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.

HAVEN BEHAVIORAL SENIOR CARE OF NORTH DENVER 8451 PEARL STREET SUITE 100 THORNTON, CO April 9, 2012
VIOLATION: QAPI Tag No: A0263
Based on the nature of deficiencies cited, the hospital failed to comply with the Conditions of Participation of Quality Assurance/Performance Improvement (QAPI). The hospital failed to
ensure that all processes in their QAPI program were completed such that re-occurrences of sentinel events would be highly unlikely and the quality of care was sufficient to prevent future patient harm. Specifically, the hospital failed to fully investigate the death of a patient following a choking event to identify cause(s) and prevent possible future adverse outcomes. Additionally, staff were insufficiently trained to assess and evaluate patients on special diets and who were known to be at risk due to age and physical as well as psychiatric illnesses.

The facility failed to meet the following standards under the Condition of Quality Assurance/Performance Improvement:

A 0267 QAPI Quality Indicators
The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services, and operations.

A 0288 QAPI Feedback and Learning
[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.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review, the hospital failed to fully investigate an adverse patient event in which the patient choked on a snack of string cheese, stopped breathing, required cardiopulmonary resuscitation (CPR), and expired at an acute care hospital the same day. The string cheese snack was not part of the patient's mechanical, chopped diet. Although the code blue response was reviewed and deemed appropriate, management did not investigate the association of inappropriate food given to a patient who was high risk for choking in the first place. A root cause for the choking event was not identified until surveyors arrived at the facility to investigate the complaint. Furthermore, no corrective actions were implemented until surveyors requested an immediate plan of action.

Findings:
1. Patient #1 was a [AGE] year old female transferred to the facility on [DATE] for overly aggressive behavior on a M1 Hold. She was also having auditory hallucinations and displayed paranoid angry behavior. Other diagnoses included: bipolar disorder, dementia, schizophrenia, congestive heart failure, and recent urinary tract infection. The patient normally resided at a long term care (LTC) facility. A review of the history form from the LTC facility revealed a diet of mechanical soft. A review of the admission orders to the hospital demonstrated a diet order for regular, mechanical chopped. No dietitian consult was requested. No cause for the special dietary consideration was addressed in the record by either nursing or medical personnel.

a) On 03/23/12 the medical record noted that Patient #1 received a snack of string cheese and apple juice shortly before 11:00 a.m. She collapsed a short time later requiring the Heimlich maneuver resulting in removal of at least two pieces of cheese. CPR was required as the patient lost both pulse and respirations and she was transported to a local acute care hospital where she expired.

b) An interview with Staff #2 who was with the patient when she collapsed, revealed the following: s/he noticed the patient was sitting in a chair near the nursing station and had urinated on self so s/he escorted the patient back to her room at which time she collapsed. Staff #2 noticed the patient was choking, performed the Heimlich maneuver, and called for help. A second certified nursing assistant arrived and helped to scoop out a piece of cheese. They started compressions as the patient was not breathing and had turned blue. A nurse brought an Ambu bag and started to provide oxygen to the patient. Staff #2 did not know why or if the patient "gulped the cheese" nor was s/he aware the patient was on a special diet. Staff are notified of diets in shift reports and on the Kardex. CNAs also get report from the nursing staff.

c) An interview with Staff #9 who completed the physical exam of the patient on 03/22/12 revealed that s/he was aware of the mechanical soft diet, but did not assess a reason for it or determine a swallowing problem. S/he examined the patient's mouth and throat noting dentures, but did not do anything beyond this. Typically s/he would go to the dining room and observe and talk with the patients, but because this patient was so new, s/he had not had a chance to observe her behavior.

d) An interview with Staff #3 revealed the following: there are typically two nurses who admit patients and fill out admission forms and orders from past medical history and transfer forms. Nursing personnel provide information to each other in report.

e) An interview with the kitchen director and kitchen manager (contractual service) revealed that diet orders are faxed to the kitchen each day. A mechanical chopped diet does not include string cheese unless it is chopped in small pieces. Snacks are provided to the facility in bulk and it was understood that nursing personnel at the facility would distribute appropriately to patients. Nursing personnel would have to chop up the cheese.

f) An interview with the Director of Nursing (DON) revealed that diet orders are written in the Kardex at the nursing station and reviewed by all staff each shift. Although diet information is on the Kardex, s/he acknowledged that staff may not be aware of a patient's diet at times. Any staff member can grab snacks off of the snack cart which was located in the locked nutrition room.

