patient elopements. In addition, this failure resulted in a lack of the immediate availability emergency patient supplies.

FINDINGS

POLICY

According to the policy, Suctioning: Oral, Nasopharyngeal Oropharyngeal, the following equipment is maintained per facility policy and checked daily for function: portable suction unit with tubing, Yankauer catheter tip.

REFERENCE

According to the Daily Emergency Cart Checklist, Suction Machine Check: with tubing and Yankauer.

1. The facility did not support patients' right to safe care when it failed to ensure adequate processes were in place to prevent the recurrence of patients eloping or attempting to elope from the facility.

a) On 02/10/17 at 3:44 p.m., a "Code Green" alarm was announced over the intercom system at the facility. At 4:50 p.m., an interview was conducted with the Chief Executive Officer (CEO #1), who revealed a Code Green alarm meant a patient had eloped from the facility. CEO #1 stated the patient was a 17-year-old who was outside for recreational therapy when s/he ran and jumped on top of a window ledge, climbed onto the roof and left the facility.

b) A review of the Incident Report Log from 10/01/16 - 01/31/17 revealed the facility experienced multiple attempted patient elopements and successful elopements during the period reviewed. Specifically, 2 successful patient elopements and 8 attempted patient elopements from the facility had occurred during the timeframe. According to the incident reports:

i) On 10/30/16 at 1:20 p.m., Patient E broke through double doors in an elopement attempt from the secured unit. Police were contacted. This occurred on a locked adult inpatient unit (Unit 400).

ii) On 12/09/16 at 4:50 p.m., Patient F was out of control, throwing his/herself against the door, had eloped during a earlier shift and was coaxed back to the unit. There was no earlier incident report documenting what had occurred during the earlier shift elopement. This occurred on a locked adolescent inpatient unit (Unit 700).

iii) On 12/16/16 at 7:22 p.m., Patient B was in a family meeting when the patient became angry and agitated, destroyed the conference room table, punched a hole in the wall, threw a chair at the wall and eloped from the facility. Additional Progress Note documentation documented by Registered Nurse #15 (RN) stated the patient ran towards the assessment and referral department, pushed through the locked doors, ran towards the ambulance door and pushed through that door eloping. Patient B did not return to the facility. The ambulance door was observed to be a locked door leading from a hallway to the outside.

iv) On 12/16/16 at 1:36 a.m., Patient G attempted to elope by breaking through 2 locked doors on the unit and into the hallway. Patient G made statements of self-harm and threats to staff prior to the elopement attempt. This occurred on Unit 400.

v) Patient H had 1 successful elopement and 3 elopement attempts documented during his/her visit from 01/16/17 to 01/31/17. Patient H was located on the secured Unit 400.

On 01/19/17 at 5:47 p.m., Patient H was observed (by camera) trying to elope from the facility. The patient jumped the dutch door, jumped into the nurses station and ran for the door. When Patient H was unable to elope, Patient H jumped back onto the unit. The attempt was not witnessed by floor staff.

On 01/19/17 at 8:17 p.m., Patient H eloped from the rooftop of a facility building during a smoke pass, with the help from another patient. A Code Green was called and the Police Department was notified. Patient H returned hours later.

On 01/22/17 at 9:00 p.m., Patient H became agitated, ran down the hall and smashed into the exit door, damaging the frame and caused the door to crack open.

On 01/25/17 at 12:00 p.m., Patient H required an escort and medications after the patient eloped from the secured unit.

vi) On 01/20/17 at 9:11 a.m., Patient A was posturing at staff, threatened spitting, experienced increased agitation which lead to ripping picture frames with large screws off the wall and throwing. The patient ran through 4 sets of doors to the front lobby where Patient A was restrained. Patient A was located on the secured Unit 400.

vii) On 01/27/17 at 2:40 p.m., a Code Green on unit 700 was called after Patient C kicked a door open.

c) On 02/09/17 at 4:13 p.m., an interview with a Mental Health Technician (MHT #2) was conducted. MHT #2 stated s/he recalled working on a patient unit approximately one month ago when a patient became agitated and rammed into the locked doors of the unit until they broke. MHT #2 explained staff debriefing meetings usually occurred after negative patient incidents; however, s/he was not involved in the debriefing meeting after the incident s/he had just described. When asked if any education or changes in process occurred as a result of the incident, MHT #2 stated s/he was told the facility was looking into fixing the doors and that s/he was attempting to stand closer to the doors in order to decrease risks of patients breaking through them.

