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 July 2, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the manner and degree of deficiencies cited, the hospital failed to comply with the Condition of Patient Rights. The facility failed to protect and promote each patient's rights.

On 7/12/12 at 11:30 a.m., the determination was made that an Immediate Jeopardy (IJ) situation existed related to the facility's failure to investigate allegations of physical abuse as well as the facility's failure to ensure that physical and chemical restraints were being used in a safe and effective manner. The facility was notified of the IJ situation on 7/12/12 at 12:45 p.m. and the IJ situation remained at the time of exit.

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

A 0145 - Patient Rights: Free from Abuse/Harassment
The facility failed to ensure that patients were free from all forms of abuse. The facility failed to document investigations into allegations of abuse against patients by facility staff. The failure placed all patients in the facility at risk of being subjected to abuse.

A 0154 - Use of Restraint or Seclusion
The facility failed to ensure that all patients were afforded the right to be free from inappropriate physical or chemical restraints.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews, record review, and policy/procedure review the facility failed to ensure that patients were free from all forms of abuse. The facility failed to document investigations into allegations of abuse against patients by facility staff. The failure placed all patients in the facility at risk of being subjected to abuse.

Findings:

1. Abuse Allegation #1:

a. An interview with the facility's Director of Human Resources was conducted on 7/11/12 at 10:28 a.m. S/he stated that in April 2012 s/he had received a verbal allegation from another employee of the facility that Behavioral Health Technician (BHT)#1 had used a towel in a shower to restrain a patient. S/he stated that s/he then went to the facility's Nurse Manager to relay the allegation to him/her. S/he stated that the Nurse Manager then approached BHT#1 to address the allegation.

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that s/he had received the complaint from the Director of Human Resources regarding BHT#1. S/he stated that BHT#1 had "used a towel to secure the patient's arms" which s/he confirmed would have constituted a restraint. S/he confirmed that the use of the towel as a restraint was not consistent with the facility's practices and expectations. S/he stated that s/he did not consider the allegation one of abuse; rather that it was a "unique teaching" that was needed.

c. An interview with the facility's Risk Manager was conducted on 7/11/12 at 1:57 p.m. S/he stated that s/he was not aware of the allegation described above prior to 7/11/12.

d. A review of facility documents revealed that there was no documentation of an investigation performed by the facility. The facility provided documentation that BHT#1 was counseled about the incident..

2. Abuse Allegation #2:

a. An interview was conducted with the facility's Director of Human Resources on 7/11/12 at 10:28 a.m. S/he stated that in May 2012 s/he had received a verbal allegation from BHT#2 (an employee of the facility) that BHT#1 had been physically abusive against patients. S/he stated that s/he asked BHT#2 to place her concerns in writing.

b. An internal facility document dated 5/21/12 written by BHT#2 stated that s/he was concerned that BHT#1 was physically abusive to patients. BHT#2 alleged that BHT#1 had "grabbed [Sample patient #22's] hand and in a quick maneuver which I have witnessed [BHT#1] using before firmly pressed [Sample patient #22's] thumb-knuckle towards his/her palm. [The patient] cried out 'ouch, ouch, ouch you're hurting me' and [BHT#1] held the position on [the patient's] thumb and led him/her away."

c. An interview was conducted with the facility's Risk Manager on 7/10/12 at 12:20 p.m. S/he stated that an investigation was conducted regarding the allegations of abuse by BHT#1 against Sample patient #22. S/he stated that s/he could not provide documentation to the surveyor's for review. A subsequent interview conducted on 7/10/12 at 1:07 p.m. revealed that s/he had spoken with 3 additional BHTs as part of his/her investigation into the allegations of physical abuse by BHT#1. S/he provided the internal facility documents maintained to document the investigation of the allegation of abuse.

d. A review of internal facility documents maintained by the facility's Risk Manager revealed that the documents contained sparse notes without details of what was said or which staff were interviewed and when.