g) A review of the policy, "Clinical Consults" revealed that all patients will be screened for nutritional risk within 24 hours of admission by nursing services. Identified criteria included unintentional weight loss, < 10 lbs in one month, home use of enteral or parenteral nutrition, nausea/vomiting/diarrhea > 3 days, decreased oral intake, < 50% of usual intake, and newly diagnosed diabetic patients. There was no mention of patients requiring special diets such as a mechanical chopped diet.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review, the hospital failed to analyze the cause of an adverse event (patient choking and death) and implement corrective actions that included learning throughout the hospital. Specifically, until surveyors requested a plan of action, management at the hospital failed to identify the root cause of a choking event, evaluate systems and processes in place that contributed to the event, and provide learning to all personnel to help prevent another such adverse event in high risk, geriatric psychiatric patients.

Findings:
1. Patient #1 was a [AGE] year old female transferred to the facility on [DATE] for overly aggressive behavior on a M1 Hold. She was also having auditory hallucinations and displayed paranoid angry behavior. Other diagnoses included: bipolar disorder, dementia, schizophrenia, congestive heart failure, and recent urinary tract infection. The patient normally resided at a long term care (LTC) facility. A review of history form from the LTC facility revealed a diet of mechanical soft. A review of the admission orders to the hospital demonstrated a diet order for regular, mechanical chopped. No dietitian consult was requested. No cause for the special dietary consideration was addressed in the record by either nursing or medical personnel.

a) On 03/23/12 the medical record noted that Patient #1 received a snack of string cheese and apple juice shortly before 11:00 a.m. She collapsed a short time later requiring the Heimlich maneuver resulting in removal of at least two pieces of cheese. CPR was required as the patient lost both pulse and respirations and she was transported to a local acute care hospital where she expired the same day.

b) An interview with Staff #2 who was with the patient when she collapsed revealed the following: s/he had noticed the patient was sitting in a chair near the nursing station and had urinated on self so s/he escorted the patient back to her room at which time she collapsed. Staff #2 noticed the patient was choking, performed the Heimlich maneuver, and called for help. A second certified nursing assistant arrived and helped to scoop out a piece of cheese. They started compressions as the patient was not breathing and had turned blue. A nurse brought an Ambu bag and started to provide oxygen to the patient. Staff #2 did not know why or if the patient "gulped the cheese" nor was s/he aware the patient was on a special diet. Staff are notified of diets in shift reports and on the Kardex. CNAs also get report from the nursing staff.

c) An interview with Staff #9 who completed the physical exam of the patient on 03/22/12 revealed that s/he was aware of the mechanical soft diet, but did not assess a reason for it or determine a swallowing problem. S/he examined the patient's mouth and throat noting dentures, but did not do anything beyond this. Typically s/he would go to the dining room and observe and talk with the patients, but because this patient was so new, s/he had not had a chance to observe her behavior.

d) An interview with Staff #3 revealed the following: there are typically two nurses who admit patients and fill out admission forms and orders from past medical history and transfer forms. Nursing personnel provide information to each other in report.

e) An interview with the kitchen director and kitchen manager (contractual service) revealed that diet orders are faxed to the kitchen each day. A mechanical chopped diet does not include string cheese unless it is chopped in small pieces. Snacks are provided to the facility in bulk and it was understood that nursing personnel at the facility would distribute appropriately to patients. Nursing personnel would have to chop up the cheese.

f) An interview with the Director of Nursing (DON) revealed that diet orders are written in the Kardex at the nursing station and reviewed by all staff each shift. Although diet information is on the Kardex, s/he acknowledged that staff may not be aware of a patient's diet at times. Any staff member can grab snacks off of the snack cart which was located in the locked nutrition room.

There was no planned training for personnel that included dietary consults or education. Upon request of the surveyors, a partial plan was provided to the surveyors at 7:30 p.m. on 03/28/12. Included in the plan was a dietary order sheet with all patient names and their respective ordered diets to be placed on the snack cart each day at 5:00 a.m. along with examples of special diets. Additionally, the hospital identified the need for corrective action to identify, handle, prepare and administer snacks involving dietary orders, and training of current and new hire staff (registered nurses and behavioral health technicians) regarding the special diets and checking the list of patients each day to ensure appropriate snack delivery to patients. Personnel on duty this date were being trained on the above protocol with additional training planned over the next several days to capture all staff.