d) On 02/10/17 at 11:29 a.m., an interview was conducted with MHT #4 who revealed s/he worked primarily on Unit 400, which was a locked acute adult care unit. MHT #4 stated s/he had never seen a patient break through doors in the facility but s/he had been caring for patients in the gymnasium when a patient broke through the doors on unit 400. MHT #4 stated patient care issues were usually addressed in staff Town Hall meetings or at MHT meetings; however, MHT #4 could not recall discussing patients eloping or attempting to elope at any of the meetings s/he had attended.

e) On 02/09/17 at 10:17 a.m., an interview with Registered Nurse (RN #3) was conducted. RN #3 stated s/he was aware of incidents where patients were able to leave secured patient care units by pushing through locked doors. RN #3 stated s/he had not received any training on how to decrease the potential for patients to elope from the facility.

f) On 02/09/17 at 3:45 p.m., an interview with the Director of Plant Operations (Director #16) was conducted. Director #16 stated the first incident of a patient breaching a locked door occurred on 12/16/16. This was in contrast to the Incident Report Log that documented Patient E broke through a set of double doors on unit 400 on 10/28/16. Director #16 stated in December s/he researched to assess if there were similar issues occurring at other facilities with secured doors being broken through. Director #16 had found that a sister facility had installed additional magnetic lock and bolt systems to their doors for added security. Director #16 stated s/he was planning to install additional magnetic lock and bolt systems to 2 of the doors that had been breached to see if the added security was successful. Director #16 stated s/he was granted approval by the facility's corporate office to place an order for two of the magnetic lock and bolt systems; however, they had not been received and installed at the time of the interview.

An additional interview with Director #16 was conducted on 02/10/17 at 10:30 a.m. Director #16 stated the order for the two additional magnetic lock and bolt systems was placed on 02/09/17 (7 days after the survey had begun) and s/he was waiting to schedule a time for the installation. Director #16 stated installing the additional magnetic lock and bolt systems could have potentially prevented future incidents of patients breaking through locked doors.

g) The Director of Quality and Risk Management (Director #5) was interviewed throughout the investigation. On 02/10/17 at 7:56 a.m., video surveillance of Patient A breaking through doors on 01/20/17 was reviewed with Director #5. Director #5 stated a security company came to the facility after the incident and tested all of the doors to assess if they were in working order. Director #5 then stated s/he was not sure if the security company offered any suggestions on how to prevent future locked doors from being breached.

On 02/10/17 at 10:06 a.m., Director #5 described education opportunities offered to staff pertaining to patient elopements or attempted elopements. In December, Director #5 stated a memo explaining hallway monitoring expectations was given to all direct care staff and signed off in their personnel files. In addition, Director #5 stated debriefing meetings occurred with involved staff after events of patients breaking through doors and documentation of the meetings would be filed in the patient's medical record.

A review of 9 direct care staff personnel files was conducted (3 MHT's, 2 RNs, 2 therapists and 2 intake assessment staff) and revealed only one staff member (a MHT) received a memo regarding hallway monitoring expectations. In addition, a review of Patient A's medical record revealed no evidence a debriefing meeting was conducted with involved staff regarding the 01/20/17 incident of the patient breaking through 4 sets of doors.

On 02/13/17 at 12:34 p.m., an interview was conducted with Director #5, who stated s/he was not aware of the incident that occurred on 10/28/16 where Patient E broke through a set of double doors. Director #5 explained that staff were performing weekly safety checks on all doors to ensure the doors were in working order. In addition, Director #5 stated after receiving input from the facility's corporate home office, the decision was made to reinforce the magnetic locks on the doors. Director #5 then stated s/he did not know why the order for the additional magnetic lock and bolt systems had not been submitted until 02/09/17.

h) On 02/10/17 at 2:19 p.m., an interview with the Chief Executive Officer (CEO #1) was conducted. CEO #1 stated s/he relied on the Director of Plant Operations (Director #16) for his/her guidance on solutions with the issues pertaining to locked doors being broken. CEO #1 stated s/he was unsure if installing additional magnetic lock and bolt systems was the solution because s/he did not know if the sister facility who implemented the systems was successful. CEO #1 then stated 2 sets of magnetic lock and bolt systems had been ordered on 02/09/17 and that Director #16 had received approval to order a new door to replace a door that had been damaged when a patient broke through it on 01/20/17.

The facility delayed implementing actions for approximately 2 months to increase security and safety measures after being aware of patient elopements and elopement attempts in December 2016. During this delay there were 2 successful elopements from the facility and 5 elopement attempts documented.