3. Abuse Allegation #3:

a. An internal facility document dated 5/21/12 written by BHT#2 stated that s/he was concerned that BHT#1 was physically abusive to patients. BHT#2 alleged that when Sample patient #21 was "attempting to get out of his geri-chair (a normal behavior for this patient given his/her mental status)" s/he heard BHT#1 "shout to the patient from across the room telling him/her to 'sit down', the patient did not comply, again [BHT#1] shouted 'sit down'." (In the document, BHT#2 stated that there was no response from the patient.) "[BHT#1] then walked over grabbed the patient by his/her right arm and right leg and shoved him/her back onto the geri-chair, the patient started fighting with his/her free left hand. [BHT#1] then grabbed both hands and firmly locked them across the patient's chest. The patient continued the struggle, kicking his/her legs and grumbling incoherently, yet [BHT#1] held on. I walked to [BHT#1] and told him/her to 'let him/her go', s/he did not and the struggle continued. Frustrated, I walked away and went to speak with the charge nurse."

b. An interview with the facility's Risk Manager was conducted on 7/10/12 at 1:07 p.m. S/he stated that s/he had no notes regarding the investigation that was conducted in regards to this allegation. S/he stated that s/he would normally take notes when conducting interviews and would then destroy the notes after submitting an occurrence report to the State when allegations met reporting criteria. S/he stated that s/he had not reported this allegation as an occurrence to the State.

4. The facility failed to have a policy that addressed how allegations of abuse were to be investigated.

a. A review of the facility's policies/procedures throughout the survey revealed that the facility had a policy addressing reporting of patient abuse. The policy stated, "Reports of Abuse or Neglect that occur while the patient is hospitalized will be thoroughly investigated by the Risk Manager or other staff as assigned by the Chief Executive Officer in addition to following the required reporting."

b. An interview with the facility's Risk Manager was conducted on 7/10/12 at 1:50 p.m. S/he stated that s/he could not locate a policy that stated how an investigation of allegations of abuse were to be conducted and documented.

c. An interview with the facility's corporate Vice President of Clinical Operations was conducted on 7/10/12 at 2:47 p.m. s/he stated that s/he would expect that investigations performed by the facility into allegations of abuse would be documented in some form.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on record review, staff interview, and policy/procedure review the facility failed to ensure that all patients were afforded the right to be free from inappropriate physical or chemical restraints.

Findings:

1. The facility failed to ensure that when patients were physically restrained in order for involuntary, emergency medications to be administered to patients that the staff treated the episodes as physical restraints.

a. An interview with RN#1 on 7/11/12 at 11:29 a.m. revealed that the facility routinely would hold down patients for the administration of "emergency medications." S/he stated that if patients would not take their medications and the physician determined that the patient would need the medication as an injection, an order would be written for an "emergency medication." S/he stated that it was rare that a patient would allow an "emergency medication" injection to be performed and therefore would have to be held down for the safety of all involved. S/he stated that s/he had been trained that holding a patient down was not considered a physical restraint unless the patient was held for more than 5 minutes.

b. A review of the facility's records revealed that a log maintained to document the instances when patients received "Emergency Involuntary Medication" revealed that the log contained 128 entries since 1/1/12. A review of a sample of 22 patient records revealed that there were instances of patients receiving emergency involuntary medications ordered by physicians that were not included in the log.

c. A review of the facility's "Restraint Log" revealed that the facility had not recorded any instance of a patient being physically restrained.

d. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility had been under the impression that as long as a physical hold that met the definition of a physical restraint under the regulations was less than 5 minutes than it was not considered a physical restraint episode. S/he stated that s/he was now clear that any time a patient was held in a way that restricted movement and did not allow for the patient to easily escape that it was considered a physical restraint and should be handled as such. S/he confirmed that the facility's policy did not mention the 5 minute exception that s/he had referred to and that the policy did adequately address the regulations. S/he stated that the facility's nursing staff had not yet been reeducated regarding the facility's policy and the facility's practice that was not in compliance with the regulations.

2. The facility failed to ensure that when patients were physically restrained by staff by being held that the staff treated the episodes as physical restraints

a. A review of the facility's policy titled, "Restraint, Physical" stated the following:
"Policy
A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This policy applies to physical restraint only-mechanical restraint is not utilized.
Restraint is ordered by a practitioner only for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others.
Use of restraint is only employed as a last resort in emergency situations, after less-intrusive and non-physical interventions have been attempted or ruled-out. Orders for restraint shall never be written as a standing order or on as needed basis (PRN).
PROCEDURE
A trained registered nurse may initiate restraint in the absence of a practitioner. The attending/covering practitioner will be contacted during the initiation of restraint or immediately after.
The order shall indicate the reason and maximum duration of restraint.
The registered nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion progress notes and the RN Restraint/Seclusion Assessment.
Restraint episodes will be documented on the following forms: Restraint/Seclusion Flow Sheet, RN Restraint/Seclusion Assessment, Restraint/Seclusion Practitioner Order, Restraint/Seclusion progress notes and Patient Debriefing."

