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 13, 2011
VIOLATION: LICENSURE OF NURSING STAFF Tag No: A0394
Based on review of 17 personnel records and staff interviews it was determined that nursing services has failed to provide proof of licensure for Licensed Psychiatric Technicians. The facility currently has one employee working as a Licensed Psychiatric Technician without licensure. The facility has also previously employed others in this role without licensure requirement.
The findings were:

Staff sample #9 was certified as a Certified Nurse Aide (CNA) but was in job title of Licensed Psychiatric Technician (LPT). There was currently one combined job description for both roles. Per an interview with the Director of Nursing on 7/11/2011 at approximately 4:05 p.m., when asked about the certification of the employee working as a LPT, he/she stated the employee was given this classification to allow for higher salary range. "I honestly did that to bring her/him in for more money because s/he has a BS(Bachelor of Science) in gerontology and a lot of experience. I take full responsibility for that."

In summary, nursing services did not ensure that nursing personnel had valid licensure/certification.
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on personnel file review, staff interview, and review of the facility's policies/procedures the facility failed to ensure that all non-employee files contained proper orientation documentation to the facility, facility-specific job descriptions and evaluations of performance for the shifts worked as evidenced in five of five agency nursing staff files reviewed. This failure did not ensure non-employee nurses adhered to the policies and procedures of the hospital. This created the potential for negative patient outcome.

The findings were:

An initial review of a sample of the facility's personnel files revealed that a non-employee/agency CNA's personnel file did not contain any evaluations of the CNA's performance. The Director of Nursing was informed on 7/12/2011 of the absence of the evaluations. The Director of Nursing provided three evaluations for the non-employee/agency CNA to the surveyors on 7/12/2011 at approximately 4:00 p.m. A review of the three evaluations revealed that the "date of service" listed on the evaluations were 6/16/11, 6/12/11, and 6/27/11. The evaluations were signed by the facility staff on 7/12/11. An interview with the Director of Nursing on 7/13/2011 at approximately 7:45 a.m. confirmed that all three evaluations were completed and signed on 7/12/2011. When asked why the forms were completed and signed on 7/12/2011, instead of on the days the CNA provided care, the Director of Nursing stated, "No one ever filled them out...because they [the facility's staff] are not great at doing them [the evaluations]." S/he state that s/he knew that the evaluations needed to be done and included in the files maintained by the facility. S/he stated that "if we have a bad one [a bad agency staff member], they [the facility's staff] do them [the evaluations]."

The policy and procedure titled "Agency Staff," that was last revised May 2011, was reviewed on 7/13/2011. It stated the following, in pertinent part:
"...PROCEDURE
1. Agency personnel are booked through local registries. An Agency Employee Profile is completed by the agency on each agency personnel working at HBND and kept on file at HBND. DON/designee will ensure that all required documentation is obtained prior to being accepted for assignment to the hospital...
4. Agency personnel will be oriented to the hospital and instructed regarding their individual assignment of the shift charge Nurse or nursing staff. Director of Social Services (social services staff), prior to working. Agency personnel will be given an orientation packet prior to or upon arrival for their review and completion. Orientation will be documented on the agency Orientation Checklist and include:
a. Fire
b. Safety
c. Infection Control
d. Confidentiality
e. Reading Haven's Agency Orientation Manual...
5. Agency staff member complete the Agency Orientation Sheet, verifying completion of these requirements...
9. An agency evaluation will be completed on all registry/agency personnel at the end of each shift worked by the supervising HBND personnel and/or Director of the department for three work shifts...
13. An agency binder is located in the nursing station and will be maintained by the Director of Nursing. The nurse in charge of the shift will review the nursing agency file to assure that all required documents have been obtained. The nurse in charge will also review any performance evaluations to identify any potential areas of weakness."

On 7/11/2011 a list of all nursing staff, including agency/pool staff was requested and provided. The facility maintained a manila folder for each agency staff member as well as a large binder for all agency staff. The binder contained a copy of licenses and certifications held by each agency staff member as well as a form that was titled "Agency Staff Checklist of Orientation." The manila folder for each agency staff member contained all other documentation that the facility had for each staff member. In the folder were original signed documents for orientation, privacy policy acknowledgments, evaluations of past shifts, and a sheet that was titled "Haven Behavioral - North Denver Agency Orientation."

An additional sample of five of the listed agency nursing staff was selected from the list. A review of the five sample agency personnel files on 7/13/2011 revealed that all five (samples #1 through 5) of five personnel files maintained on agency staff did not have a job description from the facility that delineated the expected performance or duties for the facility.

Sample agency personnel file #1 was a Certified Nurses' Aide (CNA) who had been to the facility for 11 shifts in 2011 the most recent shift was 4/30/2011. The manila folder contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the CNA and signed on 12/7/10. The file contained only one form titled "Haven Behavioral - North Denver Agency Personnel Evaluation" dated 3/23/2011. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was signed by the same person that signed the "Agency Employee Profile" on the line provided for the "Signature of Agency Representative" which listed his/her title as "Staffer," not Charge Nurse.

Sample agency personnel file #2 was a Registered Nurse (RN) who had not been to the facility, yet was listed on the list of agency staff. The manila folder for sample agency personnel #2 contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 5/20/2011.

Sample agency personnel file #3 was a Registered Nurse (RN) who had been to the facility for three shifts in 2011 the most recent shift was on 6/5/2011. The manila folder did not contain a form titled "Haven Behavioral - North Denver Agency Orientation," rather the staff member responsible for the maintenance of the agency personnel files provided a separate stack of papers with a fax date/time stamp of "7/11/2011 [2:40 PM]", which contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 6/1/11. The file contained only one form titled "Haven Behavioral - North Denver Agency Personnel Evaluation" dated 6/1/2011.

Sample agency personnel file #4 was a Registered Nurse (RN) who had been to the facility for fifteen shifts in 2011 the most recent shift was on 7/1/2011. The manila folder contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 11/23/10. The file contained only two forms titled "Haven Behavioral - North Denver Agency Personnel Evaluation" dated 12/9/10 and 4/14/11.

Sample agency personnel file #5 was a Registered Nurse (RN) who had been to the facility for seven shifts in 2011 the most recent shift was on 6/20/2011. The manila folder contained a form titled "Haven Behavioral - North Denver Agency Orientation" that was initialed by the RN and signed on 3/22/11. The file contained only one form titled "Haven Behavioral - North Denver Agency Personnel Evaluation" dated 5/31/2011. Additionally, the Agency Orientation form contained a line on the bottom of the form for the "Signature of Nursing Supervisor/Unit Nurse" that was left blank.

An interview with the facility staff member that was responsible for the maintenance of the agency staff personnel files on 7/13/2011 at approximately 9:45 a.m. revealed that the "manila folder contains information that is faxed from the agency" and that the "orientation form in there is from the agency and faxed to us." S/he stated that the form within the binder that was titled "Agency Staff Checklist of Orientation" was the documentation of the orientation from the facility. S/he confirmed that the "Agency Staff Checklist of Orientation" did not have a place for a signature or name of the person that completed the orientation with the agency staff member. When asked how the agency staff member was made aware of the "Location of the Fire Extinguishers, Fire Alarms, Oxygen Tanks, A.E.D. (Automated External Defibrillator)" as well as introduced to the "Medication Room and Policies" and demonstrated "Medication Administration" s/he stated that the agency filled the forms out and was not sure how those portions of the form/orientation were carried out by the agency." When asked why the dates on the facility's "Agency Staff Checklist of Orientation" matched the faxed form from the agency titled "Agency Orientation", s/he stated that s/he did not know. S/he confirmed that the agency staff member #2 had not been in the building although the portions titled "Location of Fire Extinguishers, Fire Alarms, Oxygen Tanks, A.E.D." and "Introduction to Medication Room and Policies" and "Demonstration of Medication Administration" were completed on the "Agency Orientation."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on staff interviews and review of facility documents, the facility failed to ensure that all drugs and biologicals were administered by nursing personnel in accordance with Federal and State laws specifically in the administration of controlled substances.

The findings were:

Cross Reference to A 0494: Pharmacy Drug Records for findings related to the hospital's failure to ensure that accurate records were kept for the distribution of all scheduled drugs. Specifically, for findings related to staff member #1's suspected diversion of medications.
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, staff interview, and review of the facility's records the facility failed to ensure that accurate records were kept for the distribution of all scheduled drugs.

The findings were:

A review of the facility's medical records and Narcotic Administration Records/Controlled Substances Administration Records revealed that Staff Member #1 had made incomplete/illegible/false and erroneous entries in the records which the facility concluded was diversion.

The facility's former pharmacist documented 5/13/2011 that Staff Member #1 had questionable entries in the NAR (Narcotic (CII) Administration Record) and CAR (Controlled Substances (CIII-CV) Administration Record) which were records that the facility utilized to account for controlled substance administration and counting. The following were listed by the facility's former pharmacist:
2/15/2011: 0630 Shift Change Count: Staff Member #1 signed/no witness signature.
2/26/2011: 0210: 1 Vicodin removed with no patient identified by Staff Member #1.
3/4/2011: 1840 Shift Change Count: Staff Member #1 signed/no witness signature. (Controlled)
3/10/2011: 0630 Shift Change Count: Staff Member #1 signed/no witness signature. (Controlled)
3/4/2011: 1840 Shift Change Count: Staff Member #1 signed/no witness signature. (Narcotics)
3/10/2011: 0630 Shift Change Count: Staff Member #1 signed/no witness signature. (Narcotics)
3/11/2011: 0230: Last count of Percocet was 19 tablets by Staff Member #1.
3/11/2011: 0630 Shift Change Count: 17 Percocet by Staff Member #1. (2 Tablets unaccounted for)
3/31/2011: Narcotic count at end of 3/31 for Percocet was 22 with the last entry by Staff Member #1
4/1/2011: Narcotic count for beginning of 4/1/2011 for Percocet was 21 (1 tablet unaccounted for)
4/2/2011: 0630 Shift Change Count: Staff Member #1 signed/no witness signature.
4/2/2011: 1900 Shift Change Count: Staff Member #1 signed/no witness signature.
4/2/2011: Narcotic count at end of 3/31 for Percocet was 34 with the last entry by Staff Member #1
4/3/2011: Narcotic count for beginning of 4/3/2011 for Percocet was 33 (1 tablet unaccounted for)
4/3/2011: 1900 Shift Change Count: Staff Member #1 signed/no witness signature.

The facility's former pharmacist had identified the following twelve patients as having questionable documentation in their records by Staff Member #1. The documentation demonstrated probable diversion or overdose. Often doses were given too early, or additional tablets were removed than were ordered. Also, statements given to the facility's former pharmacist revealed that Staff Member #1 had forged other nurses' signatures in the records. The following examples were listed by the facility's former pharmacist:

Sample patient #5: Sudafed 30 mg was removed for this patient by Staff Member #1 on 2/20/2011 at 0500 according to the Controlled Substances (CIII-CV) Administration Record (CAR). No documentation was present on the patient's Medication Administration Record (MAR) for Sudafed and the chart did not include any orders for Sudafed.

