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 Nov. 17, 2011
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the nature of deficiencies, the facility failed to be in compliance with the Condition of Participation of Nursing Services. Specifically, the hospital failed to ensure that all nursing staff were adequately trained to appropriately respond to a patient found unresponsive, pulseless and without respiration by immediately initiating cardiopulmonary resuscitation as required by facility policies and procedures. In the eight days subsequent to the event, the facility failed to take effective actions to ensure that the nurses would not fail to initiate timely cardiopulmonary resuscitation measures if/when another instance of cardiac or respiratory arrest occurred. These failures may have contributed to the death of sample patient #1 and were determined to constitute an Immediate Jeopardy to the health and safety of all current and future patients in the facility. The Immediate Jeopardy situation was not corrected prior to the complaint survey exit conference.

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

Tag A 386 - Organization of Nursing Services
The hospital failed to ensure that all nursing staff were adequately trained to initiate timely cardiopulmonary resuscitation measures when presented with a patient in full cardiac/respiratory arrest.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff/physician interviews and review of facility documents and policies/procedures, the hospital failed to ensure that all nursing staff were adequately trained to initiate timely cardiopulmonary resuscitation measures when presented with a patient in full cardiac/respiratory arrest. The failure may have contributed to the death of sample patient #1 and was determined to constitute an Immediate Jeopardy to the health and safety of all current and future patients in the facility.

The findings were:






Policy/Procedure Review
A facility policy titled "CPR Initiation", last revised April 2011, stated the following in pertinent parts:
"... A Staff Member trained in CPR shall initiate CPR immediately upon a patient to be experiencing cardiac or respiratory arrest. When patient has a full code status and is not DNR status...
The first person at the scene of a cardiopulmonary arrest will immediately initiate CPR procedures in accordance with the American Heart Association's Guidelines for Basic Life Support..."

A facility policy titled "Advanced Directives", last revised June 2011, stated the following in pertinent parts:
"... If the patient has a current copy of the CPR Directive from their facility. A copy of that form is requested to accompany the patient to the hospital. That form will be placed in a page saver and placed in the Legal section of the Chart for ready availability in emergency situations. A "Do Not Resuscitate" order is written by the attending physician in the patients chart. A DNR sticker is placed on the front of the chart for ready availability."


Medical Record Review
A review of the medical record of sample patient #1 on 11/17/2011 revealed the following in pertinent parts:
The patient was a [AGE] year old patient admitted with vascular dementia. The patient was admitted on [DATE]. On 11/9/2011 at approximately 11:15 PM a nurse's note was written by Staff Member #1. The note stated: "patient was found non-responsive during 15 minute check at 10:15 PM. RN was called to assess. Requested a set of vital signs, only a temp of 97.8 registered, repeat set show temp 97.3. No BP, respirations, or pulse. RN placed call to [internal medical group] physician to please come to unit. RN call 911 [city] PD/FD arrived on unit at 10:25 PM . Could not find DNR paperwork CPR started by FD [10 minutes after the patient was found]. At 10:30 PM called acting DON. Called patient's guardian and was called back by [city] Adult Protective Services 'on call', [city] FD stopped CPR and [local acute care hospital] physician pronounced at 10:52 PM by phone. Coroner called..." In multiple documents within the chart, the patient was listed as a full code and to perform CPR/Resuscitation if necessary. No document within the medical record referred to the patient as having an Advanced Directive or to not be resuscitated.


Facility documents
An internal facility document that recounted the events of 11/9/2011 stated the following, in pertinent parts:
"At 10:15 PM [Behavioral Health Technician] noticed patient seemed to not be breathing. Notified [Registered Nurse] to come assess. Patient was non-responsive to stimuli, had [another staff member] do set of vitals, non-registered on monitor except temp 97.8 second attempt no vitals registered except temp 97.3. RN called [internal medical group] physician to come to unit, called 911 - [city] FD and PD. Called acting DON, Searched chart for DNR papers. None found. FD arrived and started CPR at 10:25 PM [10 minutes after the patient was found by staff]..."