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility had been under the impression that as long as a physical hold that met the definition of a physical restraint under the regulations was less than 5 minutes then it was not considered a physical restraint episode. S/he stated that s/he was now clear that any time a patient was held in a way that restricted movement and did not allow for the patient to easily escape that it was considered a physical restraint and should be handled as such. S/he stated that staff received Crisis Prevention Institute (CPI) training which included physical interventions for violent patients. S/he stated that the techniques taught were designed to limit the mobility of individuals and would be considered a physical hold. S/he confirmed that the facility's policy did not mention the 5 minute exception that s/he had referred to and that the policy did adequately address the regulations. S/he stated that the facility's nursing staff had not yet been reeducated regarding the facility's policy and the facility's practice that was not in compliance with the regulations.

3. The facility failed to ensure that when patients were prescribed and received injections of medications used as a restriction to manage the patients' behaviors that the facility staff treated the episodes as chemical restraints.

a. A review of the facility's policy titled, "Restraint, Chemical" stated the following:
"POLICY
Chemical Restraint is defined as a drug or medication used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition. These medications are used in addition to or in replacement of the patient's regular drug regimen to control extreme behavior during an emergency.
PRN medications related to the diagnosis and presenting condition which are ordered in response to exacerbation of normally anticipated symptoms and included in the plan of care for the patient are considered standard treatment and would not be classified as Chemical Restraint. Medication categorized as chemical restraint is administered only after less restrictive efforts at assisting the patient in regaining control have been attempted or ruled out.
PROCEDURE
Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner. When medication categorized as chemical restraint is ordered the following actions will be taken:
The R.N. will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion progress notes and the RN Restraint/Seclusion Assessment.
The patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained registered nurse that the chemical restraint has ended, based on assessment of the behavioral and medical condition of the patient.
Vital signs will be taken immediately following administration of the medication and then minimum q 30 minutes x 2. The practitioner will be notified immediately if the vital signs are abnormal.
Chemical restraint episodes will be documented on the following forms: Restraint/Seclusion Flow Sheet, RN Restraint/Seclusion Assessment, Restraint/Seclusion Practitioner Order, Restraint/Seclusion progress notes and Patient Debriefing."

b. An interview with the facility's Nurse Manager was conducted on 7/11/12 at 12:28 p.m. S/he stated that the facility did provide medications upon the order of a physician that would be considered chemical restraints. S/he stated that it was his/her understanding that if the patient received the medication orally normally, then the receipt of the medication as an injection would not be considered a chemical restraint. S/he stated that the injection of a medication that would limit or decrease the patient's ability to interact with their environment would be considered a chemical restraint. S/he stated that the facility had seen an increase in the prescription of injectable medications that could be considered chemical restraints recently. S/he stated that s/he had educated the nursing staff that it was appropriate to question orders that appeared to be chemical restraints and spoken to the facility's medical staff members.

c. A review of the facility's "Restraint Log" revealed that in 2012, there had been 4 episodes of chemical restraints (on 2/15/12, 4/24/12, 4/27/12 and 4/27/12). Additional review of the facility's "Emergency Involuntary Medication Log" revealed that the log contained 48 entries in 2012 that would be considered chemical restraints according to the definition given by the Nurse Manager and regulations.

d. A review of Sample Patient #21's record revealed that the patient was prescribed emergency medications on two separate occasions. On 5/11/12 at 1:00 p.m. the patient was prescribed Zyprexa (an antipsychotic) 5 mg and Benadryl (an antihistamine) 100 mg to be injected every 6 hours as needed. On 5/11/12 at 1:00 p.m. the patient received the ordered medication as an injection. The patient received an additional dose on 5/12/12 at 9:45 a.m. On 5/13/12 at 11:30 a.m. the patient was prescribed Zyprexa 10 mg and Benadryl 100 mg to be injected one time. The patient received the ordered medication as an injection on 5/13/12 at 11:40 a.m. On both days, the patient was violent and was "hitting and grabbing staff" and required the medication as an intervention to restrict the patient's behavior. The patient was not receiving Benadryl prior to the injections. The "Emergency Involuntary Medication Log" contained only the dose that was given on 5/13/12 at 11:40 a.m. The patient's chart did not contain the required restraint documentation as described in the policy above.