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

A-0144 CARE IN SAFE SETTING The patient has the right to receive care in a safe setting. Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which pose a safety risk to patients or others, were not accessible to patients in the inpatient psychiatric units in two of five patient care units observed.

Based on observations, interviews and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which posed a safety risk to patients or others, were not accessible to patients in the inpatient psychiatric units in two of five patient care units observed.

Findings include:

Facility policy:

According to the policy, Environmental and Hospitality Rounds, Tasks for day/evening Environmental Rounds: Gather all linens on the floor, and all excess linens on beds and sinks or shelving. Check bedding for 5 pieces of linen and remove the rest. Bring new linen if necessary. 5 primary pieces of linen include: 1) pillow case 2) blanket (max of two) 3) top sheet 4) bottom sheet 5) hand towel. No hygiene items should be left in the room or bathroom.

1. The facility failed to ensure excess linens and hygiene products were monitored and not accessible to patients within patient rooms in the inpatient psychiatric units.

a. On 6/13/22 from 10:20 a.m. to 11:35 a.m., observations revealed excess linens and hygiene products were left unsupervised in patient rooms.

i. At 10:41 a.m., observations of Room 1205 the Torrey's Peak Unit - Adult Mental Health Unit revealed three blankets lying on top of the bed.

This was in contrast to the Environmental and Hospitality Rounds, which read the maximum amount of blankets allowed was two.

ii. At 11:26 a.m., observations of Room 821 of the Pikes Unit -Intensive Treatment Unit (ITU) revealed a basket with a comb, toothbrush, toothpaste, hand lotion, and mouthwash in the room. There was also a bottle of shampoo observed in the shower of the bathroom.

iii. At 11:33 a.m., observations of Room 819 of the Pikes Unit - Intensive Treatment Unit (ITU) revealed a basket containing multiple hygiene items on the shelf next to bed B and there were three blankets observed on top of the bed. In addition, there was also a brush, toothbrush, deodorant, toothpaste, and a bottle of body lotion in the shower. On top of Bed A, a robe was observed under the patient pillow.

During this observation, the director of risk (Director) #4 stated the robe was not allowed to be in the room due to infection control risk. Director #4 then removed the robe from the room and placed it in a locked patient belongings closet.

iv. At 11:35 a.m., observations of Room 817 of the Pikes Unit -Intensive Treatment Unit (ITU) had 3 blankets in the room with only one patient occupying the room at the time. There was one blanket on the bed and two blankets on the floor when observed.

b. Interviews

i. An interview on 6/13/22 at 11:35 a.m. with Mental Health Technician (MHT) #5 on Pikes Unit (Intensive Treatment Unit) was conducted. MHT #5 stated environmental checks were expected to be completed every shift by a tech, which included conducting a walkthrough of the unit, emptying trash, picking up extra linen, and checking under the bed and in pillows for contraband. MHT #5 reported during environmental checks the MHT was also expected to look for food and food wrappers in patient rooms, assess whether the lights were working properly, ensure the bathroom was safe for use, collect hygiene items, and remove any excess clothing. MHT #5 reported an inventory was not kept on items allowed in rooms during environmental rounds. MHT #5 stated there was no indication documented of when a patient was given more than two blankets. MHT #5 then reported having hygiene products left in patient rooms could result in a risk for self-harm.

ii. An Interview on 6/13/22 at 12:20 p.m. with Charge Nurse (RN) #6 was conducted. RN #6 stated safety items found during safety checks included pens, garbage, paper clips, and other things that could be used to potentially harm self or others. RN #6 reported that the environmental checks were conducted each shift, three times a day, with no set time to complete within the shift. RN #6 reported there was a cubby located behind the nurses station that had a slot for each patient's hygiene box, although there was no procedure for checking in or out hygiene items. RN #6 reported she was not aware of how much linen a patient was allowed to have. RN #6 reported the only way staff would know if an extra blanket was given to a patient on the previous shift would be if this information was passed on in report. RN #6 reported a potential risk for self-harm or harm to others if extra linens or hygiene products were found in patient rooms.

