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.

CEDAR SPRINGS BEHAVIORAL HEALTH SYSTEM 2135 SOUTHGATE RD COLORADO SPRINGS, CO March 3, 2011
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the number and nature of deficiencies cited, the hospital failed to comply with the Condition of Participation of Nursing Services. The hospital failed to have an organized nursing service that provided 24-hour nursing services. The nursing services provided did not consistently meet the standards and policies and procedures of the facility and the department of nursing services. The director of nursing services failed to ensure there was a nurse assigned to each unit that had patient(s) sleeping on the units, on the night shifts (11 p.m. - 7 a.m.). In addition, the facility failed to ensure the newly appointed director of nursing had psychiatric nursing experience/training and met the minimum qualifications in the position description, as well as state and federal requirements.

The facility failed to meet the following standards under the Condition of Participation of Nursing Services:

A 0386 Organization of Nursing Services
The facility failed to have a director of psychiatric nursing that met the minimum state, federal and facility requirements for education, training and experience. The director of nursing failed to ensure the nursing services were provided in compliance with the standards outlined in the organizational plan for nursing services.

A 0392 Staffing and Delivery of Care
The director of nursing failed to assign sufficient numbers/types of nursing personnel to respond to the psychiatric and other nursing care needs of the patient population on each unit. The director of nursing failed to ensure there was a minimum of two staff, one of those a registered nurse, assigned to staff each nursing unit when patient were present or sleeping on the unit, to maintain a safe environment for patients and staff.

A 0395 Registered Nurse Supervision of Nursing Care
The director of nursing failed to ensure a registered nurse must supervise and evaluate the nursing care for each patient. The director of nursing failed to ensure a registered nurse was assigned to each unit where patients were present or sleeping. S/he also failed to ensure all nursing care was evaluated and was compliant with all nursing policies/procedures and facility standards for care.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the number and nature of deficiencies cited, the hospital failed to be in compliance with the Condition of Participation of Patient Rights. The hospital failed to protect and promote each patient's rights.

The facility failed to meet the following standards under the Condition of Patient Rights:

A 0123 Notice of Grievance Decision
The hospital failed to, at a minimum in the resolution of grievances; provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

A 0131 Informed Consent
The facility failed to ensure Sample Patient #3 and his/her representative were granted the right to make informed decisions regarding Sample Patient #3's care. Specifically, the facility failed to notify Sample Patient #3's parent of medication changes, possible exposure to bed bugs, and restriction of the patient's rights.

A 0143 Personal Privacy
The hospital failed to ensure Sample Patient #3 was able to exercise his/her right to personal privacy. The hospital failed to ensure sufficient documentation existed, consistent with facility policy, to restrict Sample Patient #3's right to personal privacy when making him/her sleep in the day hall rather than a patient room.

A 0144 Care in a Safe Setting
The facility failed to ensure patients received care in a safe setting. Specifically, the facility staff failed to follow the facility's policies/procedures when a patient was identified as being high risk for sexually acting out and had the patient in the same room as another individual. In addition, the facility utilized an overflow unit that could accept child, adolescent and adult patients simultaneously with inadequate staffing levels to ensure a safe environment for all patients.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on staff interview, review of facility policies/procedures, and review of facility documents the hospital failed to, at a minimum in the resolution of grievances, provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion.

The findings were:

A review of the facility's policies/procedures revealed the following, in pertinent parts:
"Protection of Patients From Abuse or Neglect...
...Grievance Procedure
3) Cedar Springs has established a process for prompt resolution of patient grievances and will inform each patient whom to contact to file a grievance...
4) Investigation and Resolution of Grievances:
a) All grievances received by the facility will be acknowledged within 72 hours and be resolved within 25 working days.
a) The patient representative or designee with the involvement of the Program Director will investigate all grievances.
i) Grievances and results of any investigation will be documented and responded to either on the grievance form itself or via a written report.
ii) The results of any investigation will be formally documented..."

A sample of four written grievances submitted by patients was reviewed on 3/2/2011. Two of the grievances were submitted on pamphlets used for patients to submit grievances. The other two were submitted on a two-sided paper form used for patients to submit grievances. The two grievances submitted on the pamphlets were dated 11/29/2010 and 12/20/2010. The areas for resolution of the grievances were completed by the Performance Improvement Manager/Patient Representative on the dates the grievances were submitted. In the space provided for patient signature and area to agree with the resolution, a wish to appeal the grievance to the next level, or to withdraw the grievance - no selection was made and no signature was present of the patient to indicate patient was informed of the resolution of the patients' grievances. The two grievances submitted on the two-sided paper forms were submitted on 12/19/2010 and 2/21/2011. The area on the form for the Unit Patient Representative's Response was completed by the Patient Representative on 12/20/10 and 2/21/11. On the form where it stated "Patient Requests Appeal of Patient Representative's Response:" no selection was made by the patient and no patient initials were present where space was provided for such.

