The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CENTENNIAL PEAKS HOSPITAL 2255 S 88TH ST LOUISVILLE, CO 80027 June 24, 2014
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on interviews and review of facility documents, the facility failed to re-evaluate and adjust the patient's care plan after receiving written information the patient desired to be released for one of ten patients (patient #4).

This failure caused a delay in the discharge of a voluntary patient.

Findings

POLICY

According to facility policy Discharge Against Medical Advice, All voluntary patients who have signed themselves into the hospital for treatment have the right to terminate their stay with or without consent of the attending physician.

1. The facility failed to address patient's request to be discharged .

a) On 06/24/14 a review of Sample Patient #4's medical record was conducted. The facility used a document titled "Daily Inventory", on the back of the document there were two different areas for the patient to fill out and one area for staff to fill out. The first area was "My goal for the day". On 03/18/14 Patient #4 wrote "I am feeling better and I would like to go home." On 03/19/14 the patient wrote "Go home". The second area is "How can staff assist you in reaching your goal?" On 03/18/13 the patient wrote "help me process out so I can go home." On 03/19/14 the patient wrote "get my paperwork done so I can go home." The third area is for staff only and is observations and comments, there is no documentation in this area for both days. It is signed and dated by staff coinciding with both days.

b) On 06/23/14 a phone interview with patient #4 was conducted. Patient #4 stated that s/he had written on the daily inventory form that s/he wanted to go home for two days and this was not addressed until s/he had spoken directly to staff. At that time staff than arranged for his/her discharge.

c) ON 06/24/14 at 10:50 a.m., an interview with the facilities Patient Advocate was conducted. The Patient Advocate stated that s/he had received patient #4's complaint and went to the unit to talk to the charge nurse. The Patient Advocate stated that the charge nurse told her that patient #4 was being discharged and s/he "called it good", and closed the complaint.

d) On 06/24/14 at 11:50 a.m., an interview was conducted with Staff Member #6. Staff member #6 stated that the inventory sheet is given to patients to fill out daily. S/he also stated that staff review all sheets and address any issues via documentation on the inventory sheet in the third area on the back of the document. Staff Member #6 stated that if a patient writes that they want to go home that s/he would notify the social worker. Staff Member #6 confirmed his/her signature on the document dated 03/19/14. Staff Member #6 stated that s/he did not know why s/he did not write anything on the document or address the patient's issue and did not notify the Social Worker.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on interviews and record reviews the facility failed to provide for the shaving needs for one in ten patients reviewed (patient #7).

This led to the patient not being able to achieve his desired level of grooming and had the potential to decrease his/her sense of mental illness.
Findings

1. The facility was not staffed in a manner that enabled timely supervision of shaving activities when requested by patients. Once requested patients may not receive the opportunity to shave for two days.

a). On 06/24/14 at 10:50 a.m., an interview with the facilities Patient Advocate was conducted. The Patient Advocate stated that s/he had received a complaint from the spouse of Patient #7 stating the patient was not shaved on a regular basis. The Patient Advocate stated that all patients are monitored while shaving to ensure they did not harm themselves or others. The Patient Advocate stated that there was a delay in shaving the patient and that s/he was unsure why there was a delay. The Patient Advocate said that s/he went to the unit and informed staff that the patient needed was not until the next day because there was not enough staff.

b) On 06/24/14 at 11:52 a.m., and interview with Staff Member #6 was conducted. Staff Member #6 stated that during morning group s/he would ask patients if they wanted to shave that day. S/he stated that there is not a specific shave list and staff gets to them as they can and will try and squeeze it in for that day. S/he also stated that it can take up to two days before they can assist patients with shaving. Staff Member #6 stated that Sample Patient #7 preferred to shave on a daily basis and that staff could not accommodate that schedule. Staff Member #6 stated that all patients are monitored while shaving whether straight edge or electric razor, to ensure they did not harm themselves or others.