Staff Interviews
An interview with the Assistant Director of Nursing (DON) on 11/17/2011 at approximately 9:55 AM revealed that the facility had a patient (Sample patient #1) that had been in the facility approximately 10 days. The patient was found during 15 minute checks to be unresponsive. Staff attempted to take the patient's vital signs and were only able to obtain a temperature. An internal medicine physician (MD#1) responded to the staff's call for assistance and was present when Emergency Medical Services (EMS) personnel arrived. The patient was pronounced deceased at approximately 10:52 PM. S/he was unsure when the patient was found. She stated that in addition to the internal medicine physician the internal medicine Medical Director (MD#2) was contacted by phone and had spoken to staff that night. The Assistant DON had performed a review of the patient's care and stated that s/he did not have any concerns about the care provided. S/he stated that the patient's nurse (Staff member #1) was one of the facility's charge nurses. S/he stated that the patient was a full code (all resuscitative measures should be taken).

A subsequent interview with the facility's Assistant DON was conducted, on 11/17/2011 at approximately 11:31 AM, after a review of Sample patient #1's medical record. The Assistant DON stated that the facility's staff had been in the process of preparing for initiating CPR when EMS had arrived. S/he stated that staff did not know the patient's "DNR status" (whether or not CPR should be initiated). S/he stated that in response to this incident, staff were "debriefed" and s/he had discussed with staff the steps that needed to be taken in a medical emergency. S/he stated the facility had an Automated External Defibrillator (AED), but that it was not used, nor taken into the patient's room. S/he stated that staff were looking for a mouthpiece for CPR, but then stated that staff wouldn't be looking for a mouthpiece as the steps of CPR had changed to starting compressions immediately. S/he stated that the facility did not have a bag of emergency supplies or an equivalent emergency pack. S/he stated that s/he had discussed new policies with the facility's staff at the staff meetings on 10/26/2011 and 10/27/2011, but then stated that staff did not received a policy to review nor was there a policy for staff review in a book regarding CPR response.

An interview with MD#2 the Medical Director of the Internal Medicine Physician group was conducted on 11/17/2011 at approximately 12:01 PM. S/he stated that MD#1 did not yet have privileges at the hospital, but was present on 11/9/2011. S/he stated that s/he had received a call from MD#1 in which MD#1 stated that someone had died at the hospital and that when MD#1 arrived to the patient's room the staff had not started CPR. S/he stated that his/her arrival was approximately 10 minutes after the facility's staff had found the patient, unresponsive. MD#2 stated that s/he then called the nurses' station and spoke to staff member #1 to see if s/he needed to come to the hospital, the staff told him s/he did not need to come in. MD#2 stated that s/he then called MD#1 back who stated that EMS was there performing CPR and needed an order from their medical officer to stop CPR and declare the patient as deceased . MD#2 stated that nursing staff should have started CPR until told otherwise by the physician. "I feel as part of my job as the medical director, the nurses need to do what needs to be done." MD#2 reviewed text messages that s/he had received from MD#1 on 11/9/2011. S/he stated that MD#1 stated that CPR had not been started until at least 10 minutes after the patient was found unresponsive and that the staff needed education to not be afraid to start CPR.

A telephone interview with MD#1 was conducted on 11/17/2011 at approximately 12:16 PM with MD#2 and the Assistant DON present. MD#1 stated that s/he had received a call from the hospital's staff, stating sample patient #1 unresponsive. S/he hung up the phone and the hospital staff let MD#1 into the locked facility. When MD#1 arrived to the patient's room, the patient "was obviously dead, pupils fixed and dilated, ashen white, staff called fire department, staff unsure of code status". S/he stated that the facility's staff had not started CPR prior to his arrival which was approximately 10 minutes after the patient was found by the hospital's nursing staff. MD#1 stated that a few minutes later the fire department arrived and started CPR. Staff had found sample patient #1 unresponsive after he was yelling at them 20 minutes prior. MD#1 stated that after EMS started CPR, "I asked staff what had been done...staff stated they were uncertain of the patient's CPR status, which I told them that CPR should had been started if unknown." MD#1 confirmed that the AED remained at nurses' station and that the patient was lying in bed at a 45 degree angle upon his arrival to the room.

A subsequent interview with the Assistant DON on 11/17/2011 at approximately 12:33 PM revealed that "as the third person called: I told them to start CPR. They were in the process of getting [sample patient #1] into position...I Directed [staff member #1] to go back to the patient's room." The Assistant DON stated that s/he felt that the nurse acted negligently. S/he stated that the facility had not had a medical emergency drill in the past and did not have concrete plans for one since. S/he then confirmed that the only staff that had been trained since 11/9/2011 was the staff from that night and two other charge nurses at the facility.