A review of facility's internal quality documents revealed the parent of Sample Patient #3 had voiced a verbal grievance on 12/1/2010 when discharging the patient AMA (Against Medical Advice) that stated parent "has been extremely unhappy with patient's care. [Parent] stated his/her son/daughter had blood drawn at Cedar Springs after already having blood drawn. Patient's [parent] stated son's/daughter's medications were changed without his/her knowledge or consent. Patient's [parent] stated his/her son/daughter was placed on orange level for sexual acting out behaviors when the [patient] has had no history of this behavior. [Parent] very upset with his/her son's/daughter's care." In an area for the "findings of investigation, recommendations and outcome" the Patient Representative wrote "on 11/30/10 Risk Manager investigated blood draw and consent process and patient representative informed [parent] of outcomes and issue appeared to be resolved. Now reviewing incident regarding orange level process". No further documentation was present that stated the resolution of the grievance and when requested, the patient representative was unable to provide any further documentation of the investigation of the grievance or any resolution of the grievance.

An interview with the Patient Representative conducted on 3/2/2011 at approximately 10:45 a.m. revealed s/he was unable to find documentation of the investigation/resolution of the grievance for sample patient #3. S/he stated the forms filled out by patients for grievances allowed for documentation of the investigation and resolution of grievances and stated there was not currently such a form for verbal/telephone grievances.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on medical record review, staff interview, review of the facility's policies/procedures, and facility tour the hospital failed to ensure Sample Patient #3 was able to exercise his/her right to personal privacy. The hospital failed to ensure sufficient documentation existed, consistent with facility policy, to restrict Sample Patient #3's right to personal privacy when making him/her sleep in the day hall rather than a patient room.

The findings were:

A facility policy titled "Restriction of Patient Rights" reviewed on 3/2/2011 revealed the following, in pertinent parts:
"...1) Rights granted to acute and residential patients and Cedar Springs may be restricted or denied if clinically indicated and with a physician's order specifying the right or rights that have been restricted or denied. Rights that may be restricted by physician's order include:
a) Send and receive uncensored mail.
b) Place and receive telephone calls.
c) Have access to personal clothing and belongings in the bedroom.
d) Receive visitors from outside the facility.
e) Practice of religious rituals deemed unsafe or counter therapeutic.
2) The evaluation of restrictions for therapeutic effectiveness occurs at least every three days...but no later than every seven days...
...a) On the seventh day, a new physician's order will be obtained if the restriction is to continue.
Emergency Restriction
3) Patient's rights shall not be restricted or denied without a written physician's order unless a true emergency situation exists, in which case the charge nurse may authorize the restriction.
4) In the event of an emergency restriction of patient rights, the attending physician shall be contacted for immediate review of the restriction and shall issue restriction orders as needed.
Consultation
5) If a patient's rights are restricted, such restriction will be determined with the participation of the patient and family and will be fully explained to them...
...Notification of Restriction of Rights
7) When a physician orders a restriction of patient's rights, a "Notification of Restriction of Rights" form shall be completed in triplicate. The original constitutes the physician's order and shall be incorporated into the permanent medical record. The patient shall receive a copy. The Patient Representative shall receive the third copy...
11) If the patient refuses to sign the form, a second staff member shall witness the refusal and both staff members sign to that effect on the form. The patient shall be given a copy with an explanation provided, and the restriction will be implemented.
12) The restriction may be rescinded at any time by order of the physician."

A facility policy titled "Patient Observation" reviewed on 3/2/2011 revealed the following, in pertinent parts:
"Purpose
1) The safety of patients is of utmost importance. All patients admitted to Cedar Springs Hospital are placed on some level of observations. An increased level of observation may be initiated for those patients who are assessed to require a higher level of observation...
...8) Orange Level - for patients who have a history of sexual offense/acting out issues
a) Patient will typically remain on this level during the duration of their stay, however, this level will be reviewed every 72 hours on acute...with a corresponding Restriction of Rights form completed at the initiation and at each renewal. The restriction of rights form is required, due to the client whom is on an orange level not being allowed in their room with a peer/roommate during waking and/or sleeping hours. The client on orange level may be required to "sleep out" in a provided mobile sleep unit/boat...
...e) Staff will take care to assure that the reasons for the level orange are kept confidential. The reasons and expectations will be reviewed with the patient, and/or his/her guardian, as appropriate...
...f) Medical Record documentation shall include the following:
i) SAC sheet reflecting the patient's location and observed behaviors on a frequency ordered as per supervision level
ii) Progress note every shift reflecting a summary of the patient's status/behaviors and/or participation in programming
iii) A doctor's order renewing the continuation or discontinuation of the orange level every three days...
...iv) A completed Restriction of Rights Form every three days..."

The medical record of Sample Patient #3 revealed the following, in pertinent parts:

Physician orders for admission that were written via a telephone order by Staff Member #1 on 11/28/10 at approximately 11:40 p.m. indicated the patient's observation level was orange. An additional written telephone order dated 11/28/10 written at an unknown time stated "Orange level (patient has a history of sexual acting out)." The chart did not contain a restriction of rights form. An interview with Staff Member #1 on 3/2/2011 at approximately 4:30 p.m. revealed the restriction of rights form was not in the record and the forms are "sometimes hanged on the desk" and that the technicians would fill them out. S/he stated s/he had never seen a physician sign a restriction of rights form.

A "Needs Assessment" completed by a Licensed Clinical Social Worker on 11/29/2010 at approximately 12:43 p.m. revealed the patient denied being sexually active. The patient also denied any history of victimization or perpetration of physical, sexual, or emotional abuse/neglect, or trauma. The summary evaluation of risk of homicidal/assaultive risk was indicated to be "low to no risk." An "Intake Assessment Addendum" for "Physical Aggression/Sexual Acting Out/Elopement" indicated the patient had "None" of the indicators of Sexual Acting Out including any history of sexually acting out behaviors. Further documentation by the licensed professional counselor stated "Per chart patient has history of sexually acting out - patient is on orange level" and then stated the patient's parent denied the history which was circled, underlined, and contained an exclamation mark.