While the above plan will provide safeguards to help ensure patients receive the appropriate snacks in future and training will help to educate all staff regarding the nutritional needs of patients at risk, there was no consideration for assessment of processes of care and hospital services which might involve the medical personnel who assess patients, the dietitian and speech therapist who evaluate potential swallowing problems, or the contractual kitchen service delivering the snacks to help ensure all providers of care were fully informed and able to make appropriate decisions of care.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document review, the hospital failed to fully investigate an adverse patient event in which the patient choked on a snack of string cheese, stopped breathing, required cardiopulmonary resuscitation (CPR), and expired at an acute care hospital the same day. The string cheese snack was not part of the patient's mechanical, chopped diet. Although the code blue response was reviewed and deemed appropriate, management did not investigate the association of inappropriate food given to a patient who was high risk for choking in the first place. A root cause for the choking event was not identified until surveyors arrived at the facility to investigate the complaint. Furthermore, no corrective actions were implemented until surveyors requested an immediate plan of action.

Findings:
1. Patient #1 was a [AGE] year old female transferred to the facility on [DATE] for overly aggressive behavior on a M1 Hold. She was also having auditory hallucinations and displayed paranoid angry behavior. Other diagnoses included: bipolar disorder, dementia, schizophrenia, congestive heart failure, and recent urinary tract infection. The patient normally resided at a long term care (LTC) facility. A review of the history form from the LTC facility revealed a diet of mechanical soft. A review of the admission orders to the hospital demonstrated a diet order for regular, mechanical chopped. No dietitian consult was requested. No cause for the special dietary consideration was addressed in the record by either nursing or medical personnel.

a) On 03/23/12 the medical record noted that Patient #1 received a snack of string cheese and apple juice shortly before 11:00 a.m. She collapsed a short time later requiring the Heimlich maneuver resulting in removal of at least two pieces of cheese. CPR was required as the patient lost both pulse and respirations and she was transported to a local acute care hospital where she expired.

b) An interview with Staff #2 who was with the patient when she collapsed, revealed the following: s/he noticed the patient was sitting in a chair near the nursing station and had urinated on self so s/he escorted the patient back to her room at which time she collapsed. Staff #2 noticed the patient was choking, performed the Heimlich maneuver, and called for help. A second certified nursing assistant arrived and helped to scoop out a piece of cheese. They started compressions as the patient was not breathing and had turned blue. A nurse brought an Ambu bag and started to provide oxygen to the patient. Staff #2 did not know why or if the patient "gulped the cheese" nor was s/he aware the patient was on a special diet. Staff are notified of diets in shift reports and on the Kardex. CNAs also get report from the nursing staff.

c) An interview with Staff #9 who completed the physical exam of the patient on 03/22/12 revealed that s/he was aware of the mechanical soft diet, but did not assess a reason for it or determine a swallowing problem. S/he examined the patient's mouth and throat noting dentures, but did not do anything beyond this. Typically s/he would go to the dining room and observe and talk with the patients, but because this patient was so new, s/he had not had a chance to observe her behavior.

d) An interview with Staff #3 revealed the following: there are typically two nurses who admit patients and fill out admission forms and orders from past medical history and transfer forms. Nursing personnel provide information to each other in report.

e) An interview with the kitchen director and kitchen manager (contractual service) revealed that diet orders are faxed to the kitchen each day. A mechanical chopped diet does not include string cheese unless it is chopped in small pieces. Snacks are provided to the facility in bulk and it was understood that nursing personnel at the facility would distribute appropriately to patients. Nursing personnel would have to chop up the cheese.

f) An interview with the Director of Nursing (DON) revealed that diet orders are written in the Kardex at the nursing station and reviewed by all staff each shift. Although diet information is on the Kardex, s/he acknowledged that staff may not be aware of a patient's diet at times. Any staff member can grab snacks off of the snack cart which was located in the locked nutrition room.

g) A review of the policy, "Clinical Consults" revealed that all patients will be screened for nutritional risk within 24 hours of admission by nursing services. Identified criteria included unintentional weight loss, < 10 lbs in one month, home use of enteral or parenteral nutrition, nausea/vomiting/diarrhea > 3 days, decreased oral intake, < 50% of usual intake, and newly diagnosed diabetic patients. There was no mention of patients requiring special diets such as a mechanical chopped diet.
VIOLATION: CONTRACTED SERVICES Tag No: A0085
Based on staff interview and review of facility documents the facility failed to maintain a list of all contracted services. The facility list that was provided was incomplete and did not include the names of all contracted providers and the scope and nature of the services provided.