2. The facility failed to ensure supplies required in emergency situations were readily available on top of the emergency crash carts pursuant to facility policy.

a) A tour was conducted on 02/02/17 at 12:35 p.m., with CEO #1 in which all units were toured. During the tour all the tops of crash carts were checked against the emergency cart checklist provided. Three of the 4 carts inspected were missing emergency equipment as required by the facility emergency cart checklist.

Unit 200: missing a yankauer (a rigid hollow tube made of disposable plastic with a curve at the distal end to facilitate the removal of thick pharyngeal secretions during oral pharyngeal suctioning in medical emergencies/procedures).

Unit 300: missing yankauer and tubing

Unit 400 and unit 500 shared code cart: missing yankauer

b) On review of all facility unit Emergency Cart Checklists for February, 2017 which had a check box for suction machine check with tubing and yankauer, showed all units had been checked off as completed by staff although 3 of the 4 emergency carts were missing yankauers and/or tubing.

c) On 02/02/17 at 1:05 p.m., while on tour, an interview was conducted with RN #13 who stated if a yankauer and tubing were needed during an emergency situation and were not located on top of the crash cart, s/he would run to another unit to obtain the equipment needed.

On 02/09/17 at 2:32 p.m. an additional interview was conducted with RN #13 who stated the suction machine along with the yankauer and tubing should be located on top of the cart and if it wasn't, the risk would be a delay due to the additional time it would take to find the needed emergency equipment.

d) On 02/09/17 at 10:17 a.m. an interview was conducted with RN #3 who stated night shift staff were responsible for checking the crash carts daily and stated a yankauer and suction tubing should be located with each suction machine.

Based on observations, interviews and document review, the facility failed to implement preventative actions and process changes in response to trends of similar patient safety incidents which occurred in the facility.

The failure resulted in the risk of negative patient outcomes and may have contributed to the recurrence of patient elopements or attempted elopements from the facility.

FINDINGS

1. The facility failed to implement necessary process changes or safety measures to protect patients after a trend of elopements or attempted elopements from the facility occurred.

a) On 02/10/17 at 3:44 p.m., a "Code Green" alarm was announced over the intercom system at the facility. At 4:50 p.m., an interview was conducted with the Chief Executive Officer (CEO #1), who revealed a Code Green alarm meant a patient had eloped from the facility. CEO #1 stated the patient was a 17-year-old who was outside for recreational therapy when s/he ran and jumped on top of a window ledge, climbed onto the roof and left the facility.

b) A review of the Incident Report Log from 10/01/16 - 01/31/17 revealed the facility experienced multiple attempted patient elopements and successful elopements during the period reviewed. Specifically, 2 successful patient elopements and 8 attempted patient elopements from the facility had occurred during the timeframe. According to the incident reports:

i) On 10/30/16 at 1:20 p.m., Patient E broke through double doors in an elopement attempt from the secured unit. Police were contacted. This occurred on a locked adult inpatient unit (Unit 400).

ii) On 12/09/16 at 4:50 p.m., Patient F was out of control, throwing his/herself against the door, had eloped during a earlier shift and was coaxed back to the unit. There was no earlier incident report documenting what had occurred during the earlier shift elopement. This occurred on a locked adolescent inpatient unit (Unit 700).

iii) On 12/16/16 at 7:22 p.m., Patient B was in a family meeting when the patient became angry and agitated, destroyed the conference room table, punched a hole in the wall, threw a chair at the wall and eloped from the facility. Additional Progress Note documentation documented by Registered Nurse #15 (RN) stated the patient ran towards the assessment and referral department, pushed through the locked doors, ran towards the ambulance door and pushed through that door eloping. Patient B did not return to the facility. The ambulance door was observed to be a locked door leading from a hallway to the outside.

iv) On 12/16/16 at 1:36 a.m., Patient G attempted to elope by breaking through 2 locked doors on the unit and into the hallway. Patient G made statements of self-harm and threats to staff prior to the elopement attempt. This occurred on Unit 400.

v) Patient H had 1 successful elopement and 3 elopement attempts documented during his/her visit from 01/16/17 to 01/31/17. Patient H was located on the secured Unit 400.

On 01/19/17 at 5:47 p.m., Patient H was observed (by camera) trying to elope from the facility. The patient jumped the dutch door, jumped into the nurses station and ran for the door. When Patient H was unable to elope, Patient H jumped back onto the unit. The attempt was not witnessed by floor staff.

On 01/19/17 at 8:17 p.m., Patient H eloped from the rooftop of a facility building during a smoke pass, with the help from another patient. A Code Green was called and the Police Department was notified. Patient H returned hours later.

On 01/22/17 at 9:00 p.m., Patient H became agitated, ran down the hall and smashed into the exit door, damaging the frame and caused the door to crack open.