An "Interdisciplinary Assessment Nursing Admission Assessment" completed by Staff Member #1 on 11/29/2010 at 2:00 a.m. stated, in pertinent part: "...Patient was admitted and allowed to go to bed. Medical history says s/he has a history of sexual acting out so s/he was put on an orange level." An interview with staff member #1 conducted on 3/2/2011 at approximately 4:30 p.m. revealed s/he was unable to find in the patient's medical record where the patient had a history of sexual acting out behaviors. A review of the referring facility's records with staff member #1 revealed the medical history provided stated in a section that was titled "Trauma/Abuse History: (Include history of sexual acting out behaviors)" stated the mother and patient denied any history of abuse and did not indicate any history of sexual acting out behaviors. S/he was unable to find anywhere else in the record where such history was mentioned.

A review of the SAC sheets which documented the patient's location and activity every 10 minutes revealed that on 11/29/2010 from 12:00 a.m. until 7:00 a.m., the patient was located in his/her room sleeping. On 11/29/2010 at 9:00 p.m. the patient was sleeping in his/her room until 11:30 p.m. where the sheet revealed the patient was in the Milieu/Living Area sleeping. The patient remained in the milieu/living area the remaining sleeping hours for the morning of 11/30/2010 and then the night of 11/30-12/1/2010. The patient was discharged AMA at approximately 2:50 p.m. on 12/1/2010.

A form titled "Against Medical Advice" dated 12/1/2010 stated "I am leaving the hospital because...Poor care...Patient was placed on orange level - patient has never been sexually inappropriate."

An interview with Staff Member #3 conducted on 3/2/2011 at approximately 3:45 p.m. revealed Sample Patient #3's mother/father had contacted the facility and had spoken to Staff Member #3. S/he stated the patient's parent was concerned that his/her son/daughter had been "sleeping out" in the day hall. S/he stated that s/he explained to the patient's parent the rationale for "Orange Level" but would look into the reasoning for the patient being placed on an "Orange Level". S/he stated s/he looked through the patient's chart and had determined the patient being placed on an "Orange Level" was not warranted and s/he passed her findings on to other staff.

In summary, the facility failed to document, according to the facility's policy, appropriately when revoking Sample Patient #3's right to sleep in a room and exercise the right afforded other patients in the facility. Facility staff failed to ensure documentation was accurate and factually based when stating the patient had a history of sexual acting out behaviors.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interview, medical record review, and review of the facility's policies/procedures the facility failed to ensure patients received care in a safe setting. Specifically, the facility staff failed to follow the facility's policies/procedures when a patient was identified as being high risk for sexually acting out and had the patient in the same room as another individual. In addition, the facility utilized an overflow unit that could accept child, adolescent and adult patients simultaneously with inadequate staffing levels to ensure a safe environment for all patients.

The findings were:

Reference Tag A 0392 for findings related to inadequate staffing levels and the practice of utilizing a 12-bed "over-flow" unit to house adult patients with child/adolescent patients on the same unit, based on the bed availability and admission needs of the facility.

Cross Reference to A 0143 for findings regarding Sample Patient #3 being identified as being on Orange level, indicating the patient was at risk for sexually acting out and for findings related to the facility's policies/procedures for patients identified as orange level.

The medical record of Sample Patient #20 revealed the following, in pertinent parts:

Sample patient #20 was assigned to the same room as Sample patient #3 on 11/28/2010 until discharged on [DATE].

A review of the SAC sheets which documented the patient's location and activity every 10 minutes revealed that on 11/29/2010 from 12:00 a.m. until 7:00 a.m. the patient was located in his/her room sleeping. On 11/29/2010 at 9:00 p.m. the patient was sleeping in his/her room until 7:00 a.m.

Concurrent review of Sample patient #3's record revealed that the patients were in the same room sleeping until 11:30 p.m. on 11/29/10 where the sheet revealed sample patient #3 was then in the Milieu/Living Area sleeping. The patient remained in the milieu/living area the remaining sleeping hours for the morning of 11/30/2010 and then the night of 11/30-12/1/2010.

An interview with Staff Member #1 who was the RN on duty from 11:00 p.m. on 11/28/10 until 7:00 a.m. on 11/29/10 revealed s/he had received a telephone order from the admitting physician for Sample Patient #3 to place the patient on orange status at approximately 11:45 p.m. on 11/28/10. When asked why the patient was roomed with another patient, which was contradictory to facility policy when a patient is placed on orange status, s/he stated sample patient #3 was already asleep and s/he didn't want to wake him up. S/he revealed that during that shift s/he was the only staff member on the ward and was responsible for six patients.

In summary, staff member #1 failed to ensure the safety of sample patient #20 when s/he had identified the patient's roommate as having a risk for sexual acting out behaviors and was unable to assure the safety of Sample Patient #20 by being unable to monitor the two patients in the same room while concurrently checking every 10 minutes on the remaining four patients on the floor.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, staff interview, review of internal facility documents, and review of the facility's policies/procedures the facility failed to ensure Sample Patient #3 and his/her representative were granted the right to make informed decisions regarding Sample Patient #3's care. Specifically, the facility failed to notify Sample Patient #3's parent of medication changes, possible exposure to bedbugs, and restriction of the patient's rights.