Sample patient #6: The patient had Oxycodone 10 mg (two 5 mg tablets) ordered scheduled every eight hours and every 6 hours as needed for breakthrough pain. The order also stated to hold the medication if the patient was too sedated.

The NAR reflected that Oxycodone IR 5 mg tablets were removed by Staff Member #1 on 2/11/11 at 2200 (2 tablets) and on 2/12/2011 at 0230 and 0600 (2 tablets each time).

The patient's MAR reflected that 10 mg of Oxycodone was administered to the patient on 2/11/2011 at 2200 and on 2/12/2011 at 0230. The MAR stated that the patient was sleeping at 0330. The 0600 dose was not documented as given or held. The patient was given Narcan (an antidote for narcotics) at 0836 for falling asleep in his food.

Sample patient #7: The patient had Percocet 1/2 tablet ordered three times daily for chronic pain and 1/2 tablet every eight hours as needed for breakthrough pain.

The NAR reflected that on 2/17/2011 at 2100 - 2 tablets removed, no waste, 2/18/2011 at 0140 - 1 tablet removed, no waste, 2/18/2011 at 2100 - 1 tablet removed, no waste, 2/19/2011 at 0120 - 1 tablet removed, no waste, 2/23/2011 at 2100 - 1 tablet removed, no waste.

The patient's MARs and Nursing notes reflected the following:
2/17/2011 at 2340 the patient complained of neck pain and that "meds administered as ordered" which would have included 1/2 tablet, not the two that were removed. The MAR did not indicate that any variation to the 1/2 tablet ordered was administered at 2100 on 2/17/11 by Staff Member #1. The as-needed Percocet was documented as given by Staff Member #1 on 2/18/2011 at 0140, but did not indicate that any variation to the 1/2 tablet ordered was administered. The MAR did not reflect the 2/19/2011 0120 dose that was pulled by Staff Member #1.

Additionally, the pharmacist wrote, "On nursing flow sheet dated 2/23/11 it is documented that prn Percocet 1/2 tab 0330 for 8/10 leg pain however- it is never documented as being pulled at that time on NAR dated 2/23 or 2/24 Side 1. Note of Interest: Staff Member #1 RN pulled 2100 dose of #1 Percocet tablet on 2/23/11 but does not document on MAR and documents on MAR on 2/23/11 at 0345 that dose of Percocet given but not pulled on NAR." The order as of 2/22/2011 was to give Percocet 1 table every 12 hours.

Sample patient #8: Vicodin ordered one tablet at bedtime as well as every 8 hours as needed for pain of 6/10 or greater. MAR reflected Vicodin given as ordered on [DATE] at 2100 and on 3/16/11 at 2100. The MAR also reflected a dose of Vicodin given on 3/16/11 at 0545.

The CAR (Controlled Substances Administration Record) reflected that the 3/15 2100 and 3/16 0545 doses were removed by Staff Member #1. However, an additional dose was removed by Staff Member #1 on 3/16/11 at 0200.

The nurses notes for 3/15/11 PM through 3/16/11 AM dated 3/16/11 at 0645 stated that there was an "uneventful n[ight]"
A signed statement by the facility's former pharmacist reflected that an interview with the patient's nurse (Staff Member #2 - not the nurse that administered the patient's medications) revealed that if as-needed doses were given to her/his patients, s/he would document so in her/his notes.

Sample patient #9: The patient had Vicodin 1 tablet every 12 hours ordered and none as needed. The patient did not have Percocet ordered.

The MAR reflected that a dose of Vicodin was given on 3/15/11 and 3/16/11 at 0600 and that both doses were administered by Staff Member #2. A signed statement by the facility's former pharmacist reflected that an interview with Staff Member #2 revealed that the 3/15/11 0600 dose was given by Staff Member #2, however, s/he did not give the 3/16/11 0600 dose. Handwriting comparison by the facility determined that the signature and initials were forged by Staff Member #1.

Additionally, the NAR reflected that on 3/15/2011 at 0020 2 tablets of Percocet were removed for sample patient #9 and wasted by Staff Member #1 and Staff Member #2. The written statement by the pharmacist stated that Staff Member #2's signature was forged there as well.

Sample patient #10: Patient ordered Vicodin 1 tablet twice daily at 0600 and 1500 scheduled.

The CAR reflected that on 3/18/11 at 2100 two tablets of Vicodin were removed without a waste by Staff Member #1, 3/19/11 at 0600 two tablets of Vicodin were removed without a waste by Staff Member #1, 3/20/11 at 0600 two tablets of Vicodin were removed without a waste by Staff Member #1.

The MAR reflected that on 3/18/11 the 1500 dose was refused. There was no documentation that a dose was given later. The MAR reflected that the prescribed dose of 1 tablet was given on 3/19/11 at 0600 and 3/20/11 at 0600 by Staff Member #1, not the two tablets that were removed for each dose.

Sample patient #11: Patient ordered Vicodin 1 tablet every 6 hours as needed for pain. There was no order for Percocet in the entire chart.

The patient's MAR reflected that on 3/19/11 at 0720 2 tablets of Vicodin were given by Staff Member #1. No order was present that reflected a different dose ordered than the one tablet order present.
The patient's MAR reflected that on 3/31/11 at 2240 2 tablets of Vicodin were given by Staff Member #1. No order was present that reflected a different dose ordered than the one tablet order present.
The patient's MAR on 4/1/11 had an entry in the handwriting of Staff Member #1 of "0345." The entry did not specify how many tablets or who gave the medication or the indication for the dose.
The CAR reflected that on 3/19/11 at 0820 2 tablets of Vicodin were removed by Staff Member #1. The 2nd page for 3/19/11 at 0610 reflected that 2 additional tablets were removed by Staff Member #1. On 3/31/11 at 2100 2 tablets of Vicodin were removed by Staff Member #1. On 4/1/11 at 0320 2 tablets of Vicodin were removed by Staff Member #1.

The NAR reflected that on 3/31/11 at 2000 2 tablets of Percocet were removed for the patient by Staff Member #1 and were wasted with Staff Member #3. A signed statement by the facility's former pharmacist stated that Staff Member #3 denies that the signature is hers/his and that s/he was no longer in the facility at that time.

Sample patient #12: The patient had Percocet 1 tablet ordered every 6 hours as needed.

The patient's MAR reflected that on 4/3/11 at 0530 1 tablet of Percocet was given to the patient by Staff Member #1.

The NAR reflected that 1 tablet of Percocet was removed for this patient by Staff Member #1 on 4/3/11 at 0100 and at 0530. There was no indication of any waste.

Sample patient #13: The patient had Percocet 1 tablet ordered every 4 hours as needed for pain.

The patient's MAR reflected that on 3/5/11 doses of Percocet were given at 1900 as well as on 3/6/11 at 0025 and 0440. The MAR did not indicate that the 1900 dose was more than the 1 tablet ordered.

The NAR reflected that two tablets of Percocet were removed by Staff Member #1 on 3/5/11 at 1900. There was no indication of any waste.

Sample patient #14: The patient had Oxycodone IR 5 mg tablets ordered on [DATE] three times daily at 0600, 1200 and 1800, the order was changed 3/17/11 to twice daily at 0900 and 2100.

The patient's MAR indicated that the patient was given her 3/16/11 0600 dose by Staff Member #2 (a signed statement from the facility's former pharmacist that the initials were not Staff Member #2's). The MAR on 3/19/11 reflected that both the 0900 and 2100 doses were given by Staff Member #1.

The 3/16/11 NAR indicated that at 0600, 1 tablet of Oxycodone was removed by Staff Member #1 and marked wasted, without a co-signature. Then another tablet of Oxycodone was removed by Staff Member #1 for the 0600 dose.

The 3/19/11 NAR indicated that at 0600, 1 tablet of Oxycodone 5 mg was removed and an additional tablet of Oxycodone was removed at 0900. A signed statement from the facility's former pharmacist stated that "I believe both of these doses were removed by Staff Member #1 disguising her/his signature." Then, at 2100, Staff Member #1 removed 2 tablets of Oxycodone with a documented waste of 1 tablet, however Staff Member #1 signed as both nurses for the waste. An additional tablet of Oxycodone was removed by Staff Member #1 at 0600 on 3/20/11, but was not documented on the MAR, nor was a dose due until 0900.

Sample patient #15: The patient had Percocet 1 tablet ordered for every 8 hours as needed for pain.

The patient's MARs indicated that on 4/2/11 at 2015 a dose of Percocet was given by AR, then on 4/3/11 at 0100 a dose was given by Staff Member #1, another dose on 4/3/11 at 0600 and on 4/3/11 at 0730. The MAR did not indicate the patient's measurement of pain and the patient's nurses' notes has an entry dated 4/2/11 2200/0600 that stated an "uneventful n[ight]" that would have covered all the doses given by Staff Member #1. Additionally, there were no supplemental nurses notes during this time period. The MAR entries reveal that doses were given 5 hours apart, 5 hours apart, and then 1 1/2 hours apart respectively.

The NAR for 4/2/11 reflected that at 2015 a dose was removed by Staff Member #1, on 4/3/11 at 0100 a dose was not removed for this patient, but one was removed for Sample Patient #12. On 4/3/11 at 0540 a dose was removed for this patient by Staff Member #1. On 4/3/11 at 0730 the NAR reflects that Staff Member #4 removed a dose for this patient, but the MAR reflected that the dose was given by Staff Member #1.

Sample patient #16: The patient was ordered Vicodin 1 tablet twice daily at 0700 and 2100 scheduled for pain.

The patient's MARs reflect that a dose was given by Staff Member #1 on 3/31/11 at 2100 and on 4/1/11 at 2100. There was no indication that any variation to the one tablet dosage was given.
The CAR reflected that on 3/31/11 at 2100 two tablets of Vicodin were removed by Staff Member #1 for this patient, no wasting of the additional tablet was documented. On 4/1/11 at 2100 Staff Member #1 removed the ordered one tablet of Vicodin for this patient.

In a signed statement by the facility's former pharmacist she stated that "On the Nursing progress note dated 3/31/11 at 2200 [an hour after the MAR stated that the patient received the scheduled Vicodin (possibly 2 tablets according to the CAR)] - it is noted that the patient spikes a temperature and is instructed to give 1000 mg of Tylenol at 2245 by Physician...If the patient did receive the #2 Vicodin (which would contain 1000 mg APAP) - then why did her temp go from 100.8 at 2035, to 101.3 at 2230?"

