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HAVEN BEHAVIORAL SENIOR CARE OF NORTH DENVER 8451 PEARL STREET SUITE 100 THORNTON, CO July 24, 2013
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on observation, document review, and interviews, the facility failed to ensure that all medication errors were documented and reported to the facility's Quality Committee for review.

This failure created the potential for medication errors to be underreported by staff, specifically nursing staff.

Findings:

1. Facility Registered Nurse (RN) #1, was unaware how to complete documentation regarding a medical error that occurred in the facility on 07/23/13. Without questioning by surveyors, the medication error would likely have remained unreported and would not be available for review by the facility's Quality Committee.

a) Cross Reference Tag A0405- Nursing: Administration of Drugs: Staff RN #1 failed to observe the oral administration of a medication by Sample Patient #2 on 07/23/13, per facility policy, failed to inform any staff member, including the facility's pharmacy, that a dose of medication had been discarded and would result in a medication variance, and failed to complete a medication error report for review by the facility's Quality Committee.

b) On 07/24/13 at 2:54 p.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing, to review findings regarding the medication not administered to Sample Patient #2 and the lack of documentation of this issue. The facility's DON stated all nurses, including agency nurses, receive "med variance training" and that all nurses are expected to report medication errors on specific facility forms for review. Both the DON and the Vice President of Nursing confirmed the dose of Levaquin, not observed as taken by the patient, and the discarding of the dose by the RN, constituted a medication error. Both the DON and the Vice President of Nursing confirmed RN #1 should have made a note in the patient medical record regarding the discarded dose of Levaquin and why it was discarded. The DON reviewed the medical record for Sample Patient #2 and confirmed no nursing note was found regarding this issue. When asked if medication errors were reported by nursing staff and reviewed in Quality, the Vice President and the DON confirmed this was the expectation.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observations, document review, and interviews, the facility failed to ensure a medication was administered to a patient, Sample Patient #2, as ordered by the patient's physician, and per the facility's policy.

This failure created the potential for negative outcomes to the patient and possibly to other patients in the facility.

Findings:

1. Nursing staff did not ensure an oral medication prescribed to Sample Patient # 2 was administered.

a) On 07/23/13 at 9:12 a.m., Sample Patient #2 was observed sitting at a table in the hallway of patient Unit B, holding a medicine cup which contained a pink colored tablet. No staff member was with the patient at the time.

b) On 07/23/13 at 9:15 a.m., Registered Nurse #1 (RN #1) was observed at the patient medication cart located behind the nurses' station on patient Unit A, preparing medications to be administered. RN #1 was notified by surveyors that Sample Patient #2 was holding a medication cup containing a tablet. Sample Patient #2 could not be found immediately, but walked by the nurses' station approximately 1 minute later. RN #1 took the medication cup and tablet from the patient and the patient walked away. RN #1 stated s/he thought the tablet could be a vitamin, but upon further check of the patient's medications, found in the medication cart, and a better look at the tablet, s/he stated the tablet was the antibiotic, Levaquin. RN #1 stated s/he had dispensed medications to patients at around 9:00, a.m., in the cafeteria, must have become distracted, and had not observed Sample Patient #2 take the oral dose of Levaquin. RN #1 stated it was facility policy to observe patients take their medications and s/he confirmed s/he had not done this for all medications s/he had administered to Sample Patient #2. RN #1 was observed discarding the Levaquin tablet into the sharps container located in the bottom drawer of the medication cart.

c) On 07/23/13 at 11:33 a.m., reviewed of the facility's policy titled, "Medication Administration and Documentation," revised June, 2011, was conducted. The policy stated, "Observe the patient take the drug. If the medication is taken orally, stay with the patient until he/she has swallowed the drug." The policy further stated, "Report any drug administration errors and adverse untoward drug reactions immediately to the attending physician, pharmacist, and patient and/or family (as appropriate). Prepare and submit reports as required by the facility...Isolate defective or questionable drugs and return them to the pharmacy with an explanation of the defect to questionable item."

d) On 07/24/13 at 9:00 a.m., review of the medical record for Sample Patient #2 was conducted. Sample Patient #2 was admitted to the facility on [DATE] and on 7/19/13 at 12:30 p.m., a physician order was noted in the medical record for Levaquin, 500 mg, to be given orally, each day for 7 days. The medical record reflected the patient had a urinary tract infection. The medical record for Sample Patient #2 contained no note by nursing staff regarding the discarded Levaquin tablet from 07/23/13, including no notation that pharmacy was contacted regarding this discarded medication.

