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 July 26, 2017
VIOLATION: PATIENT RIGHTS Tag No: A0115
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-0168 - Standard: The use of restraint or seclusion must be in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient as specified under 481.12(c) and authorized to order restraint or seclusion by hospital policy in accordance with State law. The facility failed to ensure a physician order was obtained for restraints in 1 of 5 restraint records (Patient #10). This failure created the potential for unnecessary or unsafe seclusion time for patients.

A-0178 - Standard: When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1 hour after the initiation of the intervention -(i) By a -(A) Physician or other licensed independent practitioner; or (B) Registered nurse or physician assistant who has been trained in accordance with the requirements specified in paragraph (f) of this section. The facility failed to ensure the Registered Nurse (RN) evaluated patients within one hour of the application of physical restraint or seclusion of a patient in 4 of 5 adult restraint records reviewed (Patients #1, #2, #10 and #11) and failed to ensure the accuracy of restraint documentation. This failure resulted in patients not being assessed within one hour of the application of restraint or seclusion being applied. Furthermore, this failure resulted in inaccurate patient medical records.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on interviews and record review, the facility failed to ensure a physician order was obtained for restraints in 1 of 5 restraint records (Patient #10).

This failure created the potential for unnecessary or unsafe seclusion time for patients.

FINDINGS

POLICY

According to Seclusion and Restraint, seclusion shall be used in an emergency situation only and requires an order from a physician. The physician/LIP must be contacted for an order either during the emergency initiation of the restraint/seclusion or immediately (within a few minutes) after the restraint/seclusion has been initiated. Telephone/verbal orders for restraint/seclusion may be received and recorded by a Registered Nurse (RN). The physician shall authenticate the telephone/verbal order within 24 hours.

1. The facility staff did not obtain a physician order for seclusion when a patient was a danger to self or others.

a) On review of Patient #10's restraint/seclusion order form, on 05/03/17 at 4:57 p.m. the patient required physical restraint. The order authentication line had a printed physician name with no signature.

On review of the general physician orders there was no documentation of an order for restraints on 05/03/17 at 4:57 p.m.

b) An interview was conducted with RN #1 on 7/26/17 at 1:25 p.m. On review of Patient #10's medical record, RN #1 stated there was not a physician signature on the form for 05/03/17 at 4:57 p.m. Additionally RN #1 confirmed there was not an order for restraint on the physician order for the 05/03/17 at 4:57 p.m. incident. RN #1 stated without a signature from a physician the order was not sufficient.

c) On 07/26/17 at 2:00 p.m. an interview was conducted with Patient #10's Physician (Physician #4). Physician #4 stated all orders required a signature from a physician.

On review of Patient #10's form on 05/03/17 at 4:57 p.m. Physician #4 confirmed, his/her signature was not present.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on interviews and record review, the facility failed to ensure the Registered Nurse (RN) evaluated patients within one hour of the application of physical restraint or seclusion in 4 of 5 adult restraint records reviewed (Patients #1, #2, #10 and #11) and failed to ensure the accuracy of restraint documentation .

This failure resulted in patients not being assessed within one hour of the application of restraint or seclusion being applied. Furthermore, this failure resulted in inaccurate patient medical records.

FINDINGS

POLICY

According to Seclusion and Restraint, within one hour of initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, authorized Licensed Independent Practitioner, or trained Registered Nurse (RN). These evaluations will be documented in the medical record to include the following: the date and time of the evaluation, an assessment of the patient immediate situation, an evaluation of the patient's reaction to the intervention. Further required documentation included, the patient's medical and behavioral condition, to include a complete review of systems assessment, behavioral assessment as well as a review and assessment of the patient's history, drugs and medication and most recent lab work.

According to the policy, Corrections to the Medical Record by Hospital Staff, a uniform system is provided for staff to amend or correct the medical record. Health care professionals documenting in the medical record should use the defined procedure to make correction in the medical record. The author of the entry shall draw a single line through the incorrect information without obliterating it. The correct information shall be recorded above, below, or beside the incorrect information. The date of the correction and initials of the person making the correction are documented next to the corrected information with a note of explanation for the error.

According to the policy, Contents of Medical Record, the facility will provide a medical record that reflects the patient's care, treatment and services.