An interview with the facility's Director of Nursing on 7/12/2011 at approximately 11:45 a.m. confirmed the report of false documentation/diversion by Staff Member #1.
VIOLATION: REPORTING ADVERSE EVENTS Tag No: A0508
Based on staff interviews and review of facility documents, the facility failed to ensure that drug administration errors were reported to the hospital-wide QAPI program. Specifically, the hospital failed to proactively identify medication errors (including observation of medication passes, concurrent and retrospective review of patient's clinical records, implementation of medication usage evaluations for high-alert drugs, or non-punitive system with focus on the system and not the involved health professional).

The findings were:

Cross Reference to A 0494: Pharmacy Drug Records for findings related to the hospital's failure to ensure that accurate records were kept for the distribution of all scheduled drugs. Specifically for findings related to staff member #1's suspected diversion of medications.

An interview with the facility's PI/IC Manager on 7/12/11 at approximately 9:20 a.m. revealed that s/he was responsible for the follow-up of incidents including medication issues and has been in charge of the remediation classes (that the facility put into place for staff members with medication errors) when the pharmacist was no longer able to be in charge of the classes. S/he stated that this had been her responsibility since 3/2011. S/he stated that the facility relies on paper reports submitted by nursing staff or the pharmacist for the tracking of medication errors. S/he stated that the nursing staff will normally find errors during the 24-hour chart checks in which the Medication Administration Record (MAR) and the medication orders are compared to ensure that transcription of orders is accurate. S/he stated that in January there were 15 transcription errors reported. In May, the PI/IC Manager started to track the type of errors and the person who was responsible. S/he stated that in June there were 10 errors, 5 of which were transcription errors. S/he stated that in response the facility was going to work with the agency that provides many of the facility's agency nursing staff to "revamp orientation". S/he also stated that one of the facility's nurses resigned who was responsible for 5 errors in the last 2 months for unrelated reasons. S/he stated that 3 errors were pharmacy errors that included medications "dropping from the printed MAR" and medication not being filled into the patient's drawer.

An interview with the facility's Director of Nursing (DON) on 7/12/11 at approximately 1:35 p.m. revealed that the investigation into the activity of Staff Member #1 was conducted by the facility's former pharmacist and him/herself. When asked what the facility did to identify medication errors, the DON stated that the facility's PI/IC Manager would receive the reports when errors were noted on the 24-hour chart check, self-reports, when the wrong medications were found in the patient's drawer, or if the pharmacy found an error. S/he stated that there were no other methods used to identify errors. She stated that the pharmacist would mention individuals to the DON when there were questionable practices, but that the DON didn't "recall her mentioning [Staff Member #1]." In response to the diversion, the nursing orientation by the facility's pharmacist started after 4/6/11. The orientation would include the mentioning that 2 RN signatures were required for shift counts on the NAR/CAR reports. The DON stated that the facility's RNs were educated with an in-service to "tighten up the narcotic sheet and don't take it for granted. Compare yesterday's sheet to today's." S/he stated that medication errors involving narcotics would be reported as an error (and thus tracked by QAPI) when extra medication or a wrong medication was given. A missing signature would not be an occurrence. S/he stated that reports were now coming to her the next day. When asked if the policy had been changed in regards to the reporting and counts, s/he stated that didn't know and would have to check with the PI/IC Manager as s/he was doing the review with the facility's former pharmacist. The DON stated that in response to the diversion and identified errors, the facility has had in-services/education on narcotic counting/signing out/and wasting. Although documentation of this education was not provided when requested.

In a subsequent interview with the facility's PI/IC Manager on 7/13/2011 at approximately 12:35 p.m., the PI/IC Manager stated that s/he was doing audits right now regarding pain assessment and interventions and a check to see that 24-hour chart checks were being completed. S/he stated that the previous pharmacist was doing 100% audit of narcotics removed and that the new pharmacist should be. S/he stated that 2-3 times a week s/he does observations of counting and checking refrigerator temperatures and multi-dose vials. The documentation of these audits was requested and provided. The audit sheet was the facility's "Nightly Checklist" for the nurses stating the tasks that were to be completed with the PI/IC Manager's initials with a checkmark on random days below the checklist with an entry that stated, "Count, Rx Pads, Noc audits".

An interview with the facility's newly hired pharmacist on 7/11/2011 at approximately 2:05 p.m. revealed that it was his/her fourth day in the facility. S/he was unable to discuss the investigation into the activity of Staff Member #1, but was aware of it. S/he stated that s/he was too new to have put any changes in place as s/he was still becoming familiar with the facility. S/he stated it would not be difficult to review the facility's NAR/CAR records and ensure that documentation existed that supported each removal as the facility did not have a large amount of narcotic usage.
VIOLATION: DISCHARGE PLANNING NEEDS ASSESSMENT Tag No: A0806
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of medical records, policies/procedures, and staff interviews, in one of 21 sample medical records the facility failed to adequately prepare and plan for the patient's discharge disposition after an evaluation of the likelihood of the patient's capacity for self-care in his/her previous environment had been conducted. Specifically, the patient's previous environment was the street and, despite the patient's definitive diagnosis of dementia, the facility failed to ensure the patient was discharged to a safe environment and instead attempted to discharge the patient to a night shelter. This failure created the potential for a negative patient outcome due to an unsafe discharge environment.

The findings were:

1. Policies

The facility's policy titled "Discharge Planning," last revised May 2011, stated the following, in pertinent part: "...1. Discharge planning begins on admission with barriers identified... 4. Once the discharge needs have been identified, the social worker or appropriate discipline will present the list of Medicare certified agencies to the patient/family..."

The facility's policy titled "Admission, Continued Stay, Exclusion and Discharge Criteria," last revised May 9, 2011, stated the following, in pertinent part: "...Discharge Criteria: 1. Exhibits ability to control behavior in less restrictive environment; not unsafe to self or others. 2. Level of functioning improving. 3. No assaultive or destructive behavior observed. 4. No evidence of serious medication side effects. 5. No suicidal/homicidal threat/behavior 24 hours. 6. No restraints past 24 hours. 7. Nutritional intake adequate. 8. Pertinent lab values within acceptable ranges. 9. The probability of successful outcome with continued treatment at this level of care is seriously compromised because patient is non-compliant with treatment recommendation... 10. Patient is not at risk for harm to self or others."

The facility's policy titled "Discharge/Aftercare Planning," last revised May 2011, stated the following, in pertinent part: "PROCEDURE: ...6. The discharge/aftercare plan should define the following: A. Final diagnosis; B. Where the patient will live following discharge based on patient/family needs and/or wants. C. The level of care which the patient will be discharged to (i.e., partial hospitalization , intensive outpatient, outpatient, etc.). D. A listing of all medications that the patient is to continue taking after discharge. E. All professionals who will follow-up with the patient, including medical follow-up to monitor medications. F. Referrals to self-help groups, support groups, or community resources. G. Specific efforts to educate the family regarding the patient's treatment interventions, medication and prognosis. H. Follow up appointments based on the patient's clinical need..."

2. Interviews

A. Director of Nursing

An interview with the Director of Nursing (DON) in regards to sample patient #3 was conducted on 7/12/11 at approximately 10:25 am. S/he stated the patient was from another city, "found somewhere," taken to a hospital, taken to a detox facility, transferred back to an Emergency Department, and then brought to Haven. S/he stated the patient was "stable on meds." S/he explained that relatives, children, and original location/residence were unknown. S/he stated that the patient had no Medicaid, no Social Security Number, and nothing to obtain Medicaid, but "has Medicare." S/he stated that when the patient was "ready to go...got psychological testing and said [s/he] couldn't be discharged back to the street." When the DON was asked what could be done considering the patient's former disposition, s/he stated, "[S/he] was definitely homeless...so then [s/he] needs a guardian and to work on Medicaid." In regards to the process to find the patient a discharge setting, the DON stated, "Everyone kept saying to let [him/her] live on the streets... They [social workers] continued working with the patient, even though [s/he] was not meeting hospital criteria...they were only waiting for placement." The DON stated, "After [s/he] was here for numerous months, [a social worker] got in touch with a homeless shelter. I don't know if it was a miscommunication or what, but staff were very upset about her going to a shelter. [Another social worker] felt it was safe and that they would care for her...[Two staff members] took her there and the shelter then said 'we can't accept her' and so I said bring her back...No one would touch her and Denver APS (Adult Protective Services) said they couldn't help [him/her] unless [s/he] was living in Denver...The shelter was going to have [him/her] leave during the day and APS stepped in and said that [the Shelter] could not accept her...Staff were very upset...When [s/he] came back, I got [the Vice President of Clinical Services for corporate] involved." When asked how this situation could be prevented in the future, s/he stated that s/he had learned to get corporate involved much quicker. The DON confirmed that a grievance had been made by a staff member in regards to this patient's discharge to a homeless shelter.

B. Director of Social Work

An interview with the Director of Social Work (DSW) in regards to sample patient #3 was conducted on 7/12/11 at approximately 2:35 pm. S/he also stated that the patient had been homeless and that when s/he was admitted , the physician was not sure of his/her diagnosis or how long his/her history of substance abuse was. S/he stated that if people are diagnosed with a major mental illness, Adult Protective Services deems they have the right to live on the streets and will not get involved. However, if people are diagnosed with dementia, APS will readily get involved and find a guardian. S/he stated that the patient's physician ordered neuropsychic testing to determine if the patient had a major mental illness or dementia and that the testing verified s/he had dementia. S/he continued that the previous Director of Social Work had been in contact with both El Paso APS and Adam's County APS. S/he stated that "at this point, the patient was completely confused...Placement couldn't happen as the patient was so confused, without a POA (Power of Attorney) or Guardian, and not agreeable to going anywhere." S/he continued, "When it came back that [s/he] had dementia, we contacted Adams County APS and they refused guardianship due to her long history of substance abuse, living on the street, and mental illness...El Paso refused her because it was out of their jurisdiction...I took it to Adams County APS's Case Manager, Supervisor, and even the State level, who said it needed to stay at county level. Adams APS recommendation was to discharge to the street or a homeless shelter." S/he stated that Denver APS was "going to follow-up on [him/her], but they were afraid that the next day they wouldn't be able to find her..." When asked how s/he chose the particular shelter, s/he stated, "I've called many different homeless shelters in Denver. [The one I chose] would do prompting as long as [s/he] was physically able to provide needs for self. They also had Case Managers that could help and call Denver APS if concerns."

When asked further about what happened the day of the patient's attempted discharge, the DSW stated, "I don't understand what happened when [s/he] got there. I called Denver APS to explain and they said to give [the shelter] a heads up and if [s/he] has any problems they (the shelter) could call 911 and take the patient to Denver Health...I'm not sure if Denver APS called [the shelter] and they got more concerned..."

When the DSW was asked further about the patient's previous living environment, s/he stated, "[S/he] was in and out of homeless shelters, at one point was in a placement, but I just recently found out that [s/he] was in an ALR (Assisted Living Residence) but [s/he] left. [S/he] had Medicaid at that point...sometime in 2007 and 2008..." When asked if the DSW had called that previous ALR to obtain information, s/he stated that s/he had not.