The findings were:

Upon entering the facility on 04/02/12, the facility was requested to provide a list of all contracted services. Subsequently, a contract list was provided to the surveyors on 4/02/12. The list titled "HAVEN BEHAVIORAL SENIOR CARE -NORTH DENVER CONTRACTS/AGREEMENTS -JANUARY 2012," was a 2-page list of the facility's contract with headings: "CONTRACTOR, " "TYPE OF AGREEMENT/SCOPE OF SERVICE," "CLINICAL NON-CLINICAL," "DATE REVIEWED," "NEXT SCHEDULED ROUTINE REVIEW DATE," "CONTRACT EXPIRATION DATE." There was also a notebook provided to the surveyors that contained copies of contract agreements.
Review of the contract book and list on 4/03, 4/04, and 4/05/12 by two state surveyors revealed that the list did not include three contractors who had a signed contract in the contractor agreement book. Respiratory therapy, rehabilitation services and Rocky Mountain Lions Eye Bank were omitted from the contracts/agreement list. Review of the contracts book revealed that respiratory therapy and rehabilitation services were contracted with the host hospital. In addition, maintenance services also contracted with the host hospital was on the contracts list but there was no contract or description of the scope of services to be provided included in the contract book. There was no evidence of contracts for oxygen tank supply, plumbing, pest control and trash removal services.

In an interview with the CEO (Chief Executive Officer) on 4/5/12 at approximately 3:25 PM, when asked about the maintenance contract and a review of the document, s/he confirmed that the service had been omitted from the contract list but the host hospital was the service provider. S/he further stated that the facility was in the process of hiring their own maintenance personnel on an "as needed" basis to handle minor repairs and maintenance. When the CEO was asked about the lack of contracts for plumbing, pest control and trash removal, s/he confirmed that there was nothing in writing but the host hospital took care of pest control and trash removal. S/he stated that plumbing problems were handled by non contracted businesses and there was a list of plumbing businesses the staff were to call for repairs.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based upon review of the facility's policies and procedures and facility written response to grievances the facility failed to offer options for an additional investigation and did not include names and contact information for additional resources to assist in the resolution of an unsatisfactory grievance decision.

The findings were:
Review the complaint/grievance case documentation from 2012 on 4/6/12 revealed that only two grievance letters had been sent. Review of the letters revealed that they contained no contact information for the Colorado Department of Public Health and Environment, as required. The letters also did not offer the option of an additional hospital investigation by an administrative officer or the option to have the patient advocate forward the grievance and hospital investigation findings to the health department for further investigation.

The lack of compliance was confirmed with the patient advocate on 4/5/12 at approximately 1:30 p.m.. S/he stated that she had been unaware of those requirements and requested a copy of the regulations so that the letter could be changed to reflect the requirements.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical record, policy/procedure and documentation, and staff/physician interviews, the facility failed to ensure each patient had the right to formulate an advance directive and care provided in compliance with these directives in one of twenty medical records. Specifically, sample patient #1 was a DNR (Do Not Resuscitate) upon admission and the facility did not follow their policy or take precautions as to the patient's advance directive request. This failure created the potential for a negative outcome.

The findings were:

The facility's policy titled, "Advance Directives," effective 11/2011, stated the following, in pertinent part:
"POLICY...
-An Advance Directive document is a permanent part of the medical record. This includes a Medical Power of Attorney, Living will, CPR Directive and/or Medical Orders for Scope of Treatment (MOST)...
PROCEDURE
-Admitting staff will complete the Advance Directive form to determine if a patient has executed an Advance Directive and/or desires information related to the process of formulating an Advance Directive...
-If the referring facility has an Advance Directive document they will be requested to provide it if a copy has not accompanied the patient on transfer...
-The Advance Directive documents(s) shall be placed in the legal section of the chart.
-Admitting staff shall notify the admitting psychiatrist if the patient/legal representative provides a previously executed Advance Directive document that includes instruction for NO CPR.
-The admitting/attending psychiatrist will review the Advance Directive document(s) during the initial assessment and provide orders based on the directives in the document or facilitate a transfer to a facility that will honor the patient's Advance Directives.
-If the Advance Directive document includes a NO CPR directive AND the psychiatrist provides a "Do Not Resuscitate" (DNR) order the following shall occur:
*Verbal communication to all direct care staff on duty at the time the order is received by the registered nurse.
*A DNR sticker placed on the front of the chart.
*DNR indicated in the Kardex that is utilized for change of shift report.
*A purple dot which indicates "DNR" placed on the patient's armband.
*A purple piece of paper with the patient's first name and last initial placed on the wall above the patient's bed to provide additional indication to staff during times the patient is in their room. This is a secondary alert to staff- the armband with the purple dot must be verified and if not available CPR will be initiated.
-Staff training includes initiation of CPR if the patient is discovered absent of pulse or respirations unless they can CLEARLY identify the patient is DNR status. If there in any question related to the identification of the code status CPR shall be initiated."