On 01/25/17 at 12:00 p.m., Patient H required an escort and medications after the patient eloped from the secured unit.

vi) On 01/20/17 at 9:11 a.m., Patient A was posturing at staff, threatened spitting, experienced increased agitation which lead to ripping picture frames with large screws off the wall and throwing. The patient ran through 4 sets of doors to the front lobby where Patient A was restrained. Patient A was located on the secured Unit 400.

vii) On 01/27/17 at 2:40 p.m., a Code Green on unit 700 was called after Patient C kicked a door open.

c) A review was conducted of the Quality Council meeting minutes held on 12/20/16 and 01/17/17.

i) The Quality Council meeting on 12/20/16 included a review of the meeting minutes from the Quarterly Quality Risk Report held on 12/08/16. An Incident Report Trending chart was presented which revealed no elopements or elopement attempts occurred during the month of October.

This was in contrast to the incident report dated 10/30/16 which documented Patient E's elopement attempt from the facility.

ii) The Quality Council meeting on 01/17/17 included a report of two incidents in which patients were able to run through secured doors and security management was working with a vendor and other Environment of Care (EOC) Directors regarding door magnetic locks not holding in place. This was one month after the first incident of a patient breaking through secured doors occurred.

The Quality Council meeting from 01/17/17 also included a review of the meeting minutes from POD department Quality Counsel Report on 01/05/17. The meeting minutes stated in December of 2016, a security company was contacted about additional magnetic locks for certain doors due to 2 instances where a patient was able to run through the door with the mag lock in place and full contact between magnet and strike plate. The facility reached out to EOC Directors during a bi-weekly EOC conference call and found that a sister facility had the same issue and utilized these additional locks to solve the problem. Documentation stated the facility was working through the approval process now.

Additionally, the 01/17/17 Quality Council meeting included a review of the meeting minutes from the Quarterly Quality and Risk Report on 01/08/17 which noted the EOC was looking into additional magnetic locks to place on higher acute units and accessible exit areas to patients while in transition.

Further the meeting minutes stated magnetic locks on doors did not hold with full patient contact between magnet and strike plate. Further documentation revealed the EOC was to review with other EOC Directors and address the use of additional door magnetic locks.

However, there were no additional magnetic locks installed on any of the facility doors during observations conducted on 02/09/17. This was approximately 2 months after the facility identified the door lock failure and a patient had broken through secured doors. During the 2 month delay, 3 additional incidents which involved breaking or damaging doors during elopement attempts were reported.

d) On 02/09/17 at 3:45 p.m., an interview with the Director of Plant Operations (Director #16) was conducted. Director #16 stated the first incident of a patient breaching a door occurred on 12/16/16. This was in contrast to the Incident Report Log that documented Patient E broke through a set of double doors on unit 400 on 10/28/16.

Director #16 stated in December s/he researched to assess if there were similar issues occurring at other facilities with secured doors being broken through. Director #16 had found that a sister facility had installed additional magnetic lock and bolt systems to their doors for added security. Director #16 stated s/he was planning to install additional magnetic lock and bolt systems to 2 of the doors that had been breached to see if the added security was successful. Director #16 stated s/he was granted approval by the facility's corporate office to place an order for two of the magnetic lock and bolt systems; however, they had not been received and installed at the time of the interview.

An additional interview with Director #16 was conducted on 02/10/17 at 10:30 a.m. Director #16 stated the order for the two additional magnetic lock and bolt systems was placed on 02/09/17 (7 days after the survey had begun) and s/he was waiting to schedule a time for the installation. Director #16 stated installing the additional magnetic lock and bolt systems could have potentially prevented future incidents of patients breaking through locked doors.

e) The Director of Quality and Risk Management (Director #5) was interviewed throughout the investigation. On 02/10/17 at 7:56 a.m., video surveillance of Patient A breaking through doors on 01/20/17 was reviewed with Director #5. Director #5 stated a security company came to the facility after this incident and tested all of the doors to assess if they were in working order. Director #5 then stated s/he was not sure if the security company offered any suggestions on how to prevent future locked doors from being breached.

On 02/10/17 at 10:06 a.m., Director #5 described education opportunities offered to staff pertaining to patient elopements or attempted elopements. In December, Director #5 stated a memo explaining hallway monitoring expectations was given to all direct care staff and signed off in their personnel files. In addition, Director #5 stated debriefing meetings occurred with involved staff after events of patients breaking through doors and documentation of the meetings would be filed in the patient's medical record.