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

A-0392 STAFFING AND DELIVERY OF CARE 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 care of any patient. Based on interviews and document reviews, the facility failed to ensure an adequate number of nursing staff were present on each inpatient unit to meet the needs of the patients. Specifically, the facility failed to ensure each inpatient unit was staffed according to the level of patient acuity and current patient census for the unit. The failure was identified in two of five inpatient units.

Based on interviews and document reviews, the facility failed to ensure an adequate number of nursing staff were present on each inpatient unit to meet the needs of the patients. Specifically, the facility failed to ensure each inpatient unit was staffed according to the level of patient acuity and current patient census for the unit. The failure was identified in two of five inpatient units.

Findings include:

Facility policies:

The Appropriate Staffing Levels policy read, it is the policy of the facility to ensure that the appropriate numbers and qualifications of nursing staff are available at all times for the care of patients. The Chief Nursing Officer (CNO) is responsible for the development and ongoing review of staffing requirements based on numbers of patients, population served, acuity and measurements of patient outcomes that include patient falls, restraint/seclusion, medication errors, infection rates, patient complaints and grievances, as well as other types of incident occurrences. The staffing plan for Nursing Services is designed to comply with all applicable regulatory standards and is reviewed annually. The needs of patients and their medical and psychiatric care are always the primary factors when staffing needs arise.

The Nursing Department Staffing policy read, a core number of nursing staff shall be on duty at all times. Nursing staff will be adjusted according to patient census and patient acuity. A sufficient number of qualified nursing staff will be on duty at all times to provide the required level of skilled care and nursing judgment needed on each inpatient unit. A staffing matrix guideline is based on an average acuity expectation of the defined patient population. A sufficient number of qualified nursing staff will be on duty at all times to provide the required level of skilled care and nursing judgment needed. The Nurse Executive establishes the necessary number and type of staff needed to provide quality care and ensure a safe patient environment. Staffing needs are reviewed prior to every shift and adjusted based on caregiver skill, patient needs and unusual occurrences. Staffing is additionally evaluated every 4 hours and adjustments are made as needed based on census, incoming/outgoing transfers, and acuity.

Reference:

The Nursing Department Staffing Guidelines (Staffing Guidelines), which was identified by staff as the facility's staffing matrix, was provided by the facility. The Staffing Guidelines listed the name of each inpatient unit at the facility, specified the variable patient census range for each inpatient unit and the specified number of Registered Nurses (RN) and Mental Health Technicians (MHT) expected to be staffed and present on each inpatient unit according to the current patient census.

1. The facility failed to staff inpatient units according to facility policy and guidelines.

A. Patient Care Assignment Sheets were reviewed from 3/1/22/to 6/13/22 and revealed inpatient units were not staffed according to facility policy and the Nursing Department Staffing Guidelines (Staffing Guidelines). Examples include:

a. The Pikes Peak Day Shift Patient Care Assignment Sheet for 6/13/22 was reviewed and revealed the patient census on the unit was 15. According to the Staffing Guidelines for Pikes Peak, a patient census of 15 during the day shift listed two RNs and two MHTs to be staffed on the unit. The Day shift Patient Care Assignment Sheet revealed one RN and two MHTs were present on the unit.

i. On 5/23/22, the Pikes Peak unit had a night shift patient census of 27 patients. According to the Staffing Guidelines, three RNs and two MHTs were listed to be staffed on the unit. The Facility Patient Care Assignment sheet revealed the unit was staffed with one RN and one MHT.

ii. On 5/20/22 the Pikes Peak unit had a day shift patient census of 14 patients. According to the Staffing Guidelines, two RNs and two MHTs were listed to be present on the unit. The Facility Patient Care Assignment for 5/20/22 revealed one RN and two MHTs were present on the unit.

iii. On 5/17/22, 5/15/22, 5/13/22, 5/9/22 and 5/2/22 the Pikes Peak unit had a day shift patient census of 15 patients. According to the Staffing Guidelines, two RNs and two MHTs were listed to be present on the unit Pikes Peak unit. The Facility Patient Care Assignment for 5/17/22, 5/15/22, 5/13/22, 5/9/22 and 5/2/22 revealed one RN and two MHTs were present on the unit.