The facility's policy titled, "Armbands,Patient," effective 11/2011, stated the following, in pertinent part:
"POLICY
-It is the policy of Haven Behavioral to utilize armbands to alert staff to identified patient risks.
PROCEDURE
-Upon admission the following risks will be identified during the nursing assessment; allergies, DNR, high fall risk, oxygen and diabetic.
-Patient armbands will be color coded with a dot that signifies the identified risk...
*DNR - PURPLE...
-Nursing staff will place armbands on patient at time of admission.
-Registered nurses and behavioral health technicians will verify placement of armbands at various times throughout the shift, including during routine observations and medication administration."

Review of Sample patient #1 medical record revealed the outside of the chart did not have a purple label indicating DNR or another other label which designated the patient's Code status. Within the medical record, two copies of the patient's CPR Directive ("Colorado Medical Orders for Scope of Treatment") were present, which were transferred with the patient from his/her previous facility. The form stated the patient wanted "No CPR - Do Not Resuscitate/ DNR/ Allow Natural Death." It also stated the patient wanted "Comfort Measures Only... Use oxygen, suction and manual treatment of airway obstruction as needed for comfort. Do not transfer to hospital for life-sustaining treatment. Transfer only if comfort needs cannot be met in current location; EMS - Contact medical control." The form was signed by the patient on 11/3/11 and a medical practitioner (MD/APN/PA) on 11/23/11.

Further review of the medical record revealed the facility's form, titled "Advance Directives," had the following sections checked/marked, "Has formulated Advance Directives and has provided a copy to HBSC staff***."
"CPR Directive" was the section marked/checked below that statement. Also checked was "yes" to "'Your Right to make Health Decisions' provided to patient/legal representative" and the patient had signed beneath.
The referring *** statement said as follows: "Admitting staff to notify the admitting psychiatrist if the patient/legal representative provides an Advance Directive document that includes instruction for NO CPR." At the bottom of the form was a place for the physician and "staff" to sign and date. A RN signed and dated on 3/21/12 at 1300 (1:00 pm). The "psychiatrist" section was unsigned and had a yellow flag next to it, notifying the MD to sign.

The medical history and physical was conducted on the patient by a Nurse Practitioner and signed on 3/22/12 at approximately 12:00 pm. There was no documentation of the patient's request to be a DNR. The initial psychiatric evaluation (history and physical) was conducted by a different Nurse Practitioner on 3/22/12 and dictated at approximately 1700 (5:00 pm). This dictated form also had a flag on it which indicated the MD needed to sign it. Again, this assessment had no documentation of the patient's request to be a DNR. The patient choked and was coded on 3/23/12 at approximately 11:00 am.

The facility had been conducting audits on advance directives and armbands, to ensure their policies were followed.
The advance directive audit, dated Sunday 3/25/12, stated the following in regards to sample patient #1, in pertinent part:
"AD [Advance Directive] form completed Y/N: Y
AD provided to staff- if yes list document name: MOST
MD notified if NO CPR MD Name/date: chart gone - unknown if MD notified, but NO T.O. for DNR...
Comments: Full COR"
The "Identification Audit" for Armbands, dated 3/22/12, revealed the following for sample patient #1: check mark in "Kardex" box, check mark in "Allergy Red" box, and check mark in "Fall Yellow" box. The "DNR Purple" box did not have a check mark.