e) On 07/24/13 at 9:58 a.m., an interview was conducted with RN #1. When asked if s/he had completed a facility medication error report regarding the Levaquin tablet not administered to Sample Patient #2 and instead discarded, RN #1 stated s/he did not know where the forms were kept or how to complete this form for reporting. When asked if s/he had spoken to anyone, any staff member, about the discarded Levaquin tablet from 07/23/13, s/he stated s/he could not remember speaking with anyone about this issue. When asked, RN #1 confirmed the lack of observing Sample Patient #2 take this oral medication and the discarding of the medication constituted a medication error. RN #1 confirmed s/he did not make a note in the patient's medical record regarding the dose of Levaquin that was discarded and why it was discarded. RN #1 stated s/he was an agency nurse and the last time s/he worked at this facility was a "few months ago" or even 6 months ago. RN #1 stated s/he could not remember the last time s/he worked at this facility prior to 07/23/13. RN #1 stated she was on the facility's schedule on 07/23/13 and today, 07/24/13, and was not on the schedule after today. RN #1 stated s/he received orientation to this facility just less than a year ago.

f) On 07/24/13 at 11:15 a.m., in a follow up interview with RN #1, s/he confirmed that s/he did administer the ordered dose of Levaquin to Sample Patient #2 at approximately 9:30 a.m., on 07/23/13. When asked if s/he had informed the pharmacy that a dose of Levaquin had been discarded, so that the pharmacy would be informed of a medication variance, RN #1 stated s/he had not notified the pharmacy, but would do so.

g) On 07/24/13 at 2:54 p.m., an interview was conducted with the facility's Director of Nursing (DON), the facility's Director of Performance Improvement and Risk Management, and the company's Vice President of Nursing, to review findings regarding the medication not administered to Sample Patient #2 and the lack of documentation of this issue. The facility's DON stated all nurses, including agency nurses, receive "med variance training" and that all nurses were expected to report medication errors on specific facility forms for review. Both the DON and the Vice President of Nursing confirmed the dose of Levaquin not observed as taken by the patient, and the discarding of the dose by the RN, constituted a medication error. Both the DON and the Vice President of Nursing confirmed RN #1 should have made a note in the patient medical record regarding the discarded dose of Levaquin and why it was discarded. The DON reviewed the medical record for Sample Patient #2 and confirmed no nursing note was found regarding this issue. When asked if medication errors were reported by nursing staff and reviewed in Quality meetings, the Vice President and the DON confirmed this was the expectation.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and staff interviews, the facility failed to ensure that supplies, equipment, and patient care areas were maintained to an acceptable level of safety and quality.

This failure contributed to patients being exposed to potential hazards that had the potential to cause patient injury.

Findings:

1. The facility did not ensure that patients did not have access to rooms that were not in use or were undergoing maintenance.

a) On 07/22/13 at 1:10 p.m., a tour of the facility's patient Unit A was conducted with Registered Nurse (RN) #2. During the tour, Patient Room 112 was viewed. The patient bathroom in Room 112 was viewed and had a towel on the floor that was wet and did not absorb all the water, leaving free-standing water on the bathroom floor. The baseboards along the bathroom's side wall were missing, exposing wet wood. RN #2 stated this had been caused by a backflow of water that happened the previous night. RN #2 stated that maintenance had been informed and that the room was not in use. Two beds were viewed in Room 112, both of which had covers and sheets in disarray and appeared to have been used. RN #2 stated that although Room 112 was not to be used by patients that "patients wandered" around the unit and 1 patient in particular was often found in Room 112. RN #2 stated that the staff kept the door to Room 112 closed, but had no other way to secure the room or the room's bathroom from patient use. RN #2 verified that there was no signage on the door of Room 112 to identify it as not in use.

b) On 07/23/13 at 8:40 a.m., a tour of the facility's patient Unit A was conducted. During the tour, Behavioral Health Technician (BHT) #1 was observed entering patient room 112, where a patient was lying in one of the beds. BHT #1 stated that the bathroom in Room 112 was still not fixed and that Room 112 was not to be used. BHT #1 stated the patient in the bed liked to wander and actually was supposed to be in another room down the hall. BHT #1 stated that there was no way to secure Room 112 from patient access, although it was not to be used. Room 112's bathroom was viewed with BHT #1. Room 112's bathroom was unchanged from the previous day, except that the towel had been removed from the bathroom floor. BHT #1 verified that there was no signage on the door of Room 112 to identify it as not in use.

c) On 07/23/13 at 11:05 a.m., an interview was conducted with the facility's Director of Nursing (DON) and the facility's Director of Quality Management (DQM). The DQM stated that room 112 should have been, "closed off," so that it could not have been used by patients. The DON stated that the room should not have been in use, but that there was,"no way to lock the door."
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on observation, interviews, and facility document review, the facility failed to ensure that nursing staff and certified nursing assistants [Behavioral Health Technicians, (BHTs)] were trained on how to respond to an emergency situation.