1. The facility failed to ensure patients were assessed within one hour of being placed in restraints or seclusion to assess the patient's immediate situation and evaluate the patient's reaction to the intervention. Additionally, the facility failed to ensure hospital leadership did not alter staff documentation of the restraint/seclusion patient.

a) On review of Patient #11's Restraint/Seclusion Order/Record form, Patient #11 was placed in seclusion on 06/06/17 at 11:08 a.m. The One Hour Post Intervention Assessment was documented at 1:13 p.m., almost 2 hours after the patient was placed in seclusion, and signed by RN #1.

Further, the original assessment time documented was crossed out, marked as "error" and 12:08 p.m. was written. Next to the altered time were the initials of the Nurse Manager (Manager #2), who was not the original author.

On 06/06/17 at 1:24 p.m. the patient was placed in physical restraints and seclusion again. The one hour post intervention assessment was documented as completed at 3:37 p.m., more than 2 hours after the patient was restrained and secluded.

The original assessment time was crossed out and 2:24 was written next to it. There was no documentation which indicated who made the change and when the record was altered.

b) Review of Patient #1's seclusion record showed s/he was placed in seclusion on 03/15/17 at 6:53 a.m. The one hour post assessment was not completed until 9:05 a.m., more than 2 hours after the patient was secluded and 1 hour and 12 minutes past when it was due.

On 03/13/17 at 10:19 a.m. the patient was placed in seclusion. The one hour post assessment was not completed until 12:00 p.m., 1 hour and 41 minutes after the initiation of seclusion and 41 minutes past when it was due.

On 03/14/17 at 12:20 p.m. Patient #1 was placed in seclusion. The one hour post assessment was not completed until 2:22 p.m. 1 hour past when it was due.

c) On review of Patient #2's restraint form, the patient was placed in physical restraints and seclusion at 9:00 a.m. The one hour post intervention assessment was not completed until 10:30 a.m., 90 minutes after the patient had been secluded.

Further, the original time was crossed out and 10:00 a.m. was written in. There was no documentation as to who altered the medical record and the reason it was altered.

d) Review of Patient #10's restraint form revealed s/he was restrained on 04/30/17 at 6:11 p.m. However, the one hour assessment was not completed until 7:30 p.m.

All 4 records reviewed showed the patients were not assessed in the one hour time period required to evaluate current status, reaction to intervention, physical/mental status, complaints of injury, psychological status, current behavior and the continued need for restraint/seclusion along with treatment plan modifications. This was in contrast to facility policy.

Furthermore, in 2 of the 4 records reviewed, the time the one hour assessment had been completed had been altered to indicate the assessment had been completed timely. There was no evidence indicating who altered the record.

e) On 07/26/17 at 1:25 p.m., an interview was conducted with Registered Nurse (RN #1). RN #1 stated the one hour post assessments were to be documented when they were done, even if they were done past the one hour required time. RN #1 stated s/he was aware s/he had been late on assessing patients at the one hour required time. RN #1 stated coming back and changing documentation to reflect something that did not happen was false documentation.

RN #1 reviewed Patient #11's restraint documentation. RN #1 stated Patient #11 had been placed in seclusion on 06/06/17 at 11:08 a.m. RN #1 stated s/he completed a face to face assessment at 1:13 p.m. but it was changed to 12:08 p.m. by RN #1's manager.

On review of Patient #11's restraint documentation on 06/06/17, Patient #11 required a physical restraint and seclusion at 1:24 p.m. The one hour face to face assessment was documented as completed at 3:37 p.m. but then was crossed out and changed to 2:24 p.m., more than an hour earlier.

The one hour post intervention assessment included the patient's current status, reaction to intervention, physical/mental status, complaints of injury, psychological status, current behavior and the continued need for restraint/seclusion along with treatment plan modifications.

f) An interview was conducted on 07/26/17 at 3:05 p.m. with the Nurse Manager (Manager #2). Manager #2 stated s/he audited patient restraint documentation and the process to audit charts included reviewing for any blanks on the form, making sure the physician signed the form, reviewing that the 5 minute patient checks were documented and the time on the face to face patient assessment was done within one hour of the time the patient was placed in seclusion or restraints.

g) On 07/26/17 at 4:12 p.m., an interview was conducted with the Director of Nursing (DON #3). DON #3 stated the expectation for RN's was to complete a face to face assessment one hour after a patient had been in restraints or seclusion. The face to face should be documented when it actually occurred. DON #3 stated, when Manager #2 changed RN's restraint documentation it was considered falsifying documentation in patient's medical records.

DON #3 further stated s/he was unsure why Manager #2 had changed RN's documentation and Manager #2 was not trained to change RN documentation. DON #3 stated falsification of medical records was not the policy of the facility.