On 3/28/12 at approximately 11:35am, an interview was conducted with the Certified Nursing Assistant/Behavioral Health Tech (CNA/BHT) who cared for Sample patient #1. When asked about the patient's decompensation that day, s/he stated that the patient "gulped down" some string cheese and went with him/her to the patient's room. The patient went to sit on the bed and the CNA/BHT noticed a change in color and then the patient "flopped." The CNA/BHT then began to perform the Heimlich Maneuver and, eventually, successfully got some cheese dislodged from the patient's mouth. However, the patient had become unconscious and, upon assessment, lost his/her pulse. Therefore, the staff began to perform CPR (Cardiopulmonary Resuscitation) including chest compressions. The CNA/BHT was asked if the patient had a purple sign above his/her bed or a purple dot on his/her wristband to indicate that s/he was a DNR. S/he responded, "I didn't even think to look because [s/he] was choking. I saw her [choking] and knew what was happening." When asked further about the patient's code status, s/he stated, "They brought it up but we were full into CPR at that point..."

An interview was conducted with the contracted medical Nurse Practitioner on 3/28/12 at approximately 11:55 am. When asked if s/he could initiate a Code status/order, s/he stated, "The psychiatrist does that. Even any Nurse Practitioner needs a MD co-signature... I can write it and for 24 hours it stands as long as I get it signed by the MD..."

An interview as conducted with the psychiatric Nurse Practitioner (NP) on 3/28/12 at approximately 12:30 pm. When asked the integration of the NP with the MD, s/he stated that sample patient #1 was his/her patient but that the psychiatrist "oversees. I admit the patient within 24 hours and [s/he'll] co-sign." When asked about the CPR Directive, s/he stated, "I don't sign those. The psychiatrist does." When asked why sample patient #1's had not been signed by 3/23 when s/he was admitted on ,d+[DATE], s/he stated, "[S/he] came in the day before. I admitted [him/her] later in the day. I do the dictation and all the things and get that stuff back the next day and they [the psychiatrists] sign it. Usually they will sign everything in treatment team, like this DNR, but that day in treatment team is when [s/he] coded." When asked if s/he is informed by nursing staff that the patients are DNR or not, s/he stated, "They'll usually tell me. I was told that, however they [the psychiatrists] weren't there to co-sign so what I was going to do was get everything signed that day [3/23]." When asked if it was the policy and procedure to call the physician and get the order for DNR, s/he stated, "I could, but it would be signed the next day. We need the MD order before anybody does anything..."

An interview with the Director of Nursing was conducted on 3/28/12 at approximately 1:30 pm. When asked what should occur when nurses see a CPR directive during the patient's admission, s/he stated, "They notify the MD to get the DNR order and notify them on the phone if needed to get a verbal order." When asked his/her expectation, s/he stated, "That they get the MD order. It becomes part of the initial orders from the physician. It needs to be added to the admission order sheet. In most cases, Admissions and Referrals add that to the order sheet."

An interview was conducted with the contracted medical provider's group's Medical Director on 3/28/12 at approximately 2:30 pm. The physician had responded to the sample patient #1's code. When asked if s/he was made aware at that time of the patient's code status, s/he stated, "As soon as I got there I asked. It was recorded as DNR but not reported on the sheets. They did not have all the documentation so I said until we're sure we'll do this [code the patient]. I talked with [the psychiatric Nurse Practitioner] who said s/he told them the paperwork wasn't done..."

An interview was conducted with the patient's primary psychiatrist on 3/28/12 at approximately 2:45 pm. When asked if s/he had been made aware of sample patient #1's CPR Directive stating DNR, s/he stated, "No, not that I know of." When asked the usual process s/he experiences with DNR orders, s/he stated, usually nurses let me know and typically they are very good. They let me know in writing or verbally. Then I meet with the person or contact family to be sure that is rational..."

In summary, the patient presented as a DNR.The facility has a policy to call a physician, get an order, then implement a list of actions when a patient presents with a DNR. Staff failed to follow that policy. Instead, the patient was in the facility for two days without any action taken towards his/her Code Status. The patient had been evaluated by a nurse upon admission as well as two Nurse Practitioners. It was unknown if the proper implementation of the facility's Advance Directive policy would have changed the care and treatment of this patient however future patients have the potential to be harmed and their rights violated should this failure reoccur.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the nature of the deficiencies, the facility failed to be in compliance with the Condition of Participation of Nursing Services. Specifically, nursing services failed to effectively assess and address the dietary needs of geriatric psychiatric patients who were at risk for choking in ongoing assessments and multi-disciplinary treatment plans. Additionally, they failed to communicate special dietary needs to all personnel who provided snacks to these patients such that one patient received an inappropriate snack item causing her/him to choke and stop breathing. S/he was subsequently transferred to an acute care hospital where s/he expired a short time later. These failures were determined to constitute Immediate Jeopardy (IJ) to the health and safety of all current and future patients in the facility. A partial plan was provided to surveyors by hospital management on the first day of survey, but was insufficient to remove the IJ. An extended survey was determined to be necessary. A more comprehensive plan was received, and after consultation with the Centers for Medicare and Medicaid Services (CMS), the IJ was removed on 04/03/12.