This failure created the potential to cause harm to all patients served by the facility.

Findings:

1. The facility failed to ensure that staff was educated on the location of emergency equipment that was needed to respond to emergency situations requiring Basic Life Support interventions.

a) From 07/22/13 through 07/24/13, a sample of 30 patient medical records were reviewed. The sample included both open and closed medical records of patients admitted from 06/07/13 through 07/21/13. The ages of the sample patients ranged from 55 years of age to 95 years of age. Further breakdown of the patient medical records sampled revealed 3 patients were in their 50's, 8 patients were in their 60's, 8 patients were in their 70's, 8 patients were in their 80's, and 3 patients were in their 90's. Documented psychiatric diagnoses upon admission included, but was not limited to; multiple categories of dementia, anxiety, depression, schizoaffective disorder, schizophrenia, bipolar disorder, acute psychosis, Post Traumatic Stress Disorder, suicidal ideation, altered mental status, and delusions.

Review was conducted of the medical diagnoses of the 30 sample medical records. Fifteen of 30 medical records reviewed revealed an admission diagnosis of hypertension (Sample Patients #1, #2, #3, #4, #7, #13, #16, #19, #20, #22, #23, #27, #28, #29, and #30.) Five of 30 medical records revealed a history of seizure disorder upon admission (Sample Patients #3, #4, #5, #27, and #28). Ten of 30 medical records reviewed revealed a history of gastroesophageal reflux disease or esophageal reflux disease and stenosis (Sample Patients #3, #6, #7, #11, #15, #19, #20, #26, #29, and #30). Sample Patient #3 had a documented admitting diagnosis of orthostatic hypotension, and Sample Patient # 29 had a documented history of "frequent falls." Sample Patient #7 had a documented admitting diagnosis of Chronic Heart Failure, Sample Patient #12 had a documented history of "heart arrhythmias," Sample Patient #19 had a documented history of subacute stroke, Sample Patient #21 had a documented history of atrial fibrillation, Sample Patient #23 had a documented history of Coronary Artery Disease with a previous myocardial infarction, Sample Patient #25 had documented, "heart disease with minor heart attacks on 3 occasions," and Sample Patients #28 and #29 had documented Coronary Artery Disease. Sample Patient #11 had documented "long standing swallowing difficulty" upon admission, and Sample Patients #15 and #20 had documented episodes of decreased serum potassium upon admission. This is a sample, and not an all-inclusive list, of medical diagnoses upon admission, that could have led to emergency medical situations for patients in which facility staff would be required to respond with Basic Life Support.

b) On 07/22/13 at 1:47 p.m., a tour of the facility's patient Unit A was conducted. During the tour, an interview was conducted with Registered Nurse (RN) #3, regarding the location of emergency equipment, including the facility's portable suction and emergency response cart. RN #3 led the surveyors to an examination room that was located at the end of a hallway in patient Unit B, and stated this was where the portable suction and emergency response cart were located. Upon entering the examination room, no emergency response cart or portable suction was viewed. RN #3 stated that if the emergency cart was not in the room that it meant it was "being worked on by someone." RN #3 stated there was portable suction in the patient dining room, but was unable to state the location of another emergency cart in the facility.

c) On 07/22/13 at 1:15 p.m., a review of 3 Registered Nurse (RN) and 3 BHT personnel files, who all worked as full-time employees at the facility, was conducted. All 6 personnel files contained documentation that the employees were currently certified in Basic Life Support. None of the 6 personnel files contained documentation that the employees had been oriented to the location of emergency equipment needed to perform procedures during emergencies.

d) On 07/22/13 at 4:15 p.m., an interview was conducted with the facility's Director of Quality Management (DQM) and the company's Vice President of Nursing. Both the DQM and the Vice President of Nursing were informed that RN #3 was unable to locate the facility's emergency response cart. The DQM stated that s/he believed that all staff had participated in Code Blue drills and should know where emergency items were located.