The DSW continued, "Since then, I was trying to work with Denver County APS so they could get involved...their advice was to pursue guardianship...Denver APS cannot get involved [until the patient is in Denver County for] three days. [After s/he was refused at the shelter,] I called Adams APS and said the shelter refused and said at that point I have to go higher than you. So...two people from Adams APS [came out] and told me they wouldn't pursue guardianship due to the payer source info and they couldn't understand why Medicaid hadn't been applied for. I had no information, so I couldn't submit [for Medicaid]. [Adam's APS] said to do it anyway and put 'unknown' and that Adam's County could follow-up with El Paso County Human Services in order to approve Medicaid as [s/he] had previously been Medicaid. [Adams] did not follow-up. [Medicaid] said they did not have enough information. So now, the patient doesn't exit seek, is willing to sign in [to a facility], is able physically to sign [his/her] name in, and doesn't need a locked facility," which is why the patient is able to go to a facility.

When asked what had changed, as the patient was still an inpatient within the facility upon survey, the DSW stated, "[S/he] has Medicaid pending. [S/he] can go because [s/he] doesn't need a secure environment. Adams APS still will not pursue guardianship, so [s/he] will have the right to leave the facility when [s/he] wants to." When asked when the patient's discharge date would be, s/he stated that they were waiting for the PASARR approval used for the pre-admission screening process, but that the facility the patient was being transferred to had approved him/her and s/he was psychiatrically stable to go. The DSW stated the tentative discharge date was "tomorrow; We got approval today." S/he stated the patient was going to a Skilled Nursing Facility under Medicare days and eventually a Long Term Care Facility when his/her Medicaid finally "is through." When asked what could have been done differently, the DSW stated s/he felt APS should have obtained guardianship for the patient and "helped [the patient] maneuver the system." When asked about other patient situations such as this, s/he stated, "I have not had a patient to this extent in the past." However, s/he confirmed that the facility had difficulty getting guardianship for patients in the past. When asked if the facility had done Medicaid applications for patients in the past, s/he stated, "If we have the information, I've done the application for Medicaid with patients a couple times." When asked further about the attempted discharge to a homeless shelter, s/he stated, "[S/he] had no psych symptoms and was compliant, but still demented...The feedback I got was that we tried every avenue and got dead ends everywhere...The physicians based their thoughts on that (the APS recommendation), because APS had a long history with her." The DSW was asked about the other avenues that had been taken, and s/he stated, "I tried Guardianship Alliance and Silver Key and they were talking five to six months or a year for emergent guardianship appointment. I felt like I called every resource I thought of..."

A second interview with the DSW was conducted on 7/13/11 at approximately 11:40 a.m. after the medical record had been reviewed. S/he stated, "I was not the Social Worker initially." When asked if attempts had been made to contact family members, as some had been documented within the medical record, s/he stated, "There were attempts made. We didn't have any numbers and I know that in talking with El Paso [APS] they tried to get numbers to no avail...one of the Social Workers tried to Google family names and numbers..." The DSW was informed that no social worker documentation existed of attempts to contact family, to which s/he confirmed. When asked when s/he began caring for the patient, s/he stated, "I took over the weekend after Memorial Day...so basically the beginning of June." When asked further about the Medicaid application process, s/he stated, [The patient] was so confused and couldn't give us information...So that is my assumption as to why it was not done..." When asked further about the DSW's past experience in the Medicaid application process, s/he stated, "The only times I've done Medicaid applications, we've had to have financial records, a social security number, a birth certificate...I don't really know how the process works." It was noted in the medical record that the patient's Short Term Certification was terminated the day of the attempted discharge (6/15/11). The DSW confirmed that, since that time, the patient had been voluntarily at the facility.

A final interview with the DSW was conducted on 7/13/11 at approximately 1:00 p.m. The DSW was asked what may happen to the patient when [his/her] Medicare days run out at the Skilled Nursing Facility. S/he stated, "They accepted her on Medicare and I'm assuming they will help with Medicaid, but they knew [s/he] was Medicaid pending...They (Medicaid) refused [his/her] Medicaid application and have it pending because there isn't enough information. It is 'pending more information'."

C. Executive Director

An interview with the Executive Director (ED) was conducted on 7/13/11 at approximately 12:40 p.m. The ED was asked what involvement s/he had with the patient's case. S/he stated, "I was first notified about [the patient] by [the previous Director of Social Work] before [s/he] left to go to [out of state]. [S/he] said APS refused to get involved...my involvement was at the flash meetings. I would remind our team that we were absorbing [the patient's] benefit if [s/he] had further medical needs...so [s/he] would have no more Medicare days. My involvement was constant reminding and ideas...we talked to business development and another Social Worker [name of SW at the facility] who said they needed to get her back into Denver County. We looked at putting [him/her] in a hotel for a week, so we could get [the patient] in Denver County; We looked at places in Denver County that could care for [him/her]...but we couldn't find anyone...I never got involved in treatment planning. [The current DSW] announced in flash that [the patient] was leaving...I got a call that day that the shelter will not take [him/her] because the doors are not open from 8 (am) to 5 (pm). [Another program] recommended we take her to an ED in Denver...My instructions were that we were not going to do that and (instead) bring her back. I had a conversation with an assessment and referral processor for a new set of eyes...[S/he] said [s/he] had talked with [the patient] and [s/he] had googled all the people and nothing panned out...If a person comes in that doesn't have Medicaid, we can assist, but we don't run into it very often. Usually they have a Power of Attorney...We've had a handful where we've assisted..."

3. Medical Record Review

The medical record revealed the patient was initially admitted on [DATE]. The History and Physical from the outside facility that admitted the patient to Haven stated the following, in pertinent part: "...So getting a clear straight history from [him/her] is very difficult,"however it did not mention that that patient was homeless. The patient was placed on an M1 Mental Health Hold on 3/17/11 and thereafter a Short-Term Certification on 3/19/11. The Short-Term Certification was terminated on 6/15/11. The M1 documentation stated, "...homeless [patient] with no family, is disoriented to time, place, situation. Unable to make safe decisions and is gravely disabled." The family contact form from Haven's admission stated "none reported," but the bottom of the form stated, "Has family in Chicago," and two names were listed as well as "no phone #s." The insurer information revealed the patient's Medicare number. The initial "Psychosocial Assessment," completed by a member of the Social Services staff, stated, in pertinent part: "pt is homeless and will need placement...has no family or friends in Colorado. Pt states that [s/he] has family in Chicago but does not have phones #s or names to contact them..." The patient's "Psychiatric Evaluation," conducted by his/her attending psychiatrist, stated that the patient's chief complaint was "I don't know why I'm here. I need high blood pressure medicine. I'm homeless."

The "Brief Neuropsychological Assessment" was conducted on 4/1/11 by an outside physician. The 'DSM IV - TR Diagnosis" section stated that the patient's Axis I was Dementia with Alzheimer's Type and that Axis II was Depressive Disorder. The "Recommendations" section stated, in pertinent part: "A new living environment where [s/he] had more social supports and can be consistently monitored - i.e., assisted living or nursing home with a memory care unit. 2. Have a guardian and conservator appointed. 3. Add adjunction medication for both memory and depression issues. 4. Retest memory impairment in one year to evaluate pace of progression. 5. Contact children that [s/he] mentioned to see if they will offer support or take on possible guardian role."

The initial "SOCIAL WORK CONTACT LOG (SWCL)," dated 3/23/11, stated the following: "spoke c pt. pt d/t confusion & memory deficits unable to confirm [his/her] d/c & where [s/he] was residing/d/c to. [S/he] states [s/he] wants to go back to a shelter. T/C c [name] @ APS, [s/he] provided some background info & [s/he] will talk c her past case workers & will call back c further info. It appears pt has cycled through hospitals & returns to a shelter." The second SWCL, dated 3/24/11, stated the following: "T/C c [name of staff from APS]. Informed me that pt has always been D/C from hospitals to the homeless shelter. Discussed neuropsychic testing to confirm dx of dementia/chronic mental illness. Made appt c [physician] for neuropsychic testing for 4/1 @ 10 - 1 p.m. If pt has dx of dementia, APS will go for guardianship."

SWCLs revealed that the APS was contacted twice on 4/6/11, once on 4/7/11, and in person on 4/12/11 in regards to the neuropsychic testing results and arranging guardianship. The SWCL, dated 4/13/11, stated the following: "T/C c [two staff members from Adams APS] stating that they will not pursue guardianship D/T [patient's] past hx c substance abuse & mental health hx. Discussed pt returning back to homeless shelter because [s/he] has no support or resources. T/C c El Paso APS- they also will not get involved for the same reasons. Pt to D/C early next week back to the homeless shelter, as pt is agreeable." The following SWCL stated that the Social Worker contacted the patient's previous shelter and that the patient was not allowed back there for a year and a half. The next six SWCLs (dated 4/25, 5/2, 5/6, 5/17, 5/18, and 6/10) were in regards to attempting to find a shelter that would accept the patient, although none were found. An additional entry from 6/10/11 on a SWCL stated the following, in pertinent part: "T/C (with a Long Term Care Facility) to discuss options. They suggested consult DHS El Paso County to get Medicaid info & then LTCO in Adams County to do a functional assessment..."

Nursing documentation revealed that the patient was continually confused throughout the admission. Nursing documentation on the "Progress Notes," dated 4/4/11, stated the following, in pertinent part: "Pt disoriented, confused. Pt wandering unit, going into other pt's rooms and taking their belongings. Pt taking clothes out of the dryer. When redirected, pt becomes agitated stated, 'I'll call the police on you!' & 'I got these at ARC. You were with me...." The nurse progress note, dated 6/11/11, stated the following, in pertinent part: "AO x 1-2, confused, resident has poor orientation ability, cannot locate room, easily misdirected & needs constant assist..." A nurse progress note, dated 6/11/11, stated the following, in pertinent part: "Still wanders and loses sight of where the BR is as well as [his/her] room..."

Physician documentation on the "PSYCHIATRIC PROGRESS NOTE," dated 5/22/11, stated the following, in pertinent part: "Pt... same. Discharge is pending availability of a shelter." The physician progress note, dated 5/24/11, stated the following, in pertinent part: "Pt continues @ baseline waiting transfer to a shelter or a motel which now seems much more practical = [His/Her] dementia continues." The physician progress note, dated 6/14/11, stated the following, in pertinent part: "Pt continues at baseline. Continues to await transfer. [S/he] is still demented." The physician progress note, dated 6/15/11, stated the following, in pertinent part: "...There is nothing more that we have to offer her here."