Further review of Facility Patient Care Assignment forms for the Piles Peak unit revealed additional days in which nursing staff was understaffed on the unit according to the Facility Patient Care Assignment sheet and the Staffing Guidelines.

b. On 6/1/22, 6/2/22, 6/6/22, 6/8/22 and 6/9/22 the Castle unit had a patient census of 12. According to the Staffing Guidelines, two RNs and one MHT were listed to be present on the unit for a patient census of 12. The Facility Patient Care Assignment for 6/1/22, 6/2/22, 6/6/22, 6/8/22 and 6/9/22 revealed one RN and one MHT were present on the unit.

i. On 6/5/22 the Castle unit had a day shift patient census of 13 patients. According to the Staffing Guidelines, two RNs and one MHT were listed to be present on the unit. The Facility Patient Care Assignment for 6/5/22 revealed one RN and one MHT were present on the unit.

ii. On 6/13/22 the Castle unit had a day shift patient census of 15 patients. According to the Staffing Guidelines for the Castle unit, two RNs and two MHTs were listed to be present on the unit for a patient census of 15. The Facility Patient Care Assignment sheet for 6/13/22 revealed one RN and two MHTs were present on the unit.

Additional patient care units and shifts were noted to be understaffed according to the Facility Patient Care Assignment sheet and the Staffing Guidelines.

These examples were in contrast to facility policies and guidelines. According to the Nursing Department Staffing policy, the Staffing Guidelines for each patient unit would have nursing personnel staffed on the unit based on the acuity expected for the unit's defined patient population. To provide the necessary level of skilled care and nursing judgment for the patient population, the unit would be staffed with a sufficient number of qualified nursing staff determined to be needed according to the patient census and patient acuity.

B. Interviews were conducted with facility staff and revealed inpatient units were continuously understaffed and nursing staff were concerned for patient safety.

a. On 6/13/22 at 12:20 p.m., an interview was conducted with RN #1. RN #1 stated recently the Pikes Peak unit had a patient census of 27 patients and the unit was short staffed. RN #1 stated the timing of medication administrations were late as a result. RN #1 stated there was potential harm to patients when units were not properly staffed.

b. On 6/17/22 at 10:40 a.m., an interview was conducted with RN #2. RN #2 stated she had worked several nights short-staffed. RN #2 stated inpatient units were repeatedly short-staffed due to staff call-outs. RN #2 stated the use of patient restraints increased as a result of inadequate staffing of nursing personnel. RN #2 stated escalation of aggressive, hostile and assaultive patient behaviors could have been avoided had a sufficient number of nursing personnel been present on inpatient units.

c. On 6/21/22 at 9:43 a.m., an interview was conducted with Assistance Chief Nursing Officer (ACNO) #7. ACNO #7 stated nursing staff were staffed on inpatient units according to the Nursing Department Staffing Guidelines. ACNO #7 stated the Staffing Guidelines specified the number of nursing staff needed for each inpatient unit according to the current patient census. Furthermore, she stated the staffing matrix designated how many RNs and MHTs were required to be present on each inpatient unit according to the patient census. ACNO #7 stated she and Chief Nursing Officer (CNO) #3 scheduled nursing staff based on the current patient census present on each inpatient unit.

d. On 6/13/22 at 3:48 p.m., an interview took place with Chief Nursing Officer (CNO) #3. CNO #3 reviewed the Nursing Department Staffing Guidelines. CNO #3 stated the nursing services were understaffed and the facility was not able to sufficiently staff each inpatient unit according to the Nursing Department Staffing Guidelines.

The Patient Assignment Sheets for the Pikes Peak unit for 6/13/22 was reviewed by CNO #3. CNO #3 stated according to the Staffing Guidelines and the patient census for 6/13/22, the Pikes Peak unit should have been staffed with two RNs and two MHTs. However, CNO #3 verified only one RN was present on the Pikes Peak unit during the day on 6/13/22.

i. On 6/15/22 at 1:37 p.m., a second interview was conducted with CNO #3. CNO #3 stated there were gaps in nursing coverage on all inpatient units. CNO #3 stated she was aware several inpatient units were and have been understaffed. Furthermore, CNO #3 then stated inpatient units had not been staffed according to the Staffing Guidelines.