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.

PEAK VIEW BEHAVIORAL HEALTH 7353 SISTERS GROVE COLORADO SPRINGS, CO Feb. 26, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, PATIENT'S RIGHTS, was out of compliance. The hospital failed to protect and promote patient rights by failing to ensure the safety of all patients in the facility.

A130 - Standard: Exercise of Rights - the patient has the right to participate in the development and implementation of his or her plan of care. The facility failed to ensure a care conference regarding the patient's treatment plan was granted when requested by the family.

A144 - Standard: Privacy and Safety - the patient has the right to receive care in a safe setting. The facility failed to provide care in a safe setting by neglecting to perform fall risk assessments and implement fall precaution interventions for patients who were considered a high risk for falls. Further, the facility did not maintain fall risk assessments or continue implementing fall precaution interventions for patients who already sustained a fall at the facility, which may have contributed to subsequent falls while patients were under the facility's care.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on interviews and document reviews, the facility failed to ensure that a care conference was granted regarding the patient's treatment plan when requested by the family.

This failure caused a delay in shared information and collaboration in meeting the patient's need for 1 of 10 records reviewed (Patient #2).

Findings

POLICY

According to the List of Patient Rights, as a patient at (the facility) you have the following rights to provide you with the fullest measure of care, respect, privacy and dignity at (the facility): have an independent advocate, patient advocate, personal representative, legal representative and/or legal guardian participate in your treatment and any respect of your patient rights.

1. The facility failed to address a spouse's request to have a care conference.

a) On 02/22/16 a review of Patient #2's medical record was conducted. The facility used a document titled "General note" which revealed the spouse asked for a care conference with the Case Manager (CM), the patient's family, and the Psychiatrist to discuss the patient's treatment plan. The CM responded the nurse practitioner (NP) had already explained the treatment plan to the spouse and there was nothing the Psychiatrist would be able to add. The CM suggested a care conference to be set-up with a care provider, therapist, nurse and the CM. There was no evidence the spouse received a care conference or spoke with the Psychiatrist regarding the patient's treatment plan.

b) On 02/25/16 at 2:24 p.m., an interview was conducted with the Case Manager (CM #11). CM #11 stated s/he had spoken to the spouse of Patient #2 over the phone about setting up a care conference. S/he stated the facility did not have a care conference policy. CM #11 stated care conferences could be set-up at the family's request and s/he would try to set-up a care conference within one or two days following the request. CM #11 stated anyone the family requested would be brought into the care conference so the staff member could answer whatever questions the family had, although CM #11 did not include the Psychiatrist when suggesting to set-up a care conference.

CM #11 stated the patient's spouse had spoken to the NP over the phone for quite awhile, which was considered a care conference. CM #11 further stated a care conference did not take place with the spouse as requested, because shortly after the spouse had a phone conversation with the NP, placement was found for the patient and the conversation shifted to discharge planning. CM #11 further stated the only training s/he received regarding care conferences was when s/he first started in June 2015 and the training consisted of a discussion with his/her immediate supervisors.

c) On 02/25/16 at 1:27 p.m., an interview was conducted with the Director of Nursing (DON #1). The DON stated s/he had personally set-up care conferences in the past, and these conferences have included the physician, therapist, case manager, nurse, and sometimes the mental health technicians. The DON stated s/he was not aware of facility expectations regarding care conferences and s/he further stated there had not been current staff training regarding care conferences being provided to the patient's representative when requested.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations and interviews, the facility failed to ensure the safety of all patients by neglecting to perform fall risk assessments and implement fall precaution interventions for patients who were considered a high risk for falls for 10 of 16 patients (Patients #1, #2, #6, #8, #11, #12, #13, #14, #15 and #16). Further, the facility did not maintain fall risk assessments and continue implementing fall precaution interventions for patients who already sustained a fall at the facility, which may have contributed to additional falls for 3 of 16 patients (Patients #12, #13, and #14).

These failures created an increased risk to patient safety and resulted in negative patient outcomes.