The SWCLs continued to state a search of referrals and shelters done by social work staff. An entry on 6/14 documented a referral to another shelter and motel voucher program, however the shelter was full and voucher program was not applicable. On 6/14, the SWCL stated the following, in pertinent part, in regards to a shelter in Denver: "T/C to make referral. They have opening & will take pt tom night. Pt will have to leave during the day & come back in evening. Explained that pt is confused & will need prompting & direction. [Staff member at shelter] stated as long as pt physically able to eat & care for [him/her]self they can provide direction." The following day, 6/15, the SWCL stated, "T/C to ensure patient has a bed @ shelter. [Staff member at shelter] confirmed that [s/he] does. Reiterated patient is confused & needs assistance. No C/O." The following entry that same day stated that the Social Worker had contacted Denver County APS to make a referral. It stated that APS recommended contacting the shelter to give APS as a "resource if they have concerns about patient leaving tom. morn. from shelter safely." The SWCL, dated 6/15 and timed 5:45 p.m., stated the following, in regards to the shelter: "T/C stating they will [not] accept patient d/t [his/her] confusion & APS involvement."

The evening of 6/15, the patient was brought back to the facility. A nursing progress note, dated 7/3/11, stated the following in pertinent pat: "Resident confused, poor recall, remains pleasant..." SWCL documentation since 6/15 evidenced that the Social Worker continued to have communication with three different counties of APS in regards to the patient's care and placement. On 6/16/11, documentation evidenced the initiation of the patient's Medicaid application for coverage. Per documentation, Adams County APS continued to adamantly refuse assistance and, on 6/16, "When asked what options there were for finding d/c placement [APS staff member] had [no] suggestions." On 6/17, the SWCL stated that APS suggested to get the Medicaid application submitted in order to get it "pending." The SWCL evidenced communication with the State Director of APS on 6/20, who stated the "matter needs to be addressed on a county level..." The SWCL, dated 6/28/11, stated that a Medicaid Tech had been spoken with about the patient's submitted application, which was submitted on 6/21. On 7/7/11, the SWCL stated that two long-term health care facilities were contacted to discuss referral and both called back "accepting pt pending PASARR approval." The following SWCL, dated 7/11/11, evidenced communication with a long-term health care facility and stated "awaiting PASARR approval for discharge..."

4. Summary

The facility did not fully follow their policies and procedures by attempting to discharge a demented patient to a night shelter, knowing that the patient would have to go to the street the following day, thus posing an unsafe situation to a vulnerable patient. The facility utilized outside resources to attempt to find guardianship for the vulnerable patient, however, when those resources were not cooperative and assistive, the facility failed to investigate other possible resources. The facility failed to attempt the application process for Medicaid until after the patient was refused from a shelter and, instead, the facility spent their time researching discharge locations, such as shelters. The facility was aware of the patient's dementia diagnosis on 4/6 and attempted discharging the patient to a shelter on 6/15, over two months later. In contrast, the facility's staff was informed to apply for Medicaid on 6/17 and the patient was deemed "Medicaid pending" during survey and discharge to a Skilled Nursing Facility was tentatively planned for 7/13, a span of less than a month. Although social services staff had difficulties obtaining patient information, leads within the chart were present, as well as leads gathered from neuropsychic testing. The patient's capacity for self-care in the environment from which s/he came was assessed, understood to be unsafe, however the facility still attempted to discharge the patient back to the same environment.
VIOLATION: LIST OF HOME HEALTH AGENCIES Tag No: A0823
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital must document in the patient's record that the list was presented on the patient's behalf.
Based on medical record reviews, hospital policy and procedure reviews and staff interviews it was determined that the facility failed to ensure that the discharge planners provided documentation in the patient's medical record that a list of available home health agencies, skilled nursing facilities and assisted living facilities were presented on the patient's behalf. The failure created the potential for negative patient outcomes.
The findings were:

A review of 21 patient medical records on 7/11/11 through 7/13/11 revealed that four patients (sample #11, #12, #15 & #18) did not have documentation in the medical record that a list of post discharge medical providers or facilities had been provided to the patient or the individual acting on the patient's behalf.

Sample #11 was a [AGE]-year-old admitted on [DATE] with diagnoses of [DIAGNOSES REDACTED]"Pt's (patient's) previous facility has dc'd (discharged ) him and are not accepting him back." The medical record also documented the treatment/discharge plan was discussed with the patient however, no lists of certified agencies were documented in the medical record. In an interview on 7/12/11 at 8:55 a.m. with the LCS (Licensed Clinical Social Worker), he/she stated that the "Blue Book" (The Seniors Blue Book: a comprehensive source of services, senior housing options, resources and information that enrich the lives of our elder population while affording those businesses and individuals serving that population a unique medium to present their products and services) is given to the patient or those acting on their behalf if an agency referral is needed. The patient was discharged [DATE] to a SNF (skilled nursing facility) in Wyoming. In a second interview with the LCSW on 7/13/11 at approximately 11:00 am he/she stated, "the patient was transferred to the SNF due to the payer source (a state Medicaid) to keep the monies within the state." In addition, the physician discharge summary notes that the patient was glad to be going back to ALF (assisted living facility). When questioned about this change in level of care documented by the discharging physician the LCSW stated in the 7/13/11, 11:00 a.m. interview that "this was an error in documentation and I know this patient was discharged to a skilled nursing facility."

Sample #12 was a [AGE]-year-old admitted [DATE] for depressive disorder. The admission assessment stated that the patient came from home and the discharge plan was for the patient to return to home. In review of the medical record treatment plan there was no documentation that would denote the need for a higher level of care needed for this patient. The patient was discharged on [DATE] to an assisted living facility. There was no list of certified agencies documented in the medical record.

Sample #15 was a [AGE]-year-old admitted on [DATE] for depression. The patient was discharged on [DATE] with a referral to a home health agency. There was no list of certified agencies in the medical record and no documentation of the services to be provided by the agency. In an interview on 7/12/11 at 8:55 a.m. with the LCSW he/she stated, "the family was not familiar with home health agencies and asked for my recommendation." In a second interview on 7/13/11 at approximately 11:00 a.m. an inquiry was made as to the need for referral for home health as there was no documentation in the patient medical record stating why a referral was needed. The LCSW stated "the patient has had services in the home before as she has had a stroke, I believe. The services would be for OT (occupational therapy) and PT (physical therapy)." Again, when asked about the family's choice in the agency selection he/she stated "the family didn't have a preference, it (the agency) was in their local area."

Sample #18 was a [AGE]-year-old admitted on [DATE] with diagnosis of [DIAGNOSES REDACTED]. The sending facility had discharged the patient and would not accept the patient back due to escalated aggressive behavior. In the medical record there was no documentation of a list of available agencies being given to the individual acting on the patient's behalf. The patient was discharged to an assisted living facility on 6/8/11.

The Policy and Procedure titled: Discharge Planning was also reviewed on 7/12/2011 and stated the following in pertinent part:
" PROCEDURE ...
2. Ongoing discharge planning takes place during the interdisciplinary meeting with the patients at a minimum of twice (2) a week during weekly rounds. Family may be involved in this process.
3. The above is documented in the medical record and list of disciplines of staff involved.
4. Once the discharge needs have been identified, the social worker or appropriate discipline will present the list of Medicare certified agencies to the patient /family..."

The hospital policy failed to state that there was to be documentation in the medical record that there was a list of agency resources provided to the patient or the individual acting on the patient's behalf. In an interview with the LCSW on 7/13/11 at approximately 11:00 a.m. he/she stated that "we are aware that we need to document lists given to the patient/family but I don't see it in the records. For patients needing resources we always give them the Blue Book."
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0116
Based on facility tour and review of medical records/facility policy, the facility failed to ensure its Patient Rights posting was comprehensive. Specifically, the facility failed to post its own notice of Patients' Rights and, instead, posted the State of Colorado's Department of Human Services Division of Mental Health 27-65 (formerly 27-10) Care and Treatment of the Mentally III Act's Patient Rights notification. The posting of only the latter Patient Rights did not ensure each patient was fully informed, as each patient within the hospital was and is not under a M1 Mental Health Hold and subject to 27-65/27-10 regulations. This failure created the potential for a negative outcome.

The findings were:

Facility tour conducted on 7/12/11 at approximately 3:10 p.m. revealed that the Patient Advocate's photograph and phone number were posted on both units of the hospital. Observations evidenced that Patient Rights were only posted on Phase 2, the higher functioning unit, and not observed on Phase 1. Additionally, the Rights posted were that of the 27-10 (27-65) Act in English and Spanish, not the facility's own Patient Rights. Such Rights posting, as well as the patient advocate's posting, did not list the State of Colorado's phone number in order to file a complaint should the facility's grievance procedure not be adequate in resolving a patient's complaint/grievance. The posted Rights were also not comprehensive of all of CMS regulations and information.

The facility's policy titled "Patient Rights/Patient Responsibilities," last revised May 2011, stated the following, in pertinent part: "...PROCEDURE...1. The Patient Rights form shall be reviewed with all patients, family members and legal representatives during the admission process. Assistance shall be given to patients who do not speak English or Spanish, or have a disability that may hinder their understanding...2. The Patient Rights acknowledgment form shall be signed and placed in the patient's medical record. 3. Patient Rights shall be posted in conspicuous areas accessible to all patients. At a minimum posting shall be in the patient care areas. Patient Rights will be posted in English and Spanish."

Review of 21 medical records revealed that some medical records contained the 27-10 (27-65) version of Patient Rights, some contained the facility's version, and some contained both. There was no consistency to ensure each patient was somehow notified of the facility's information on Patient Rights, as well as the 27-10 (27-65) Act's information when necessary.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on facility tour/observations, staff interview, and review of facility policies/procedures, medical records, and internal documents, the facility failed to ensure patients received care in a safe setting. Specifically, the facility had identified patient falls as an issue, but had not implemented changes, such as accessible call lights. This failure created the potential for further patient harm.

The findings were:

Facility tour was conducted with the Director of Nursing (DON) on 7/11/11 at approximately 2:00 p.m. The facility had two separated units: Phase 1, for more acutely ill patients, and Phase 2, for more stable patients. While on tour, it was noted that each room had only one call light, wherein which the patient could push to request help, regardless of if the room had one or two patient beds within. The call light was on the center of the wall in each room, approximately four feet high, and was a push button that stated "PUSH FOR HELP." Fall risk stickers were noted by some patient names on the outside of the rooms and magnets were noted on the door frames on other patient rooms. When the DON was asked the difference, s/he stated that the stickers were for fall risk patients and the magnets were for high fall risk patients. Two separate rooms contained patients' mattresses on the floor, instead of on a bed frame as a fall risk intervention. When asked what other interventions were part of the facility's fall risk program, s/he stated that a fall risk assessment is conducted on each patient upon admit and that the facility uses wristbands, along with the stickers and magnets. Room 100 on Phase 1 was observed to be a very large room that the DON stated was such because the facility used to be for rehabilitation so the size accommodated for large amounts of equipment. Other rooms on Phase 1 were also noted to be large in size. It was also observed that each bed within the facility was on wheels and movable. In room 100, the wall call light was near the "A" bed (closest to the door), but not accessible from the "B" bed. When asked about this, the DON stated that 15-minute checks were conducted on all patients. Room 133 on Phase 2 was observed to be a much smaller room and the call light was centered between both beds and above a sitting chair. At the end of the tour, at approximately 2:55 p.m., the DON was asked if the facility had any other call light provisions, as some patients may not be able to reach the call lights due to the large room sizes. S/he stated, "I may have some short cords somewhere." When asked if there were any that the facility utilized regularly, s/he stated, "No."