The facility failed to meet the following standard under the condition of Nursing Services:

A 0395 A registered nurse must supervise and evaluate the nursing care for each patient.
VIOLATION: SCOPE OF RADIOLOGIC SERVICES Tag No: A0529
Based on review of policies and procedures, facility documents and staff interview the facility failed to ensure that the contracted diagnostic services met approved standards for safety and qualified personnel.

The findings were:
Review of the Haven Behavioral-North Denver policy titled Radiological Services, revised June 2011 stated in pertinent part: "OFF-SITE SERVICES:..Any patient with a serious accidental injury or serious medical illness that would require more intensive medical service will receive medical care from St. Mary-Corwin staff either through transport to the Emergency department or utilization of the Code Blue or Rapid Response Team."
Review of the facility contracts listed the (hospital corporation) Hospital Systems was the contracted provider for inpatient transfers and acute care services. The facility listed in this policy was located outside the distance parameters that would comply with the nearest facility for emergent,urgent and acute patient care transfers and was not affiliated with the contracted (hospital corporation)Hospital System.

The policy for Radiology Services: OFF -SITE SERVICES was presented to the Chief Executive Officer and the Corporate Director of Quality for their review on 4/3/12 and 4/5/12 respectively. Both facility representatives confirmed that the policy had been obtained from the corporate office and had not been reviewed/revised to address the plan for this facility.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews and documentation, nursing service personnel failed to effectively assess and evaluate the dietary needs for a new patient who was admitted on a mechanical, chopped diet, in accordance with accepted standards of practice. Patient #1 received an inappropriate snack causing her/him to choke and stop breathing. Cardiopulmonary resuscitation (CPR) was initiated and the patient was transferred to an acute care hospital where s/he expired a short time later. Although a mechanical soft, chopped diet with thin liquids was ordered for this patient, staff did not know the dietary restrictions for the patient.


Findings:
1. Patient #1 was a [AGE] year old female transferred to the facility on [DATE] for overly aggressive behavior on a M1 Hold. She was having auditory hallucinations and displayed paranoid angry behavior. Other diagnoses included: bipolar disorder, dementia, schizophrenia, congestive heart failure, and recent urinary tract infection. The patient normally resided at a long term care (LTC) facility. A review of the history form from the LTC facility revealed a diet of mechanical soft. A review of the admission orders to the hospital demonstrated a diet order for regular, mechanical chopped. No dietitian consult was requested. No cause for the special dietary consideration was addressed in the record by either nursing or medical personnel.

a) On 03/28/12 the medical record was reviewed and revealed the following: Patient #1 was admitted on [DATE] and had a nursing assessment at 11:45 a.m. Dentures were noted by the nurse, but no swallowing or eating disorders. Admission orders contained a diet for regular mechanical chopped. A Diet Order Form demonstrated a mechanical soft/chopped diet with 1/2 inch pieces or smaller for meat and vegetables and thin liquids. The Initial Treatment Plan reflected only psychiatric problems.

On 03/23/12 the Progress Notes reflected the patient received a snack of string cheese and apple juice at approximately 10:45 a.m. She collapsed minutes later and the Heimlich maneuver was performed. This resulted in the removal of at least two pieces of cheese. The patient stopped breathing, however, and was not revived although emergent transport to an acute care hospital was completed.

b) An interview with Staff #2 who was with the patient when she collapsed revealed the following: s/he did not know why or if the patient "gulped the cheese" nor was s/he aware the patient was on a special diet. Staff are notified of diets in shift reports and on the Kardex. CNAs also get report from the nursing staff. Staff #2 thought one patient was on a pureed diet right now, but could not remember who.

c) An interview with the medical nurse practitioner who completed the physical exam of the patient on 03/22/12 revealed that s/he was aware of the mechanical soft diet, but did not assess a reason for it or determine a swallowing problem. S/he examined the patient's mouth and throat noting dentures, but did not do anything beyond this. Typically s/he would go to the dining room and observe and talk with the patients, but because this patient was so new, s/he had not had a chance to observe her behavior.