FINDINGS:

POLICY

According to policy, Fall Risk Precautions, nursing staff will assess and determine risk of adult patients with regard to falls utilizing the Fall Risk Assessment tool. Based on the score on the Fall Risk Assessment, the patient will be placed on Fall Precaution. If a patient is assessed not to be at risk for falls, the patient will be re-assessed any time there is any indication a fall risk has developed, as evidenced by patients' 24-hour Nursing Assessment. Fall risk precaution nursing interventions included orienting patient/family members to surroundings, instructing patients concerning toileting, teaching transfer techniques, maintaining a clutter free environment, instructing patient to wear non-slip footwear, reassessing and observing every 2 hours after medication change or as condition worsened. Additional nursing interventions included: re-orient patients to surroundings, reminding patients to call for assistance to go to the bathroom at night, encouraging use of as needed assistance devices and when walking or transferring patients, communicating patient's "Fall Risk" during nursing shift report, placing personal items within reach, place in room near the nursing station, and identifying the patient's "Fall Risk" on patient care board.

According to policy, Fall Reduction, the Fall Risk Assessment will be completed by a Registered Nurse during the intake phase of the admission in accordance with the Morse Fall Scale. Fall risk categories will be assigned as follows: 0-24 points equals low fall risk (Green), 25-44 points equals moderate fall risk (Blue), and 45 point or above equal a high fall risk (Red). All patients placed on the high fall precaution level (Red) at admission, will be reassessed every 24 hours. After each assessment, the appropriate fall risk level will be initiated and appropriate actions will be taken, including but not limited to the following: motion alarm activated in patient's room, and review the need for a wheel chair alarm, lap band, bed alarm, and fall mat based upon patient's fall precaution level at the time of assessment and mobility needs. Yellow arm band placed on patient to identify a fall risk, appropriate signage placed at patient's doorway. Additional nursing interventions include: all patients will be encouraged to wear non-slip footwear or shoes at all times for transfers and/or walking; non-slip footwear will be color in accordance with fall precaution level. Any patient with unsteady gait will be assisted for transfers. Any patient who displays confusion or poor orientation will be monitored closely for assistance with toileting/and or transfers.

1. The facility did not ensure Fall Risk Assessments were performed and fall precaution interventions were in place for patients who were at an increased risk of falls. Additionally, the facility did not maintain fall risk assessments and continue implementing fall precaution interventions for patients who already sustained a fall at the facility.

a) Record review revealed Patient #1 was admitted on [DATE] with a diagnosis of Major Depressive Disorder with poor recent memory, poor judgment, poor insight, and s/he was not oriented to the current date, time, his/her location, or the reason s/he was in the facility. Patient #1's admission Fall Risk Assessment revealed the patient had more than one medical diagnosis, used an ambulatory aid, had a weak gait, and overestimated or forgot his/her limitations. These factors placed the patient in the highest fall risk category with a score of 55, which was the Red category. Patient #1 had no fall precaution interventions documented on admission on 12/31/15 and the patient sustained a fall on 01/01/16 which resulted in a right arm fracture at the facility.

An interview with the Director of Nursing (DON #1) was conducted on 02/25/16 at 1:27 p.m. The DON stated the facility expectation of nursing was to implement and document fall interventions for patients that were deemed a high fall risk. Further, s/he stated if a patient was a Red level fall risk, some possible interventions could include having a yellow arm band placed on the patient which indicated the patient was a high fall risk. Non-skid footwear, a Velcro lap belt, patient education, a mat on the patient's floor next to their bed, and room close to nurse's station were all possible interventions s/he would expect to see implemented and documented for a patient that was considered a high fall risk. The DON stated each of these interventions could be implemented by nursing staff without an order from a physician.

b) Record review revealed Patient #12 was admitted on [DATE] with a diagnosis of Schizoaffective disorder with impulsive behavior, poor judgment, poor insight, and s/he was not oriented to the current date, time, his/her location, or why s/he was in the facility. Patient #12 received a Fall Risk Assessment on 01/27/16 that listed a history of falls, more than one medical diagnosis, a weak gait, and that s/he overestimated or forgot his/her limitations. These factors placed the patient in the highest fall risk category with a score of 65, which was the Red category. The patient did not have another Fall Risk Assessment or any documentation of fall interventions until 02/02/16, more than 5 days later. This meant Patient #12 did not have his/her fall risk reassessed every 24 hours, which was indicated for a patient who scored Red, the highest fall risk upon admission to the facility.