Measurements with use of a tape measure were conducted on 7/12/11 at approximately 3:15 p.m. It was observed that the call light in room 100 was approximately ten feet from the "B" bed in the room. The call light in room 133 was approximately 2 and 1/2 feet from the edge of either "A" or "B" bed.

On 7/13/11 at approximately 7:45 a.m., the DON was asked further about the facility's fall risk program. S/he stated again that patients are assessed as a risk when they first "come in" and that the "treatment plan goes along with it." When asked about interventions that the facility implements with fall risk patients, s/he stated, "toileting, decreasing clutter, orienting the patients, placing beds on the floor, lots of one to ones...geri-chairs, getting patients into groups..." It was noted that the Quality Committee data/meeting minutes evidenced a large amount of falls within the facility. The DON was asked about this and stated, "The fall committee did many trends..." When asked if they identified or learned anything from the trends and data, s/he stated, "We learned absolutely nothing...there were no trends." The DON was asked what the facility's procedure is after a patient falls. S/he stated, "If it is unwitnessed or if witnessed and the patient hit their head, the nurses do neuro checks and call the SOUND (Medical Doctor's practice) MD and they come over and evaluate the patient. If it is witnessed, they (the Sound MD) might not run right over..."

On 7/12/11 at approximately 8:55 a.m., a nurse on Phase 1 was asked how patients call for help when in bed, as some of the current patients were not independent and required assistance for movement, such as a Hoyer manual lift to and from bed/wheelchair. S/he stated, "They can't reach the call lights. They make their needs known with 15-minute checks..." S/he stated most patients, such as the wheelchair bound patient, were "pretty vocal."

On 7/13/11 at approximately 9:15 a.m., a nurse on Phase 1 was asked if s/he had ever seen a manual call bell. S/he responded, "No. They have one light that flashes if they hit the wall button and another if they hit the bathroom call light." The nurse confirmed that room 106, which had two high fall risk magnets on the outside door frame, contained no manual call bells. At that time, it was observed that the following rooms contained the high fall risk magnets on the their frames: 100 (1 magnet), 101 (1 magnet), 103 (1), 104 (1), 105 (1), 106 (2), and 110 (1).

When the DON was asked further on 7/13 about the facility's fall reduction program, s/he stated, "Let me get it for you." Later, the following documents were provided: the facility's policies titled "Fall Reduction" and "Fall Risk Precautions," the "Fall Risk Assessment" which stated was contained in the Nursing Assessment, the "Daily Fall Precautions Assessment" which contained an area for a nurse to sign/date, and the "Fall Precautions Treatment Plan" which contained areas for nurses' signatures and dates.

The "Fall Risk Precautions" policy, last revised "May 2011," stated the following, in pertinent part: "Remind patient to call for assistance..." The "Fall Reduction" policy, effective "10/09," stated the following in the procedure section, in pertinent part: "Assign a manual call bell to high fall risk patients. Educate patient on use of bell..."

Review of facility internal documents revealed that one patient, after a fall, sustained a femur fracture which required surgery. The document stated that the Certified Nursing Assistant conducted a 15-minute check at 4:45 and the patient in room 100 was in the "A" bed. At 4:55, yelling was heard and the patient was found on the floor next to the bed. The patient stated the s/he could not get up because his/her hip hurt too much. A medical physician was called and came to assess the patient, x-rays were ordered and conducted, and the patient was transferred to an outside facility. The internal document stated the physician's recommendation was to do a STAT x-ray and "keep pt from getting out of bed w/out help." The proximity of the bed to the call light was not documented, but it was evidenced upon tour that the room was large, beds were movable, but only one call button was present.

Review of sample medical record #4 revealed the patient was an elderly adult with a diagnosis of dementia. The patient was assessed by nursing staff to be a high fall risk and care planning existed on falls. The nurse's Progress Notes dated 7/10/11, timed 1758, stated the following, in pertinent part: "Pt sitting on floor in door-way 110 [with] walker near by. Pt stated [s/he] was walking [with] walker and triped (tripped), striking [right lateral] brow on door frame, [Range of Motion within normal limits] Neuro's initiated [question] cataract in [left] eye: all [within normal limits], pt denies pain/discomfort, pt assists to standing position gate (gait). [Within normal limits], assisted to bed, ice pack applied to [right lateral] brow hematoma. [No] other injuries noted. DON, [CMO/phychiatric physician] and [other staff member] all notified." Although neurological checks and daily fall assessments were regularly conducted and documented by the nursing staff, the medical record did not evidence an evaluation or note by a medical staff physician or nurse practitioner (SOUND practice) until 7/12/11 at 1600, nearly 48 hours after the patient's fall. The note stated that the patient's chief complaint was nausea with vomiting three times the previous day (7/11), not the fall.

The monthly Quality Council meeting minutes were reviewed from 2/15/11 to 6/14/11. Extensive monitoring and trending had been conducted on patient falls. The data reported to the council on falls for each meeting was similar to the last. For example, the minutes stated the Fall findings for the 2/15/11 meeting, in pertinent part: "[Risk Manager] reported that there were 16 Class II falls (Falls with no injury or minor injury). All patients were on Fall Precautions. The most common location for falls was patient room. The most common time period was evening and night hours. The majority of the falls happened while patients were attempting to get out of bed..." The 2/15/11 minutes stated the Fall recommendations were: "There continues to be a re-evaluation of the Fall program both locally and within the Haven system. 1:1 staffing continues to be used for unpredictable patients on Fall Precautions who are confused as deemed appropriate by clinicians. Feedback to staff on Fall rate and trend data to assist in staff in fall prevention. Identify target/benchmark for medication variance in like medical settings." Similarly, the minutes stated that the Fall findings for the 5/21/11 meeting, in pertinent part: "[Risk Manager] reported that there were 25 Class II falls (Falls with no injury or minor injury) and 0 Class I Fall in April. All patients were on Fall Precautions. The most common location for falls was the pt room. The most common time period was evening and night hours. The majority of the falls happened while patients were ambulating...The number of falls has remained about the same each [quarter] but with a high census in 1st [quarter] the rate was less per 1000 patient days." The 5/21/11 minutes stated the Fall recommendations were: "There continues to be a re-evaluation of the Fall program both locally and with the Haven system. 1:1 staffing continues to be used for unpredictable patients on Fall Precautions who are confused as deemed appropriate by clinicians. Feedback to staff on Fall rate and trend data to assist staff in fall prevention." The most recent monthly Performance Improvement Analysis Report on Falls and Fall Reduction Program for the month of May stated the following as PLAN Actions: "Re-evaluate Fall Prevention activities. Multi-discipline input. Utilize Senior Clinical Leadership and Best Practice Resources. Feedback to staff on Fall rate and trend data to assist staff in fall prevention. Follow-up with senior clinical staff on use of gait belts." Review of all of the facility's Quality data and documents on Falls did not evidence any concrete actions or changes taken within the facility to decrease or prevent falls.

In summary, the facility had clear evidence of continued patient falls, however actions and changes were not evident. Furthermore, a serious patient fall was identified within a room wherein a call light could possibly be over ten feet from the patient's bed. Another unwitnessed patient fall had no medical practitioner notification for over two days, although the DON stated such was the protocol. Additionally, manual call lights were not available to high fall risk patients in accordance with the facility's policy and procedure.
VIOLATION: USE OF RESTRAINT OR SECLUSION Tag No: A0154
Based on staff interview and review of facility documents, the facility failed to inform patients and/or their representative that all patients have the right to be free from physical or mental abuse, corporal punishment, restraint, seclusion, or any form imposed as a means of coercion, discipline, convenience, or retaliation by staff. Additionally, the facility failed to inform patients and/or their representatives that restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This failure created the potential for a negative outcome.

The findings were:

The patient packet given to patients and/or their representatives was requested upon entrance to the facility. The facility's "PATIENT RIGHTS" notification, given to and signed by the patient or their representative upon admission, was provided and reviewed. The notification did not state within that patients had the right to be free from restraint or seclusion or this regulation in its entirety. Such was confirmed with the facility's Director of Nursing on 7/12/11 at approximately 9:45 am. S/he stated that usually the staff give the formal 27-10 (27-65) Act Patient Rights notification as well as the facility's own, however this did not ensure that the facility's own Patient Rights notification was fully encompassing of all information for those patients wherein 27-10 (27-65) Rights were/are not necessitated.
VIOLATION: QAPI Tag No: A0263
Based on the nature of the deficiencies cited, the facility failed to comply with the Condition of Participation of Quality Assurance/Performance Improvement (QAPI). The facility failed to institute and maintain a quality assurance program that included standards for timely review, assignment of priority, investigation and corrective action for unusual/adverse events that occurred.

The facility failed to meet the following Standards under the Condition of Quality Assurance/Performance Improvement (QAPI):

Tag A 0266-QAPI Medical Errors
The facility failed to ensure that the QAPI program identified and reduced medical errors.

Tag A 0267-QAPI Quality Indicators
The facility failed to ensure that the quality assurance committee process received and analyzed information regarding an adverse (sentinel) patient event. Specifically, the facility failed to present any concrete evidence that a full scale formal investigation was in progress regarding the sexual abuse of a female patient.

Tag A 0313-Executive Responsibilities
The facility failed to ensure its Executive Director/Administrator fully assessed and addressed priorities affecting patient safety, such as allegations of patient abuse, and incorporated such into the Quality Assessment and Performance Improvement Program.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interviews and review of facility documents, the facility failed to ensure that the QAPI program identified and reduced medical errors.

The findings were:

Cross Reference to A 0494: Pharmacy Drug Records for findings related to the hospital's failure to ensure that accurate records were kept for the distribution of all scheduled drugs. Specifically for findings related to staff member #1's suspected diversion of medications.

Cross Reference to A 0508: Reporting Adverse Events for findings related to the hospital's failure to ensure that drug administration errors were reported to the hospital-wide QAPI program. Specifically, the hospital failed to proactively identify medication errors (including observation of medication passes, concurrent and retrospective review of patients' clinical records, implementation of medication usage evaluations for high-alert drugs, or non-punitive system with focus on the system and not the involved health professional).

A review of the facility's internal documents revealed that on 2/15/2011 it was reported by the PI/IC Manager that there were "...15 [medication] events in January...due to transcription errors...confusion between regular and extended release..." The recommendations/actions of the facility were to track the variances "...by RN for accountability and review with specific RN's..."