The findings were:

1. Orange Status: Cross Reference to A 0143 for findings related to the hospital's failure to document contact with Sample Patient #3's parent when the patient was made to sleep in the day hall rather than in a patient room.

2. Bedbugs
An interview conducted on 3/1/2011 at approximately 11:30 a.m. with the Director of Integrated Services, revealed the hospital had recently treated a patient care unit for bedbugs. An invoice dated 12/2/2010 was provided at the time of interview which stated in the comment section "Treated 6 units for bedbugs, treated office, hall, and rec room. No activity found."

An e-mail from the Director of Integrated Services to the CEO, Patient Representative, and Director of Nursing dated 11/30/2010 stated the following, in pertinent parts:
"[Contracted pest control company] was here this morning to check for bedbugs in the Willow Unit. He indeed found some bedbugs on the unit and on clothing of a patient who was recently admitted to the unit...Right now there are 6 patients on Willow...My recommendation is to have the patients' clothing washed and brought back to the Willow Unit on Wednesday (tomorrow)...then we will promptly move them to the Ponderosa Side and they will stay overnight. This will free up the Willow unit Wednesday afternoon for preparation of the treatment by [contracted pest control company] which will take place on Thursday [12/2/2010]...
...I have spoken to [the Director of Nursing] about this issue and s/he was involved in the decision making regarding the treatment of the bedbugs. [The Director of Nursing] has questions about what parental/guardian notification would be appropriate for the patients on the Willow Unit. They have already notified (at the time of discovery) the patients' parents but no additional notifications have been made. We need direction on what would be appropriate in this situation. I do not feel we need to blow this out of proportion..." The facility did not have any documentation of which patients' parents were notified or who in the facility had notified the patients' parents.

A review of the facility's medical records revealed the following, in pertinent parts:
Sample patient #10 was an adolescent patient admitted to the facility on [DATE]. A nursing note on 11/28/2010 at approximately 6:40 p.m. stated, in pertinent part: "...Patient has been diagnosed with bedbugs. Family residence has not been treated. Patient treated with Rid, hot shower, and clean clothes per [physician]." A night shift report provided by the facility on 3/3/2011 revealed the patient was admitted to the Willow Wing.

Sample patient #3 was an adolescent patient admitted to the facility on [DATE] at approximately 11:00 p.m. A night shift report provided by the facility on 3/3/2011 revealed the patient was admitted to the Willow Wing. The medical record did not contain any notation the patient or the patient's parent was notified of the bed bug findings.

3. Medication Changes
A review of the facility's policy titled "Informed Consent for Treatment with Psychotropic Medication" last revised 09/2001 revealed the following, in pertinent parts:

"Purpose:
1) To prescribe procedures to be followed in administering psychotropic medications to patients...
...Informed Consent:
4) Informed consent will be obtained prior to the initiation of psychotropic medication from the patient and the patient's parent/legal guardian, if applicable...
...Medication Changes:
12) Anytime that medication regimens, such as dosage, is changed, an explanation of the change will be provided to the patient and/or patient's family or legal guardian.
13) A new informed consent and education will be provided for any change in medication class."

Staff interviews conducted on 3/2/2011 revealed the following, in pertinent parts:

An interview with Staff Member #1 on 3/2/2011 at approximately 4:30 p.m. revealed parents are notified and consent is obtained for all home medications when patients are admitted . S/he stated parents are contacted again only if new medications are added, not if the dosage of a previously consented medication is increased or decreased. S/he stated consent is obtained for all home medications, regardless if they are to be given in the hospital.

An interview with Staff Member #2 on 3/2/2011 at approximately 2:30 p.m. revealed s/he was the nurse on the unit when Sample Patient #3 arrived at the hospital. S/he stated s/he was responsible for the medication reconciliation, but Staff Member #1 was responsible for the remaining admission documentation. S/he stated s/he had written the medication names on the consent sheet and that when parents are contacted for medication consent, the medication names are the only documentation. S/he stated parents were not notified if medication dosages are changed.

A review of Sample patient #3's record revealed the following, in pertinent parts:

A "medication reconciliation/physician orders" form dated 11/28/2010 listed the patient's home medications as: Lamictal 200 mg at bedtime, Seroquel 200 mg in the morning and at noon, Seroquel 300 mg at bedtime, Clonidine 0.1 mg twice daily, Clonidine 0.05 mg at noon, and Geodon 120 mg at bedtime. The order stated to continue only Lamictal and Clonidine. A "Medication Informed Consent/Verification of Medication Education" form stated:
"My doctor had prescribed the following medications: as needed
Cepastat for the treatment of sore throat
Tylenol for the treatment of pain
Maalox for the treatment of stomach distress
Lamictal for the treatment of mood
Seroquel for the treatment of mood
Clonidine for the treatment of mood
Geodon for the treatment of mood..."

The form did not contain dosages of the medications. The form was signed by staff member #1 and staff member #2 and stated that the patient's parent had given verbal consent via telephone on 11/28/2010.