Patient #12 did not have fall precaution interventions in place on 02/02/16, 02/04/16, or 02/05/16, and the patient sustained an unobserved fall on 02/05/16, which resulted in the patient hitting his/her head and leaving a "big bump" per the Fall Log. After the fall, Patient #12 did not have a Fall Risk Assessment completed the next day on 02/06/16, and did not have fall interventions in place on 02/07/16 or 02/08/16.

Subsequently, Patient #12 sustained a second fall at the facility on 02/08/16, resulting in him/her hitting his/her head again, leaving a "small bump." After the second fall, Patient #12 did not have any fall interventions put in place on 02/09/16 or 02/10/16, and did not have a Fall Risk Assessment or interventions put in place on 02/11/16.

Patient #12 sustained an unobserved third fall on 02/12/16 in his/her patient room. After sustaining the third fall, Patient #12 did not have Fall Risk Assessments or fall interventions put in place on 02/13/16 or 02/14/16 before sustaining an observed fourth fall in the facility's day room on 02/15/16, per the facility Fall Log. After the fourth fall, Patient #12 did not have fall interventions on 02/16/16, a Fall Risk Assessment or fall interventions on 02/17/16, fall interventions on 02/18/16, and Fall Risk Assessments or fall interventions on 02/19/16 until the patient discharged from the facility on 02/22/16.

This meant the patient did not have the appropriate fall risk assessments or interventions in place at the facility for more than a week after sustaining his/her fourth fall and being considered the highest type of fall risk patient at the facility. The facility did not maintain fall risk assessments or continue implementing fall precaution interventions for Patient #12, which may have contributed to subsequent falls while the patient remained under the care of the facility.

An interview with the Director of Nursing (DON) was conducted on 02/25/16 at 1:27 p.m. The DON stated the expectation of nursing staff was to complete a fall risk assessment upon the patient's admission to the facility, and to reassess the fall risk every 24 hours thereafter for patients that admitted as a high fall risk. After reviewing the documentation of fall risk assessments and fall interventions for Patient #12, the DON stated the assessments and interventions were not meeting expectations.

c) Record review revealed Patient #13 was admitted on [DATE] with a diagnosis of Impulsive Disorder with impaired concentration and attention span, impaired recent memory, and s/he was not oriented to the current date, time, his/her location, or why s/he was in the facility. Patient #13 had a witnessed fall in a patient room on 01/26/16 at 6:15 a.m., hitting his/her right hip. No Fall Risk Assessment was completed or fall interventions implemented after the fall, and the patient sustained a second fall in the dining room, falling to the floor on 01/26/16 at 1:30 p.m. Again, no Fall Risk Assessment or fall interventions were documented on 01/26/16 or 01/27/16. On 01/28/16 at 5:15 p.m., Patient #13 sustained a third fall while walking in the facility cafeteria, falling to the floor.

No Fall Risk Assessments or fall interventions were completed during the patient's stay in the facility between 01/16/16 through 02/06/16. The patient subsequently fell on [DATE] at 6:50 p.m. and was found on the floor after hitting his/her head. No fall interventions were implemented and documented by RN #14, RN #15, or Licensed Practical Nurse (LPN) #8 on 02/07/16, or on 02/08/16 before the patient discharged from the facility on 02/09/16, despite Fall Risk Assessments indicating the patient had a history of falls, more than one medical diagnosis, the patient requiring the use of a walking aid, a weak gait, and the patient overestimated or forgot limitations. The facility did not maintain fall risk assessments or continue implementing fall precaution interventions for Patient #13, which may have contributed to subsequent falls while the patient remained under the care of the facility.