A review of 9 direct care staff personnel files was conducted (3 MHT's, 2 RNs, 2 therapists and 2 intake assessment staff) and revealed only one staff member (a MHT) received a memo regarding hallway monitoring expectations. In addition, a review of Patient A's medical record revealed no evidence a debriefing meeting was conducted with involved staff regarding the 01/20/17 incident of the patient breaking through 4 sets of doors.

On 02/13/17 at 12:34 p.m., an interview was conducted with Director #5, who stated s/he was not aware of the incident that occurred on 10/28/16 where Patient E broke through a set of double doors. Director #5 explained that staff were performing weekly safety checks on all doors to ensure the doors were in working order. In addition, Director #5 stated after receiving input from the facility's corporate home office, the decision was made to reinforce the magnetic locks on the doors. Director #5 then stated s/he did not know why the order for the additional magnetic lock and bolt systems had not been submitted until 02/09/17.

Although the facility was aware of a recurrent patient safety concern for approximately 2 months, they failed to implement process changes until a concern was raised during a survey by the State agency.

Based on observations and interviews the facility failed to have a Registered Nurse (RN) present for immediate availability on each patient care unit.

This failure created an environment where patients were placed in the care of staff unqualified to provide RN level of care.

FINDINGS

POLICY

According to the policy, Staffing Plan for Provision of Care, there shall be sufficient number of qualified and competent registered nurses on the unit to provide patients with nursing services which require the judgment and specialized skill of the competent registered nurse.

1. The facility routinely left patients unsupervised by RN staff on patient care units.

a) A tour of the adolescent psychiatric units was conducted on 02/10/17 at 3:49 p.m. with the Chief Executive Officer (CEO #1). Observation revealed the RN responsible for patient care for unit 600 was off the unit and the RN for unit 700 was conducting a family meeting off unit and behind a closed door as well. The Director of Nursing (DON #6) was located outside of the nursing station on the phone with the town police due to a patient elopement.

This left two patient care units without RNs present to provide immediate patient care .

b) Review of the Registered Nurse (RN) and Mental Health Technician (MHT) staffing schedules from 01/01/17 to 02/12/17 revealed Unit 600 and Unit 700 were listed together with the same staff scheduled to work on both of the units. Sixteen days in January, 2017 and 6 days in February, 2017 showed only one RN scheduled to work on both Unit 600 and Unit 700. For example, on 01/20/17, the combined census for Unit 600 and Unit 700 was 18 patients; however, only 1 RN was scheduled to work on both Unit 600 and Unit 700 throughout the day.

c) On 02/10/17 at 11:29 a.m. an interview was conducted with MHT #4, who had worked on several units in the facility. S/he stated there was not enough staffing to care for patients at the facility and s/he had been left alone on the units without a RN. S/he stated each hallway represented its own unit. S/he stated if there wasn't a nurse on the unit the walkie-talkie could be used to contact help but sometimes nurses did not respond to the call. MHT #4 stated s/he has had to call emergency codes over the walkie-talkie to get help with patients when left alone on the unit.

d) On 02/09/17 at 4:29 p.m. an interview was conducted with Therapist #7, who stated MHTs were left alone on the units in charge of patient care. S/he stated an incident had occurred the night before were s/he had to intervene on the unit to maintain patient safety due to a nurse not being available on the unit.

e) During an interview on 02/09/17 at 10:17 a.m. during an interview with RN #3, who floated to several different units in the facility, stated his/her biggest concern was with the lack of appropriate staffing and there was not always a nurse on the unit. RN #3 stated the nurse to patient ratio was supposed to be 10 patients assigned to 1 nurse; however, s/he frequently was assigned more than 10 patients.

f) During an interview, on 02/09/17 at 2:32 p.m., RN #13 who was working with the geriatric patient population, stated s/he felt overwhelmed due to the lack of appropriate staffing at the facility. S/he stated the geriatric psychiatric unit had been left without nursing staff as recently as today. Two Mental Health Technicians (MHT's) were left on the unit while the RN went to lunch.

g) On 02/10/17 at 12:45 p.m. an interview was conducted with the House Supervisor (RN #15) who was in charge of the facility on the evening and night shift. RN #15 stated nurses were expected to be on the unit at all times and s/he was aware of nurses leaving the unit for breaks without another nurse watching the unit. S/he stated the risk of not having a nurse on the unit could be a patient emergency with untrained MHT's to care for the patient. RN #15 stated RN's took a walkie-talkie with them to lunches.

h) On 02/09/17 at 5:20 p.m. an interview was conducted with the Director of Nursing (DON #6) who stated s/he was aware units were left without a RN. DON #6 then stated the facility did not have a stated patient ratio and explained RN patient assignments were based on the acuity of the patients which was determined by the RN responsible for creating the staffing schedule.