The chart did not contain any additional medication consents. Admission orders dated 11/28/2010 stated that in addition to the medications to be given per the medication reconciliation form were to be Seroquel XR 150 mg in the morning and at noon, Seroquel XR 300 mg at bedtime and to discontinue the patient's home Seroquel and Geodon.

A physician's order dated 11/30/2010 at approximately 10:30 a.m. stated to discontinue the Seroquel XR and to resume Geodon 160 mg at bedtime and Seroquel 300 mg twice daily.

The chart did not contain documentation of subsequent contact with the patient's parent to obtain consent or notify that medication dosages were changed or that medication was discontinued or restarted.

In summary, the hospital failed to notify Sample Patient #3's parent when medications were changed which was not consistent with facility policy. The hospital failed to document any notification of the patient's parent of restricting the patient's right to sleep in a room as well as the possible exposure to bedbugs.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records, policies/procedures, and staff interview, it was determined the facility failed to ensure a registered nurse evaluated the nursing care for each patient. Specifically, nursing staff did not ensure physician orders were completed and that vital signs were monitored in three of twenty sample medical records. This failure created the potential for a negative patient outcome.

The findings were:

The facility's policy titled "Vital Signs," dated with a most recent approval of 6/10, was reviewed on 3/1/11. It stated the following in the policy section, in pertinent part: "...On the acute care programs, vital signs are also to be taken every morning...All vital signs are to be documented within one hour of taking them on the Vital Signs Flow Sheet..."

Review of medical records was conducted on 3/1 and 3/2/11. It revealed the following:

Sample medical record number four was an adolescent patient admitted [DATE] and discharged [DATE]. On 2/19 at 7:25 p.m., vital sign monitoring was ordered via a physician telephone order to be done upon admission, then once per day. Review of the "Daily Vital Signs or Detox Vital Signs Graphic Sheet" revealed that vital signs were taken on 2/19 (admit), 2/21, and 2/22. There was no documentation for vital signs monitoring completed on 2/20.

Sample medical record number twelve was an adolescent patient admitted [DATE] and discharged [DATE]. On 11/29 at 3:00 p.m., vital sign monitoring was ordered via a physician telephone ordered to be done "Upon admission, then once per shift." Review of the "Daily Vital Signs or Detox Vital Signs Graphic Sheet" revealed vital signs were taken on 11/30, 12/2, 12/3, and 12/4. There was no documentation for vital signs monitoring completed on 12/1 as well as no documentation to indicate the vital signs were checked once per shift.

Sample medical record number thirteen was an adolescent patient admitted [DATE] and discharged [DATE]. On 11/29 at 9:45 p.m., vital sign monitoring was ordered via a physician telephone order to be done "Upon admission, then once per shift." Review of the "Daily Vital Signs or Detox Vital Signs Graphic Sheet" revealed that vital signs were taken on 11/30 at 8:00 a.m., 12/1 at 11:00 a.m., 12/2 at 8:00 a.m., and 12/3 at 11:30 a.m. Therefore, although vital signs were monitored daily, then were not taken every shift as per physician order.

An interview with the facility's Director of Nursing was conducted on 3/1/11 at approximately 3:00 p.m. When asked about vital signs monitoring on the acute units, s/he stated, "They usually do them days and evenings depending on the unit...They usually do them early in the morning and they should do them on the 3-11 shifts and then, if issues, they recheck on the night shift..." S/he stated that vital signs are not routinely checked on nights unless there is a medical issue because the patients are sleeping, but that vital signs are usually checked very early in the morning.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on staff interviews and review of facility documents, including staffing schedules, the director of nursing failed to ensure all patient units had a nurse assigned to the units when patients were present or sleeping on the units. The director of nursing also failed to ensure there were at least two staff assigned to an occupied unit to ensure the safety of all patients and staff. The failures created safety risk for staff and patients and the potential for negative patient outcomes.

The findings were:

1. Interviews with the Director of Nursing/Staff Schedule Review:

On 3/2/11 at approximately 12:30 p.m., the director of nursing was interviewed about several nursing issues, including minimum staffing on the two 12-bed child/adolescent units (Willow and Ponderosa). S/he stated Willow was the primary child/adolescent unit and the mirror image adjoining unit (Ponderosa) was used as an "over-flow" unit. It could have children, adolescents and adults all sleeping on the same unit at night and possibly "programming" during the day and evening on an adult unit (Hickory and Cottonwood) or the other child/adolescent unit (Willow). S/he stated the routine overnight shift (11 p.m. - 7 a.m.) staffing for Willow and Ponderosa was for one nurse to cover both units. S/he stated s/he had "a nurse for each unit for residential treatment units because it was required," but stated s/he had been told by the administrator they didn't have to have a nurse on each unit, just have one on the adjoining unit that was "readily available."