e) On 07/23/13 at 8:45 a.m., a tour of the facility's patient Unit A was conducted. During the tour, Behavioral Health Technician (BHT) #1 was interviewed in regard to the location of emergency equipment, including the facility's automated external defibrillator (AED), portable suction, and emergency response cart. BHT #1 stated that all of the items were located in an examination room at the end of the hallway in patient Unit B, which was the same room RN #3 had shown surveyors the previous day. BHT #1 was unable to state any other location where these items were located. The examination room at the end of the hallway in patient Unit B was viewed by the surveyors, but did not contain any emergency equipment.

f) On 07/23/13 at 10:35 a.m., the facility's Quality Management binder for 2013 was viewed with the facility's Director of Quality Management (DQM). The facility's DQM verified this was the current binder for the year. Inside the binder, documentation of emergency drills including Code Blue drills (cardiac/respiratory arrests) were documented. The binder contained three documented Code Blue drills between 01/01/13 and the current date of 07/23/13. The mock Code Blue drills were documented on the facility's "Code Blue Evaluation" forms. The dates and times of the Mock Code Blue drills were documented as 01/09/13 at 3:47 p.m., 05/27/13 at 2:50 a.m., and 07/16/13 at 2:40 p.m.

The Code Blue Evaluation forms contained an area to document the evaluation of staff response to the Code Blue drills. It was documented on the evaluation form dated 01/09/13 at 3:47 p.m., that staff did not bring all necessary equipment to the code blue drill, including the AED and the emergency medications. It was also documented that the Registered Nurse did not make appropriate staff assignments during the code blue drill, and that the Behavioral Health Technicians did not know their roles and responsibilities during the Code Blue drill.

It was documented on the evaluation form dated 05/27/13 at 2:50 a.m., that the bags of emergency equipment, that were contained on the emergency cart, were missing items and contained documentation stating, "see note of missing items." No note of missing items was located in the Quality Management binder. The facility's DQM stated that s/he was unaware of what items were missing and was unable to locate a list of the missing items.

It was documented on the evaluation form dated 07/16/13 at 2:40 p.m., that the facility staff did not bring all necessary equipment, including a vital signs machine and a backboard, to the Code Blue drill.

The DQM stated s/he believed these Code Blue drills were discussed at Quality Meetings. The Quality Management binder contained no documentation that the Code Blue drills or their evaluations had been discussed at quality meetings. The DQM was unable to provide any documentation, including meeting minutes, that the Code Blue drills or their evaluations had been discussed at the facility's quality meetings.

g) On 07/23/13 at 10:53 a.m., an interview with the facility's Director of Nursing (DON) and DQM was conducted. The DON stated that s/he had been alerted by the DQM on 07/22/13 that nursing staff and Behavioral Health Technicians (BHTs) could not locate emergency equipment in the facility. The DON stated that during shift change on 07/22/13, s/he had educated nursing and BHT staff on the location of emergency equipment, but was unable to provide documentation of this education. The DON stated that all emergency equipment was located on patient Unit A and that the AED was behind the nursing station and the emergency cart and portable suction were located in the copy room on patient Unit A. The DON was made aware that on the morning of 07/23/13, BHT #1, who had worked on both 07/22/13 and 07/23/13, was still unaware of the location of emergency equipment.

h) During the same interview, the facility's policy, "Code Blue," was reviewed with facility's DON and DQM. The policy stated, "The DON will conduct Code Blue drills each shift, minimum quarterly. The Code Blue drill event will be documented on the Code Blue Record. The Code Blue drills will be evaluated through completion of the Code Blue Evaluation form by the Registered Nurse. The Code Blue Evaluation will be reviewed by The Director of Nursing to identify training needs, process issues, etc. Results of the evaluations will be submitted to Quality Council and Medical Executive Committees." The DQM and DON verified this was the facility's current policy, but were unable to provide documentation of how the Code Blues drills and evaluations were addressed at Quality Council or Medical Executive Committee. The DON stated that it was his/her expectation that the Code Blue evaluations would be discussed at Quality meetings and that Code Blue drills would be conducted more frequently.

i) On 07/24/13 at 9:32 a.m., an interview was conducted with RN #1. RN #1 stated she had attended a Code Blue drill the night before on 07/23/13, and also another Code Blue drill on the morning of 07/24/13, at the facility. RN #1 stated that during the Code Blue drill, staff members got the actual emergency equipment, including portable suction, an AED, and emergency medications. RN #1 stated s/he participated in the Code Blue drills, but was unable to state where the emergency medications were located or how to access them in case of an emergency situation.