On 02/13/17 at 2:43 p.m. an additional interview was conducted with DON #6 who stated all patient units, including Unit 600 and Unit 700, were considered separate units with a shared nursing station. DON #6 stated the expectation was that each patient unit had a minimum of one RN and one MHT assigned at all times. DON #6 then stated on night shift the nurses assigned to patient care Unit 400 and Unit 500 would cover each other and the nurse assigned to Unit 600 and Unit 700 for their meal breaks. This resulted in 1 RN assigned to 2 patient care units at the same time.

i) The Director of Quality (Director #5) was interviewed several times throughout the survey. On 02/09/17 at 11:40 a.m., Director #5 stated all patient care units were scheduled to have at least one RN staffed at all times. Director #5 then stated guidelines were used to determine how many patients were assigned to RNs and that s/he liked the patient assignments at 10 patients to 1 RN.

On 02/10/17 at 10:06 a.m., Director #5 stated a RN was not always on the unit with the patients. S/he felt the facility used a transitional model of care and MHT's were qualified to care for patients due to training in Cardiopulmonary Resuscitation and de-escalation techniques, which was in contrast to policy. Review of job descriptions for a RN noted the position summary stated the skills required of the RN is a comprehensive understanding of the approved scope of nursing practice and application of nursing standards and practices. Review of the job description for the mental health technician revealed nursing standards of practice were not listed as skills required.

On 02/13/17 at 12:34 p.m., Director #5 stated Unit 600 and Unit 700 were separate patient units and the facility staffed one RN to work on both units at the same time.

Based on interviews and document review, the facility failed to provide ongoing nursing care based on facility policy for 4 of 11 records reviewed (Patients #2, #4, #8 and #10). In addition, nursing staff failed to ensure telephone verbal orders, physician orders and face to face evaluations were signed by physicians in 2 of 11 medical records reviewed (Patients #4 and #6)

These failures prevented reassessment of patients and alerting of staff and physicians in patient condition changes.

FINDINGS:

POLICY

According to the policy, Vital Signs, any of the following abnormal vital sign readings on adult and Geriatric patient will be reported to the unit nurse immediately: blood pressure (B/P)-greater than 140/90 or less than 100/60 and for child/adolescents: greater than 140/90 or less than 95/60. If abnormal findings were obtained by the automatic vital signs machine, repeat vital signs within 5-10 minutes to verify the finding using a manual B/P cuff and pulse reading.

Verification of vital signs must be completed by a registered nurse along with assessment in regards to hydration, medication changes, new admission anxiety etc. Registered Nurse (RN) notifies the physician of the abnormal findings and any corresponding symptoms or complaints immediately or within 30 minutes of verifying the abnormal vital signs (VS). Notification of the physician and their orders must be documented in the patient's chart.

According to the policy, Medical Treatment Log, the purpose was to ensure all individuals who present themselves for treatment services are documented in the Request for Medical Treatment log located on every nursing station indicating the need for a History and Physical (H&P). This log will be reviewed daily by the medical providers and patients will be seen and treated accordingly.

According to the policy, Verbal/Telephone orders and Test Results, verbal orders must be authenticated by the person who issued it at the earliest opportunity but no more than 48 hours after issued. Authentication consists of the prescriber verifying the order in the chart.

1. The nursing staff failed to reassess patients after abnormal blood pressures were obtained. Furthermore, nursing staff did not report the abnormal vital sign findings to the physician assigned to the patient's care.

a) Record review showed Patient #2 was admitted to the facility on 11/23/16 with a diagnosis of Bipolar. According to the History and Physical, dated 11/24/16, the patient also had the additional diagnoses of hypertension. Review of a Vital Signs Flowsheet, dated 11/24/16-11/27/16, showed Patient #2 had 4 out of 8 blood pressure reading as abnormal with readings as high as 181/120 on 11/26/16. According to the flowsheet there was no reassessment and no documentation the physician had been notified. This was in direct contrast to the facility's policy.

i) Record review showed Patient #4 was admitted to the facility on 11/22/16 with a diagnosis of Major Depressive Disorder. Review of the Vital Signs Flowsheet, dated 11/26/16, showed Patient #4 at 4:17 p.m. had an abnormal blood pressure of 170/70. According to the flowsheet no reassessment, along with no documentation the physician had been notified was documented.

ii) Record review indicated Patient #8 was admitted to the facility on 01/30/17 with Schizophrenia. Review of a Vital Signs Flowsheet, showed Patient #8 had 2 blood pressure readings as abnormal. On 02/02/17 at 6:28 a.m., 154/95 and then again on 02/03/17 at 6:43 a.m., 144/93. No further documentation of reassessment or notification of the physician as required by the facility policy was evident.