On 3/10/2011 it was reported by the facility's former pharmacist in the presence of the facility's Medical Director, CEO, DON, and PI/IC Manager that "...an area of improvement s/he had been monitoring for several months, the lack of 2 RN signatures on the shift change count and lack of signature on single dose sign out on sheets..." The recommendations/actions by the facility were to continue to monitor and that the DON would work with individuals that were not compliant. It was stated that the review would be "a formal review and is included in the RN's clinical file." No documentation was noted in the file of Staff Member #1 who was identified in the pharmacist's review of having missing signatures on the shift change and single dose sign out sheets.

On 3/15/2011 it was reported by the PI/IC Manager "...that there were 8 [medication] events in February...66.7% of the variances were omission of medications due to transcription errors...the other 2 errors were PRN's [as needed doses of medications] given earlier than ordered..." The recommendations/actions of the facility were unchanged from the previous month.

On 4/19/2011 it was reported by the PI/IC Manager that "...there were 5 [medication] events in March..." which included "...transcription errors...printed MAR errors...[and] wrong dose..." Not mentioned in the report was information that was discovered by the pharmacist that was reported as "...investigation of issues with the count sheets has apparently uncovered drug diversion in March and probably into April..." The recommendations/actions of the facility were unchanged from the previous two months and did not address the uncovered diversion.

On 5/21/2011 it was reported by the PI/IC Manager that "...there were 9 [medication] events in April..." which included "...omission of medications due to transcription errors...[and] a wrong dose..." The recommendations/actions of the facility were unchanged from the previous three months and did not address the diversion that was mentioned the previous month.

On 6/14/2011 it was reported by the PI/IC Manager "...that there were 10 [medication] events in May..." which included "...missed orders...a home med[ication] not requested to be refilled by family - omission...printed MAR error...an incomplete, incorrect order, and...a med[ication] discontinued without an order..." The recommendations/actions of the facility remained unchanged from the previous four months.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on staff interviews and review of informal facility documents, facility policies/procedures and medical records, the facility failed to ensure that the quality assurance committee process received and analyzed information regarding an adverse (sentinel) patient event. Specifically, the facility failed to present any concrete evidence that a full scale formal investigation was in progress regarding the sexual abuse of a female patient.

The findings were:

The facility's policy and procedure entitled, "Critical Event Review and Reporting," stated the following in pertinent part:
"SENTINEL EVENTS - Haven Behavorial will provide an effective mechanism for immediate investigation, analysis of information and response to Sentinel Events to assure continuous improvement of the safety and quality of care provided to our patients. Our goal is to seek out and understand the causes that underlie such an event in an effort to reduce the probability of Sentinel Events in the future. A "sentinel" event signals the need for immediate investigation and response...
DEFINITIONS: SENTINEL EVENT: Haven's definition of a Sentinel Event is: "an unexpected event involving death or serious physical or psychological injury, or the risk thereof." Serious injury specifically includes loss of limb or function. The phrase "or the risk, thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The definition of a sentinel event at the hospital includes the following: ...Rape..."

According to medical record review, a demented eighty-three year old female was sexually abused (raped) on 7/3/11 at 9:50 p.m. by a psychotic fifty-nine year old male patient. The following discharge summary described the hospital course, in pertinent part: "Initially, (pt's. name) was admitted on an M1 due to homicidal ideation...His homicidal ideation did clear and by the time I did his initial psychiatric evaluation, he admitted to making the wrong decision and that he did not want to hurt his psychiatrist anymore and he seemed pretty apologetic about the whole situation. However, that evening, one of the other residents went into his room and he said he was attracted to her and he proceeded to have sexual intercourse with her and was not upset at all. Due to that, the nurse on side A, which he had been transferred to, called me and also called the director of nursing and we abided by the directions of Haven's policy and procedure, we then called the (city) Police Department. They came and arrested (pt's. name) for sexual assault..."

The facility had followed their protocol in the prior observations of both patients and alerted the proper authorities of the incident after it occurred. However, through the following interviews it could not be determined exactly how the investigation of the incident was progressing or who was ultimately responsible for ensuring that it continued to progress and be incorporated into the facility's QAPI (Quality Assurance/Performance Improvement) activities.

An interview was conducted with the Director of Nursing (DON) on 7/12/11 at approximately 11:30 a.m. The DON was questioned regarding the process of reviewing the incident and moving forward with the investigation to determine if having done patient care differently would have resulted in a less negative outcome. The DON stated that a type of round-table discussion would be scheduled with staff that were involved when the incident occurred and they would "pick the whole thing apart' with the question of "what could we do differently?" The round-table discussion had been scheduled for 7/11/11; however, the survey team showed up so "we will reschedule."

Interviews were conducted with the Performance Improvement/Infection Control Manager at various times on 7/12/11 and 7/13/11. The manager stated that a walk-through regarding the incident was scheduled but now needs to be rescheduled. S/he also spoke about a quality meeting scheduled for 7/12/11 that was postponed until 7/19/11. Both cancellations were due to the survey team being in the facility. When questioned why there didn't appear to be an urgency by the facility to investigate this incident, the manager stated that s/he had done a lot of work on this incident and had informal documentation that s/he would make copies of for this surveyor. The copies of the informal documentation were made available for review on 7/13/11 at approximately 1:10 p.m. It consisted of some sticky notes and pages of one-line entries that gave a date, time, name and a very brief remark. The entries that applied to this incident were more of a general nature and did not meet the criteria of being investigative.

An interview was conducted with the Clinical Vice President (VP), the Chief Executive Officer (CEO) and the Corporate Director of Nursing on 7/13/11 at approximately 12:15 p.m. The VP stated that a CEA (Critical Events Analysis) would be done and later incorporated into the RCA (Root Cause Analysis). The meeting scheduled for 7/12/11 and postponed until 7/19/11 was the CEA. S/he did not seem to be aware that a round-table and/or walk-through meeting was to be a precursor to the CEA and clarified to this surveyor which staff member was to be in charge. The VP further stated that, of course, with the survey team being in the facility it set back the investigation.

Prior to exit on 7/13/11 at approximately 1:15 p.m., the CEO stated that the reason this incident had not been thoroughly investigated was that s/he and staff were spending a significant amount of time getting reports from police and so consumed with gathering data for reporting correctly to the Department.

In summary, there was no clear delineation of investigative tasks that needed to be performed or any prioritization of tasks. Per the facility, the survey team was used as an explanation to postpone every meeting that involved the investigation regarding this event. This was a "sentinel event" and time was of the essence. The failure of the hospital to coordinate a timely investigation created the potential for negative patient harm for the other vulnerable patients.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on staff interviews and review of informal facility documents, facility policies/procedures and medical records, the facility failed to ensure that the quality assurance committee process received and analyzed information regarding an adverse (sentinel) patient event. Specifically, the facility failed to present any concrete evidence that a full scale formal investigation was in progress regarding the sexual abuse of a female patient.

The findings were:

The facility's policy and procedure entitled, "Critical Event Review and Reporting," stated the following in pertinent part:
"SENTINEL EVENTS - Haven Behavorial will provide an effective mechanism for immediate investigation, analysis of information and response to Sentinel Events to assure continuous improvement of the safety and quality of care provided to our patients. Our goal is to seek out and understand the causes that underlie such an event in an effort to reduce the probability of Sentinel Events in the future. A "sentinel" event signals the need for immediate investigation and response...
DEFINITIONS: SENTINEL EVENT: Haven's definition of a Sentinel Event is: "an unexpected event involving death or serious physical or psychological injury, or the risk thereof." Serious injury specifically includes loss of limb or function. The phrase "or the risk, thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. The definition of a sentinel event at the hospital includes the following: ...Rape..."

According to medical record review, a demented eighty-three year old female was sexually abused (raped) on 7/3/11 at 9:50 p.m. by a psychotic fifty-nine year old male patient. The following discharge summary described the hospital course, in pertinent part: "Initially, (pt's. name) was admitted on an M1 due to homicidal ideation...His homicidal ideation did clear and by the time I did his initial psychiatric evaluation, he admitted to making the wrong decision and that he did not want to hurt his psychiatrist anymore and he seemed pretty apologetic about the whole situation. However, that evening, one of the other residents went into his room and he said he was attracted to her and he proceeded to have sexual intercourse with her and was not upset at all. Due to that, the nurse on side A, which he had been transferred to, called me and also called the director of nursing and we abided by the directions of Haven's policy and procedure, we then called the (city) Police Department. They came and arrested (pt's. name) for sexual assault..."

The facility had followed their protocol in the prior observations of both patients and alerted the proper authorities of the incident after it occurred. However, through the following interviews it could not be determined exactly how the investigation of the incident was progressing or who was ultimately responsible for ensuring that it continued to progress and be incorporated into the facility's QAPI (Quality Assurance/Performance Improvement) activities.

An interview was conducted with the Director of Nursing (DON) on 7/12/11 at approximately 11:30 a.m. The DON was questioned regarding the process of reviewing the incident and moving forward with the investigation to determine if having done patient care differently would have resulted in a less negative outcome. The DON stated that a type of round-table discussion would be scheduled with staff that were involved when the incident occurred and they would "pick the whole thing apart' with the question of "what could we do differently?" The round-table discussion had been scheduled for 7/11/11; however, the survey team showed up so "we will reschedule."

Interviews were conducted with the Performance Improvement/Infection Control Manager at various times on 7/12/11 and 7/13/11. The manager stated that a walk-through regarding the incident was scheduled but now needs to be rescheduled. S/he also spoke about a quality meeting scheduled for 7/12/11 that was postponed until 7/19/11. Both cancellations were due to the survey team being in the facility. When questioned why there didn't appear to be an urgency by the facility to investigate this incident, the manager stated that s/he had done a lot of work on this incident and had informal documentation that s/he would make copies of for this surveyor. The copies of the informal documentation were made available for review on 7/13/11 at approximately 1:10 p.m. It consisted of some sticky notes and pages of one-line entries that gave a date, time, name and a very brief remark. The entries that applied to this incident were more of a general nature and did not meet the criteria of being investigative.

An interview was conducted with the Clinical Vice President (VP), the Chief Executive Officer (CEO) and the Corporate Director of Nursing on 7/13/11 at approximately 12:15 p.m. The VP stated that a CEA (Critical Events Analysis) would be done and later incorporated into the RCA (Root Cause Analysis). The meeting scheduled for 7/12/11 and postponed until 7/19/11 was the CEA. S/he did not seem to be aware that a round-table and/or walk-through meeting was to be a precursor to the CEA and clarified to this surveyor which staff member was to be in charge. The VP further stated that, of course, with the survey team being in the facility it set back the investigation.

Prior to exit on 7/13/11 at approximately 1:15 p.m., the CEO stated that the reason this incident had not been thoroughly investigated was that s/he and staff were spending a significant amount of time getting reports from police and so consumed with gathering data for reporting correctly to the Department.