Review of the staffing schedules for January/February, 2011 with the director of nursing on 3/3/11 at approximately 9:30 a.m., revealed the following findings, which s/he confirmed:
Overnight shift findings -
January 5, 2011, Willow - 8 patients, 1 registered nurse (RN), 1 mental health technician (MHT); Ponderosa - 2 patients, no RN, no MHT
January 6, 2011, Willow - 8 patients, 1 RN, 1 MHT; Ponderosa - 3 patients, 1 RN, no MHT
January 7, 2010, Willow - 8 patients, 1 RN, 1 MHT; Ponderosa - 4 patients, 1 RN, no MHT
January 8, 2011, Willow - 10 patients, 1 RN, 1 MHT; Ponderosa - 4 patients, 1 RN, no MHT
January 9, 2011, Willow - 10 patients, no RN, 1 MHT; Ponderosa - 4 patients, 1 RN, no MHT
January 10, 2011, Willow - 8 patients, 1 RN, 1 MHT; Ponderosa - 3 patients, 1 RN, no MHT
January 11, 2011, Willow - 12 patients, 1 RN, 1 MHT; Ponderosa - 3 patients, no RN, 1 MHT
January 12, 2011, Willow - 12 patients, 1 RN, 1 MHT; Ponderosa - 4 patients, 1 RN, no MHT
January 13, 2011, Willow - 10 patients, 1 RN, 1 MHT; Ponderosa - 4 patients, no RN, 2 MHT's
January 14, 2011, Willow - 11 patients, 1 RN, 1 MHT; Ponderosa - 9 patients, no RN, 1 MHT
January 15, 2011, Willow - 10 patients, 1 RN, 1 MHT; Ponderosa - 8 patients, no RN, 1 MHT
January 16, 2011, Willow - 10 patients, 1 RN, 1 MHT; Ponderosa - 5 patients, 1 RN, no MHT
January 17, 2011, Willow - 10 patients, 1 RN, 1 MHT, 1 MHT (for 1:1); Ponderosa - 8 patients, no RN, 1 MHT
January 18, 2011, Willow - 10 patients, 1 RN, 1 MHT, 1 MHT (for 1:1); Ponderosa - 9 patients, no RN, 1 MHT
February 7, 2011, Willow - 6 patients, 1 RN, 1 MHT; Ponderosa - 5 patients, 1 RN, no MHT
February 8, 2011, Willow - 4 patients, 1 RN, 1 MHT; Ponderosa - 8 patients, no RN, 1 MHT
February 10, 2011, Willow - 5 patients, no RN, 1 MHT; Ponderosa - 10 patients, 1 RN, 1 MHT
February 11, 2011, Willow - 7 patients, 1 RN, 1 MHT; Ponderosa - 7 patients, no RN, 1 MHT
February 12, 2011, Willow - 7 patients, 1 RN, 1 MHT; Ponderosa - 8 patients, nor RN, 1 MHT

Review of the schedules revealed no evidence of the nursing supervisor being assigned to staff the unit when no nurse was assigned, as the director of nursing had alleged. S/he confirmed there was no evidence in the scheduling or description of duties indicating the nursing supervisor was available to remain on a unit if no nurse had been assigned to that unit.

2. Review of Policies/Procedures Related to Overnight ( 11 p.m. - 7 a.m.) Staff Duties/Patient Care Needs:

Review on 3/2/11 of the policy/procedure "Sleep Time" (Issued/Revised 10/01) revealed the following, in pertinent parts:
"...Rationale
2) Sufficient rest is an important requirement for physical and mental health. The objective of the sleep time routines is to maintain a physically safe and emotionally secure environment conducive to a good night's sleep...
Monitoring
5) The most important function of the overnight staff is to assure the safety and well-being of the patients under their supervision during the night. Staff must be aware that patients who do not feel that they are being adequately supervised may be at risk of increased anxiety and greater tendency to act impulsively or inappropriately. Therefore, patient will feel neither safe nor secure without the knowledge that unit staff are monitoring them closely throughout the night.
6) At all times a member of the unit's overnight staff will be assigned to patrol the hallways containing patient rooms so as to increase their ability to detect any unusual circumstances during the night. Staff shall not position themselves behind the nurse's station for the night...
7) Evening and night staff are responsible for visually checking on each patient a minimum of every 15 minutes during the night once the patients are in bed, and documenting this on the 15-minute check sheet. These checks are to be completed at staggered times to avoid predictability.
8) All staff are responsible for being aware of any patient who is in need of particularly close observation for such things as suicide precautions, runaway precautions, seizures, drug reactions, etc...
Methodology
16) On adolescent units using motion detectors, overnight staff will immediately proceed to a bedroom in which the detector goes off and determine the reason for the detector's activation. Prior to leaving the room, staff will inspect the detector to assure it has not been tampered with.
a) Any circumstances or suspicions of patient attempts at inappropriate behavior shall be immediately reported to the nursing supervisor or charge nurse, and room mate will be separated as deemed necessary to assure safety and security.
17) Occasionally, a patient will need the emotional support of the night staff, such as when he or she has had a nightmare, is afraid or is undergoing an emotional crisis. In such a situation, all that is normally required of the overnight staff is that he/she be a sympathetic and active listener for as brief a time as possible. Then the patient should be encouraged to go back to bed. Ordinarily, however, the overnight staff does not encourage interaction with the patient. The presence of the staff should not be stimulating to the patient in such a way as to cause sleeplessness.
18) If the night staff are concerned about any unusual or suspicious patient behaviors they should contact the supervisor and/or charge nurse, and report their concerns..."

3. Review of Policy/Procedure Related to Sufficient Staffing:

Review on 3/2/11 of the policy/procedure "Protection of Patients From Abuse or Neglect" (Reviewed 1/10), revealed the following, in pertinent parts:
"...Prevention
2) Abuse and neglect is best prevented by having a sufficient number of trained and competent personnel on duty at all times in order to carry out each individual's treatment plan..."