iii) Record review showed Patient #10 was admitted to the facility on 01/20/17 with Intermittent Explosive Disorder. Review of a Vital Signs Flowsheet, showed Patient #10 had 11 of 16 blood pressure reading as abnormal with blood pressure readings as low as 76/40 on 01/29/17 at 6:50 a.m. According to the flowsheet there was no reassessment of the 11 abnormal blood pressures. Furthermore, no further documentation of physician notification was found, which was in contrast to policy.

b) On 02/09/17 at 4:13 p.m. an interview with Lead Mental Health Technician (MHT) #2 was conducted. MHT #2 stated VS were documented on the Vital Sign flow sheet by MHTs. The Vital Sign flowsheet reflected the facility's policy for abnormal VS parameters. The MHT stated an abnormal blood pressure would be greater than 160/100. This was in direct contrast to the facility's policy which stated a blood pressure (B/P) greater than 140/90 was abnormal.

c) On 02/09/17 at 10:17 a.m. an interview was conducted with Registered Nurse (RN #3) who stated any abnormal VS was expected to be rechecked by the mental health technician (MHT) at the RN's direction. If still abnormal, the RN's were expected to check a manual blood pressure (B/P) and notify the physician.

RN #3 stated a blood pressure of 181/120, would be concerning for risks such as a stroke, massive headache or an aneurysm. S/he stated low B/P in a patient could indicate dehydration or overmedication and risks of low blood pressure in a patient could result in death. RN #3 stated usually MHTs did not know the normal ranges for B/P.

d) On 02/08/17 at 12:24 a.m., the Director of Nursing (DON #6), was interviewed. DON #6 stated the expectation of nursing staff, after finding abnormal vital signs, would be to recheck the vital signs and if the results were still abnormal the expectation would be for the RN to notify the patient's physician. Director # 6 stated there would be many risks to patients, with VS outside of parameters, especially patients on psychiatric medications.

2) The nursing staff failed to verify and follow-up on patient's medical complaints to ensure the patients were seen and treated by medical providers accordingly.

a) A review of the History and Physical (H&P) board & Medical treatment Log (the Log) for units 200, 300, 400 for the month of January 2017 and 1 week in November 2016 for unit 500 revealed 24 medical concerns were not signed off by a practitioner indicating the practitioner was aware of the issue.

A review of the Log for unit 500, dated 11/26/16, showed Patient #2 was placed on the Log with a concern of the patient thinks s/he may be having an allergic reaction to Lithium (generalized swelling, relieved with Benadryl). No practitioner signature was documented to show evidence the concern was noted and addressed by the physician.

On review of Patient #2's medical record, there was no documentation the patient's allergic reaction was addressed by physician staff. Patient #2 was given Benadryl on 11/26/16 at 7:35 p.m. by the RN. The physician order for Benadryl was for 25 milligrams (mg) at bedtime as needed for sleep. There was no documentation of facial swelling or follow up of the medication before or after the medication was given by the RN.

b) On 02/09/17 at 10:17 a.m. an interview and review of the Log for Patient #2's entry on 11/26/16 was conducted with RN #3. RN #3 stated the medical board was for the medical team to review issues RNs identified with patients. S/he stated a nurse would be expected to review the Log in the morning to see if the medical team had addressed the patients concerns. On review of the Medical Treatment Log for Patient #2 s/he stated according to the documentation the patient's allergic reaction was not addressed.

c) On 02/13/17 at 2:45 p.m. an interview was conducted with DON #6 who stated, after s/he personally reviewed Patient #2's medical record, s/he found no documentation regarding an allergic reaction or facial swelling as indicated on the Log. S/he stated the facility had policies to follow up on allergic reactions and would consider the patients puffy face after a medication to be an allergic reaction.

According to DON #6, a practitioner signature indicated the patient's concerns had been addressed. S/he also reviewed the Log to see if signatures were missed but had not addressed the issue of missing signatures to the log.

3) The nursing staff failed to ensure telephone verbal orders, physician orders and face to face evaluations were signed by physicians.

a) A review of Patient #6's medical record revealed 6 Telephone Order Read Back (TORB) orders in the patient's medical record which were not signed by a physician.

i) On 01/30/17 at 2:50 p.m. an order was placed by the RN which stated: "room search, all personal items removed, random skin checks every shift".

On 01/30/17 at 6:15 p.m. a TORB was documented by a RN which stated: "Pt [patient] was unit restricted with finger foods only until [s/he] allows nursing to complete ordered skin checks".