d) An interview with Staff #3 revealed the following: there are typically two nurses who admit patients and fill out admission forms and orders from past medical history and transfer forms. Nursing personnel provide information to each other in report.

e) An interview with the kitchen director and kitchen manager (contractual service) revealed that diet orders are faxed to the kitchen each day. A mechanical chopped diet does not include string cheese unless it is chopped in small pieces. Snacks are provided to the facility in bulk and it was understood that nursing personnel at the facility would distribute appropriately to patients. Nursing personnel would have to chop up the cheese.

f) An interview with the Director of Nursing (DON) revealed that diet orders are written in the Kardex at the nursing station and reviewed by all staff each shift. Although diet information is on the Kardex, s/he acknowledged that staff may not be aware of a patient's diet at times or what particular snacks are approved for a special diet. It was unclear who provided the snack to Patient #1. Any staff member can grab snacks off of the snack cart which was located in the locked nutrition room. No training of nursing personnel regarding assessment and evaluation of patients with dietary issues had been initiated by the DON or other management personnel since the adverse event. There were no communication issues between providers (e.g., nurses and behavioral health technicians) identified by management since the adverse event, yet staff were not aware of dietary restrictions for patients.


In summary, there was no evidence that patient #1's special dietary needs were considered as part of her total care or that staff were educated regarding a need for complete assessment and evaluation of physical issues in patients that were known to be high risk.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of medical records and policy /procedure, the nursing personnel failed to include physical needs in their care plans for 2 of 50 sample records. Fall prevention and special dietary needs of high risk patients were not documented in the care plan.

1. Review of medical record #1 revealed an order for mechanical chopped diet. Although the specific diet was documented on the Kardex, the diet was not included in the patients care plan. S/he was given an inappropriate snack, choked and stopped breathing. S/he was transferred to an acute care hospital where s/he expired on the same day. The care plan did not address any swallowing issues or measures to prevent choking.

2. Review of medical record #28 admitted on [DATE]. A "Daily Fall Precaution Assessment on 02/03/12 revealed the patient was a high fall risk due to age over 65 and altered mental status. There was no treatment plan for falls.
VIOLATION: EMERGENCY GAS AND WATER Tag No: A0703
Based on review of facility documents and staff interview, the facility failed to have knowledge of an emergency water supply to meet the needs of the facility in an emergency situation, as required.

The findings were:
1. On 4/05/12 at approximately 3:25 P.M. in an interview with the facility's CEO (Chief Executive Officer) s/he stated that the emergency water supply is contracted with the building landlord but s/he was not aware of the arrangement or the service provider.

2. Review of the facilities contract list on 4/3/12 revealed no contract to supply or store emergency water for the facility.
VIOLATION: RESPIRATORY CARE PERSONNEL POLICIES Tag No: A1161
Based on review of policies and procedures and staff interview the facility failed to identify and document in writing the qualifications of personnel to perform specific procedures and the amount of supervision required for personnel to carry out specific procedures. Specifically, the facility failed to assign responsibility for oxygen therapy treatments and for monitoring and storing compressed oxygen tanks.

The findings were:
Review of the facilities policies and procedures for respiratory therapy revealed there were two polices related to oxygen therapy administration, monitoring and storage. The policies were titled: 1) Oxygen Therapy, revised June 2011 and 2)Oxygen-Safe Use of Compressed Oxygen, revised May 2011. The policies and procedures failed to document the personnel to carry out these specific procedures.
1. Oxygen Therapy stated in pertinent part: ... " PROCEDURE ...2. Obtain portable oxygen equipment or oxygen concentrator. 3. Explain procedure to patient. 4. Attach nasal cannula to patient. 5. Adjust flowmeter to ordered flow. 6. Place OXYGEN-IN USE sign on door. 7. Document, time, flow, and patient's response to treatment.
2. Oxygen-safe Use of Compressed Oxygen, stated in pertinent part:.. " 1. Staff will store compressed oxygen ...2. Staff will place a sign reading [oxygen in use] on the door .... "

In an interview with the Director of Nursing(DON) on 4/3/12 at approximately 2:20 PM s/he stated that all respiratory care was performed by RN's (Registered Nurses).
During an interview with the DON on the following morning the two above cited policies and procedures were presented to him/her for review. S/he stated that they (the staff) all know who is responsible but did confirm that the policy should state the assigned staff responsible.