4. Overnight Nurse Interview and Patient Care Findings Related to Inadequate Staffing:

Cross Reference to A 0143 for findings regarding Sample Patient #3 being identified as being on Orange level, indicating the patient was at risk for sexually acting out and for findings related to the facility's policies/procedures for patients identified as orange level.

The medical record of Sample Patient #20 revealed the following, in pertinent parts:

Sample patient #20 was assigned to the same room as Sample patient #3 on 11/28/2010 until discharged on [DATE].

A review of the SAC sheets which documented the patient's location and activity every 10 minutes revealed that on 11/29/2010 from 12:00 a.m. until 7:00 a.m. the patient was located in his/her room sleeping. On 11/29/2010 at 9:00 p.m., the patient was sleeping in his/her room until 7:00 a.m.

Concurrent review of Sample patient #3's record revealed the patients were in the same room sleeping until 11:30 p.m. on 11/29/10 where the sheet revealed that sample patient #3 was then in the Milieu/Living Area sleeping. The patient remained in the milieu/living area the remaining sleeping hours for the morning of 11/30/2010 and then the night of 11/30-12/1/2010.

An interview with Staff Member #1 who was the RN on duty from 11:00 p.m. on 11/28/10 until 7:00 a.m. on 11/29/10 revealed s/he had received a telephone order from the admitting physician for Sample Patient #3 to place the patient on orange status at approximately 11:45 p.m. on 11/28/10. When asked why the patient was roomed with another patient, which was contradictory to facility policy when a patient is placed on orange status, s/he stated sample patient #3 was already asleep and s/he didn't want to wake him up. S/he revealed that during that shift s/he was the only staff member on the ward and was responsible for 6 patients.

Review of the staffing schedules for November 28, 2010 - December 1, 2010 (hospital stay for sample patient #3) with the director of nursing on 3/3/11 at approximately 9:30 a.m., revealed the following findings, which s/he confirmed:
Overnight shift findings -
November 28, 2010, Willow - 8 patients, 1 RN, no MHT; Ponderosa - 5 patients, 1 RN, no MHT (which confirmed the allegation of staff member #1 that s/he was alone on Willow with 8 patients).
November 29, 2010, Willow - 6 patients, 1 RN, 1 MHT; Ponderosa - 5 patients, 1 RN, 1 MHT
November 30, 2010, Willow - 5 patients, 1 RN, no MHT; Ponderosa - 6 patients, no RN, 1 MHT
December 1, 2010, Willow - 0 patients, no staff; Ponderosa - 11 patients, 1 RN, 1 MHT

5. Overnight (11 p.m. -7 a.m.) Nurse Additional Non-Patient Care Duties:

Review on 3/2/11 of the facility policy/procedure "Nightly Chart Audits" (Issued/Revised 1/08) revealed the following, in pertinent parts:
"Policy:
It is the policy of (the facility) to perform nightly chart audits, with an audit tool, in order to assure documentation/transcription protocols have been accurately accomplished.
Procedure:
1) Nightly chart audits will be performed on charts and medication administration records nightly on the acute units, and weekly on residential units.
2) The RN will audit each patient's chart, with Audit Form tool (found in front of patient's chart)..."

6. Duties of the Nursing ("House") Supervisor:

Review on 3/2/11 of the nursing policy/procedure "Organization and Direction (Issued/Revised 10/01)," revealed the following information about the facility-wide responsibilities/duties of the supervisor, in pertinent parts:
"Organization
10)...c) House Supervisors are responsible for leadership and assurance of program integrity during the specific time period, such as evening or weekend hours. They are delegated functional authority for decision-making and problem solving and therapeutic care during these times.
11) Each unit within the three programs is staffed by RN's twenty-four (24) hours/day...
Interdepartmental Relationships
13)...a) Admissions Department...In the absence of admission personnel, the Nursing Supervisor assumes the responsibility for admissions, referrals, consultations, and inquiry calls in conjunction with the on-call admissions staff..."

On 3/2/11 at approximately 12:30 p.m., the director of nursing was interviewed about several nursing issues, including minimum staffing on the two 12-bed child/adolescent units (Willow and Ponderosa). S/he confirmed the nursing supervisor was responsible for oversight of all of the inpatient and residential programs on the campus, as well as taking inquiry calls and coordinating admissions.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on staff interview and review of medical records, personnel files and other facility documents, the facility failed to ensure the director of nursing met the minimum qualifications outlined in the facility job description for that position. Specifically, the facility appointed a nurse with no previous psychiatric nursing work experience or specialized training. In addition, the facility failed to ensure that all standards outlined in the nursing services plan titled "Organization and Direction (Issued/Revised 10/01)" were implemented. Finally, the director of nursing failed to ensure the nursing department had adequate numbers of qualified staff to implement the standards, as well as all other nursing policies and procedures.

The findings were:

1. Director of Nursing - Lack of Psychiatric Experience or Training:

Review on 3/1/11, of the facility job description "Director of Nursing," revealed the following, in pertinent parts:

"POSITION SUMMARY:
Oversees and administers the delivery of quality nursing care and services in accordance with standards of patient care and hospital policies and procedures; advises medical staff and department heads in matters related to nursing services; collaborates closely with other department heads to assure standards of care are followed and quality services are provided...