On 01/31/17 at 5:28 p.m. a TORB was placed by the RN which stated: "Remove personal items from room, place patient on M1 hold, place [patient] in seclusion up to 1 hour."

On 01/31/17 at 9:26 p.m. a TORB was written by a RN which stated physical hold/escort less than 5 minutes.

None of the TORB's had physician signatures, which was in contrast to facility policy.

ii) On review of Patient #6's Physician Order for Restrictive Interventions for Behaviors form documented on 01/31/17 at 5:28 p.m. and 8:49 p.m., the physician's section intended for documenting about the intervention was blank , along with no signature by physician on either form.

Additionally, on review of the One Hour Face to Face Evaluation for Patient #6, for 01/31/17 at 5:28 p.m. and again at 8:49 p.m. showed there was no physician signature on either form.

b) A review of Physician Orders, dated 11/27/16 at 7:30 p.m., in Patient #4's medical record, showed a TORB was documented by a RN: Norco 5/325, 1 tablet, orally, 3 times a day, as needed, for pain. The order was signed by the RN with no signature from the provider.

c) On 02/09/17 at 10:17 a.m. an interview was conducted with RN #3 who stated TORB's were to be signed by the physician the following day. S/he stated the risk for not having a physician sign the verbal orders could be a nurse could be ordering things the provider may not have ordered.

d) On 02/13/17 at 2:45 p.m. an interview was conducted with DON #6. S/he stated TORB orders needed to be signed by the provider within 48 hours per policy and the risk of not having a TORB signed by a physician was the order could not be authenticated.

Based on observation and interviews the facility failed to ensure control solution used for quality control checks of glucometers were not expired for 2 of 3 medication rooms toured. Further, the facility failed to ensure broken glucometers were taken out of service prior to use on patients.

This failure created the potential for negative patient outcomes due to inaccurate blood glucose monitoring.

FINDINGS

POLICY

According to the policy, Glucometer Testing and Quality Controls, write down the date when the control solution was first opened. Discard three months after the date of first opening. Maintenance was to be performed according to the manual.

According to the policy, Medical Equipment Management Program, when any piece of equipment used or may come into contact with a patient, visitor, or employee was deemed not to be operating properly or had been broken or damaged, it should be removed immediately from service and a defective tag attached securely to the item.

REFERENCE

According to EvenCare G2 Blood Glucose Monitoring System User's Guide, record the "date opened" on the bottle label, discard the bottle and any remaining test strips after 6 months from date of opening.

Important: if cracking of the plastic housing was noticed stop using the device.

1. The facility did not identify the expiration dates on the EvenCare control solutions or test strips used on equipment for monitoring patient's blood glucose levels.

a) On 02/09/17 at 11:40 a.m., a tour of the shared medication room for unit 600 and unit 700 revealed opened glucose control solutions and test strip bottles. The expiration date written on the control vials was ineligible due to fading and smudging of the writing and the test strips bottle had no date indicating when the bottle had been opened or when the test strips expired.

During the tour an interview with Registered Nurse #12 (RN), who was working in the medication room for 600 and 700 units, was conducted. RN #12 was unable to identify the expiration date written on the control solution. RN #12 stated when dating control solution for expiration, the procedure was to write the date the solution was opened and then the solution was good for 30 days. RN #12 was unsure when test strips expired.

b) On 02/09/17 at 12:10 p.m. a tour of the medication room for unit 200 revealed glucose control solutions and test strips bottle in use, none of which had open or expiration dates written on the bottle. Furthermore, the glucose monitor on the unit had a plastic rubber band around the machine and was missing the back casing of the machine.

During the tour, an interview was conducted with RN #13 who was working in the medication room of unit 200 with the geriatric patient population. RN #13 stated s/he was unsure when glucose solution or test strips expired. RN #13 also stated the glucose monitor on the unit with a missing back and a rubber band around the machine had been in place for approximately 1 to 2 weeks. S/he stated the rubber band was in place to hold the batteries in place. RN #13 stated s/he had used the machine this morning but was unable to get the machine to function properly.

c) During an interview on 02/13/17 at 2:45 p.m. with the Director of Nursing, (DON #6), s/he stated staff was expected to follow facility policy and the risk of using a broken glucometer or outdated control solutions could be an inaccurate reading of the patient's blood glucose level.

d) During an interview on 02/13/17 at 1:22 p.m. with the Director of Quality and Risk, (Director #5), s/he stated the broken glucometer on Unit 200 should have been taken out of commission and notification to the DON should have happened. S/he stated the risk of using broken glucometers and outdated control solution could be inaccurate results.