In summary, there was no clear delineation of investigative tasks that needed to be performed or any prioritization of tasks. Per the facility, the survey team was used as an explanation to postpone every meeting that involved the investigation regarding this event. This was a "sentinel event" and time was of the essence. The failure of the hospital to coordinate a timely investigation created the potential for negative patient harm for the other vulnerable patients.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on review of facility documents, personnel files, and staff interviews, the facility failed to ensure its Executive Director/Administrator fully assessed and addressed priorities affecting patient safety, such as allegations of patient abuse, and incorporated such into the Quality Assessment and Performance Improvement Program. This failure did not ensure all areas for improvement were evaluated and created the potential for a negative patient outcome.

The findings were:

A review of the facility's grievance log on 7/11/11 revealed six different patient grievances in regards to one Certified Nursing Assistant (CNA). Further review of each individual grievance with the Patient Advocate revealed the following:
- The first grievance stated that the patient "witnessed an incident involving CNA [staff sample #14] and" two patients "that upset her..."
- The second grievance stated that the patient "witnessed an incident involving CNA [staff sample #14] and" two patients "that upset her..."
- The third grievance stated that "[The patient] witnessed an incident involving CNA [staff sample #14] and" two patients "that upset [him/her]. [S/he] stated that CNA [staff sampled #14] has entered [his/her] shower unannounced, wouldn't help [him/her] get up from the toilet when [s/he] asked, forced [him/her] to make [his/her] own bed, squeezed [his/her] hand really hard, withheld toiled paper and acted bossy overall..."
- The fourth grievance stated that the patient "witnessed an incident involving CNA [staff sample #14]. [S/he] want to make it clear that what [s/he] witnessed was abusive."
- The fifth grievance stated "[Staff sample #14] tried to force [him/her] to go to group. [S/he] intervened when [s/he] saw [him/her] push [a patient's] wheelchair and force [him/her] into the group. [S/he] removed [him/her] from the group. [S/he] felt like [staff #14] was constantly 'testing' [him/her], and squeezed [his/her] hand really hard. [S/he] stated that [staff #14] also forced [him/her] to make [his/her] bed. [S/he] didn't eat dinner last night so [s/he] could avoid [staff #14]. [S/he] did eat a snack after [staff #14] left."
- The sixth grievance stated "[S/he] witnessed an incident involving CNA [staff sample #14] and" two patients "that upset [him/her]. [S/he] mentioned that [staff #14] was continually bossing everyone around and provided me with the attached letter. [S/he] stated that [s/he] expressed concerns about [staff #14] to [three other staff members]. [S/he] also stated that [staff #14] left [a patient] in a chair for hours..."

Each of the six patients was informed by the Patient Advocate that appropriate actions had been taken with the CNA and that the CNA would no longer be working with patients.

An interview with the Director of Nursing was conducted on 7/12/11 at approximately 10:45 a.m. When asked about the CNA's actions, s/he stated, "When I talked to patient and staff that were there that day, that was not the case that happened..." S/he stated that the CNA rolled the patient backwards in his/her chair because s/he was dragging his/her feet. S/he stated the CNA went in the patient's room and shut the door because the patient was screaming, but that the patient could have opened the door. "That information there was from the incident report. All the patients that witnessed it had a different perception..." Later that day, at approximately 1:30 p.m., the DON was again asked about the incident with the CNA and s/he stated, "It was on the higher functioning side (less demented patients)... None of the staff witnessed abuse." When asked if the CNA was reported to the State Board of Nursing, s/he stated, "I did not report [him/her] to the board." When asked if s/he had any documentation of an investigation of the incident, s/he stated it would be in the CNA's file.

A review of the CNA's (staff sample #14) file was conducted on 7/13/11. It contained two formal internal facility reports, both written by Registered Nurses (RN), two handwritten letters, both written by CNAs, and a typed e-mail written by the facility's Risk Manager. The documents revealed the following, in pertinent part:
- The first RN's report did not detail the events of the incident, but instead stated, "Following this incident, a group was initiated on the unit to address coping for the patients. Multiple patients were present and those who contributed were... Pts stated that [staff sample #14] was 'rude' 'unbearable' 'neglectful' and 'controlling.' Pts state that [s/he] has not provided them with their needs, is sarcastic and rude and [s/he] is not respecting their rights." The follow-up section on this report stated, "1:1 support offered from night staff and concerns addressed in group. Reassured pts that they have Rights and that they will be respected. DON [DON's name] notified. Request placed for Pt Advocate [PA's name] to meet with pts to address their concerns, per pts."
- The second RN's report stated, "[First patient] did not want to go to group, [staff sample #14] CNA got in pts face & told [him/her] [s/he] 'really need to' and that [s/he] was going to redirect either to group or [his/her] room. Pt informed [staff #14] [s/he] better not put [his/her] hands on [him/her], or else. [Second patient] was sitting in front of the nursing station. [Staff #14] told [him/her] [s/he] needed to go to the process group. [Staff #14] CNA lifted up pts front wheelchair wheels and forced [him/her] to go into the day room, pt began to cry. [First patient] brought [him/her] out and [staff #14] said 'ok, then you have to go to your room' and again popped the front wheels up and made [him/her] go to her room; the pt screamed the whole time." The follow-up section on this report stated, "1:1 [with] each pt - comforted, reassured pts DON and Advocate to be informed to follow up for educational purpose for our pts & CNAs benefit."
- The first CNA's letter stated that the sample staff #14 was verbally inappropriate to staff and patients throughout the day and even "left me alone in shower room with a combative patient after I asked [him/her] to stay."
- The second CNA's letter listed "examples of [sample staff #14's] behavior." One example stated that the CNA "held [a patient] down by [his/her] wrists, not letting [him/her] get up from [his/her] chair. When [the patient] tried to say anything, [staff #14] raised [his/her] voice at [him/her] trying to maintain control..." The letter stated, "[His/her] overall attitude and demeanor was inappropriate over the weekend..."
- The e-mail from the facility's Risk Manager stated that s/he had encountered the CNA that weekend and that the CNA was "smiling" and "grabbed my left hand with both of [his/her] hands and shook my hand with both of [his/her] while squeezing it tightly." S/he stated that s/he asked "what was that about" but that CNA did not answer.

An interview with the facility's Administrator was conducted on 7/13/11 at approximately 12:30 p.m. When asked about the incident, s/he stated, "I would have to go back and reread those things to make accurate statements." When asked if s/he had any documentation of an investigation about the abuse allegations, s/he stated, "I don't have any further documentation. I was not actively involved in the investigation. I normally leave that up to HR and those folks because you've got to maintain another level if you need it...[The Patient Advocate] got several grievances and [s/he] interviewed each one of the patients and the stories were all concurrent." The Administrator and Corporate Vice President of Clinical Services (VPCS) were informed that the allegations were reportable to the State Occurrence system and possibly the State Board of Nursing. The VPCS stated, "I agree with that... That should have been reported... We failed to follow-up on the actual reporting."

The 5/21/11 Quality Council meeting minutes did not evidence any discussion of the incident with the CNA, although the meeting was held over one month after it occurred. The only documentation that referenced it was in the "Patient Rights/Grievance" section which stated that there were "10 Patient Grievances in April."

In summary, although the incident/s with the CNA were investigated to some degree, the Executive Director/Administrator did not ensure the facility fully assessed and addressed priorities affecting patient safety, such as allegations of patient abuse. There was no documentation that the patient's abuse allegations were addressed within the May Quality Council meeting, the Director of Nursing determined it was not abuse, despite the patients' allegations and documentation from staff, and the Administer was not involved in the incident. In addition, the allegations were not reported to the State Health Department and Administration had not considered reporting the CNA to the State Board of Nursing.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the manner and degree of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Nursing Services. The facility failed to ensure that it had an organized nursing service that included documented orientation and verification of competence of agency nursing staff, documented nursing meeting minutes, and that the nursing staff administered drugs appropriately.

The facility failed to be in compliance with the following standards:

A 0386: Organization of Nursing Services - The facility failed to ensure it maintained a well-organized nursing service. Specifically, the facility did not ensure staff meetings were regularly conducted and minutes maintained of such onsite. This failure did not ensure that staff not present at the meetings could be readily informed of the information discussed.

A 0394: Licensure of Nursing Staff - The facility's nursing services failed to provide proof of licensure for Licensed Psychiatric Technicians. The facility had one employee working as a Licensed Psychiatric Technician without licensure.

A 0398: Supervision of Contract Staff - The facility failed to ensure that all non-employee files contained proper orientation documentation to the facility, facility-specific job descriptions and evaluations of performance for the shifts worked as evidenced in five of five agency nursing staff files reviewed. This failure did not ensure non-employee nurses adhered to the policies and procedures of the hospital.

A 0405: Administration of Drugs - The facility failed to ensure that all drugs and biologicals were administered by nursing personnel in accordance with Federal and State laws, specifically in the administration of controlled substances.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on staff interview and facility document review, the facility failed to ensure it maintained a well-organized nursing service. Specifically, the facility did not ensure staff meetings were regularly conducted and minutes maintained of such onsite. This failure did not ensure that staff not present at the meetings could be readily informed of the information discussed and the failure created the potential for a negative outcome.

The findings were:

An entrance conference was conducted with the Director of Nursing on 7/11/11 at approximately 8:55 a.m. Nursing staff meeting minutes were requested. Again, at approximately 1:45 p.m., the DON was asked for nursing meeting minutes. S/he stated, "I do my nursing meeting minutes at home because they changed our server here so I can't access them from home. So I'll get them sent over tonight..."

The following day, 7/12/11, at approximately 2:00 p.m., the DON was asked for evidence of nursing staff meetings. S/he stated s/he was still getting them. When asked how s/he educated those staff that are not present at the meeting, because in order to do so minutes would need to be available on site, s/he stated, "I have been going over it with them verbally..." When asked how s/he knows who missed the meetings, s/he stated, "Usually I have a sign in sheet."

On 7/12/11 at approximately 3:30 p.m., the DON provided evidence of nursing meetings. That which was dated January 1st, 2011 and later is described below:
2/3/11 - "Nurses meeting," which contained minutes on over six topics;
2/9/11 - "CNA/LPT meeting," which contained minutes on over eight topics;
4/14/11 - "HAVEN CLINICAL UPDATES NEWS LETTER," which contained minutes on over nine topics;
4/20/11 - "Mandatory Staff Meeting," which contained only an agenda of 19 topics;
5/15, 16, & 17 - "Mandatory Clinical Staff Meeting," which contained only a sign-in sheet and no attached minutes or agenda;
5/25/11 - "ACTION PLAN FROM CORPORATE VISIT," which contained minutes on two topics (although it stated "Continue on other side of paper" and a second side was not provided);
5/28/11 - "HAVEN CLINICAL UPDATES NEWS LETTER," which contained minutes on over seven topics.

No sign in sheets were provided for any but one of the above educational meetings, of which did not contain minutes or an agenda. The documents were presented to surveyors after asking several times and over 30 hours after initially requested on the Entrance Conference. In summary, the minutes were not readily available to educate staff, including PRN or agency nursing staff.