SKILLS:
Possesses the knowledge, experience and skills associated with a Master's degree in nursing. Has knowledge of current theoretical approaches to delivering nursing care; knowledge of leadership, management, and performance improvement concepts and implementing strategies to improve the delivery of nursing care to patients; knowledge of applicable state, federal and JCAHO standards and regulations; effective communication and conflict resolution skills; demonstrates skills in managerial, fiscal and personnel management.

EXPERIENCE/EDUCATION:
Three years management experience with a minimum of eight years experience in a psychiatric inpatient setting. Bachelor's Degree from an accredited school of nursing. Prefers a Master's degree in Nursing. If Bachelor's degree, must have the skills associated with a master's degree in nursing or a related field..."

Review on 3/1/11 of the personnel file for the director of nursing revealed s/he had no psychiatric training or experience. S/he had worked in cardiac care, pediatric cardiac care and pediatric and newborn intensive care nursing areas as a clinical nurse, nurse educator and as a program manager. His/her highest professional degree level was Bachelor of Science in nursing.

The findings in the personnel file were confirmed with the director of nursing during an interview on 3/1/11 at approximately 2 p.m. S/he stated s/he had 28 years as an intensive care and pediatric nurse and she felt that qualified her to do any kind of nursing, including psychiatric nursing. S/he further stated that all of the unit nurse leaders were experienced psychiatric nurses, so s/he could rely on them for the psychiatric expertise. When asked if s/he planned to get a psychiatric nurse certification to build his/her knowledge base in psychiatric nursing, s/he stated s/he had no plans for that and also stated that if s/he got an advanced degree in nursing, it would probably not be in psychiatric nursing. S/he also stated s/he met once a month with a masters level psychiatric nursing instructor who had oversight of nursing students placed at the hospital, and s/he provided one page supervision/consultation notes from meetings for 8/10, 9/10, 10/10, 11/10, 1/11. Review of the notes on 3/1/11, revealed the monthly one-hour meetings were primarily focused on administrative preparation for a Joint Commission survey, some discussion of student nurse issues, other administrative issues and some discussion of patient care behavior management and milieu. Per the interview, the director of nursing clarified that the consultant provided the meetings as a courtesy because of the student placement arrangement with the facility. On the last day of the survey, a copy of the consultant's resume, listing the qualification related to inpatient psychiatric nursing and administrative skills, was requested. The compliance manager confirmed the facility did not have that information available, since the consultant was a clinical nursing instructor and his/her primary relationship with the facility was in that capacity.

2. Review on 3/2/11 of the nursing policy/procedure "Organization and Direction (Issued/Revised 10/01)" revealed the following, in pertinent parts:

"General
...3) Nursing Services takes all responsible steps to provide quality nursing care based on individual needs.
4) Nursing Services takes all responsibility to promote and maintain the optimal professional conduct and practices of its members..."

NOTE: Reference Tag A 0131, A 0143, A 0144 for finding related to nursing failure to provide individualized care and protect the rights of Sample Patient #3 and to follow policies/procedures to maintain a safe environment related to Sample Patients #3 and #20. Reference Tag A 395 for findings related to nursing staff failure to comply with the policy/procedure on vital signs for Sample Patients #4, #12 and #13.

"5) Nursing Services supports the organization's decentralization philosophy that places authority and responsibility for decision-making at the program and individual level, albeit, under the 24-hour supervision of a registered nurse..."

NOTE: Reference Tag A 0392 for findings related to failure to have a registered nurse assigned to each patient unit when patients were present or sleeping on the unit.

"Responsibility
8) The Nurse Executive is a qualified registered nurse with appropriate education and/or experience and licensure in the state of Colorado. He/she has demonstrated ability in psychiatric nursing practice and administration.
9) The Nurse Executive is employed on a full-time basis and has the authority and responsibility for taking all reasonable steps to assure the optimal quality of nursing care is provided consistently throughout the facility..."

NOTE: Reference the above findings under "1. Director of Nursing - Lack of Psychiatric Experience or Training"

"Organization
10)...c) House Supervisors are responsible for leadership and assurance of program integrity during the specific time period, such as evening or weekend hours. They are delegated functional authority for decision-making and problem solving and therapeutic care during these times.
11) Each unit within the three programs is staffed by RN's twenty-four (24) hours/day...
Interdepartmental Relationships
13) ...a) Admissions Department...In the absence of admission personnel, the Nursing Supervisor assumes the responsibility for admissions, referrals, consultations, and inquiry calls in conjunction with the on-call admissions staff..."

NOTE: Reference Tag A 0392 related to findings regarding the failure to have a registered nurse on each patient unit where patients were present or sleeping. In addition, the tag contained findings related to the director of nursing relying on the Nursing Supervisor ("House Supervisor") to "cover a unit," if a nurse was not assigned, despite the multiple duties/responsibilities of that position for all acute and residential units on the campus...

"Committees and Meetings
19) To ensure that Nursing Services' functions are monitored, that reports and recommendations for patient care are reviewed and acted upon, that problems in nursing care are identified, and that Nursing Services' policies and procedures are reviewed and/or revised, a nursing department meeting is held at least monthly. This is chaired by DON or designee, and may address/discuss the following:
...b) Review, revision, and approval annually of all policies and procedures that specifically affect or relate to nursing practice..."

NOTE: Review of the nursing policy/procedure manual on 3/2/11 revealed the nursing policy/procedure manual had not been reviewed since January, 2008.