An interview with DON #1 was conducted on 02/25/16 at 1:27 p.m. The DON stated the lack of fall risk assessments and fall interventions for Patient #13 after the patient fell on [DATE] was not meeting facility expectations because s/he expected patients to be assessed and fall interventions to be implemented after a patient sustained a fall in the facility.

d) Record review revealed Patient #14 was admitted on [DATE] with a diagnosis of Major Depressive Disorder and problems with activities of daily living, poor judgment, and poor insight. Patient #14 had an unwitnessed fall to the floor on 01/26/16, but no fall risk assessments were completed or fall precaution interventions were implemented between 01/27/16 until 02/05/16. S/he had inconsistent charting on 02/04/16 - steady, unsteady and staggering gait were charted.

Patient #14 sustained a subsequent fall to the floor on 02/05/16, after which, no fall interventions were documented in the patient's medical record for that date. The patient didn't have a Fall Risk Assessment or fall interventions completed two days later on 02/07/16, and fall interventions also were not implemented the next day on 02/08/16.

Patient #14 sustained a third fall at the facility on 02/09/16 in his/her patient room. According to the facility Fall Log, the patient "bumped" his/her head, and was given ice for treatment.

After Patient #14 sustained the third fall at the facility, the patient didn't have fall interventions in place the following day on 02/10/16, and didn't have a Fall Risk Assessment or fall interventions in place on 02/11/16.

The patient sustained a fourth fall at the facility when s/he was found on his/her bathroom floor on 02/11/16. The patient did not have any Fall Risk Assessments or fall interventions documented for the next 10 of 12 days until the beginning date of the survey. The facility did not maintain fall risk assessments and continue implementing fall precaution interventions for Patient #14, which may have contributed to subsequent falls while the patient remained under the care of the facility.

e) Record review revealed Patient #15 was admitted on [DATE] with a diagnosis of Bipolar Disorder with impulsive behavior. The patient sustained a fall on 02/10/16 at midnight, falling to the floor of his/her bathroom. No Fall Risk Assessments were completed or fall interventions implemented for Patient #15 up to the date of the survey (02/22/16).

An interview was conducted with RN #9 who was assigned to care for Patient #15 on 02/24/16 at 3:51 p.m. S/he was unaware that Patient #15 had previously fallen at the facility. No Fall Risk Assessments had been completed for the patient since the patient fell and no fall interventions were in place as of the date of the survey.

The facility did not maintain fall risk assessments and continue implementing fall precaution interventions for Patient #15, which increased the risk of a subsequent fall while the patient remained under the care of the facility.

f) Similarly, the facility did not ensure fall risk assessments were completed and fall interventions were implemented and maintained for 5 other patients in the facility considered high risk for falls (Patients #2, #6, #8, #11, and #16).
VIOLATION: QAPI Tag No: A0263
Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.21, QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT PROGRAM, was out of compliance.

A-0273 - Standard: Data Collection and Analysis - The facility failed to maintain a comprehensive quality program which showed measurable improvement in facility selected quality indicators, and demonstrated that the indicators resulted in improved health outcomes. Further, the facility failed to demonstrate the Governing Body specified the frequency and detail of data collection for its quality program. These failures resulted in incomplete quality processes and missed opportunities to improve patient safety and health outcomes.

A-0283- Standard: Quality Improvement Activities - The facility failed to take actions aimed at performance improvement, analyze if the implemented actions were successful, and track performance to ensure that improvements were sustained. The failure resulted in opportunities that affect health outcomes, patient safety, and quality of care were overlooked by the quality department, resulting in potential negative patient outcomes.

A-0308 - Standard: QAPI Governing Body - The facility's governing body failed to ensure the facility's Quality Assessment and Performance Improvement (QAPI) program involved all departments and services of the hospital including contract or arranged services. The failure resulted in opportunities that affect health outcomes, patient safety, and quality of care were overlooked by the quality department, resulting in potential negative patient outcomes.

A-0309 - Standard: Executive Responsibilities - The facility's Governing Body failed to ensure the facility possessed a comprehensive quality program that demonstrated selected quality indicator improvement actions were directed, approved, and evaluated. This failure resulted in the facility's ongoing Quality Assessment and Performance Improvement (QAPI) efforts not being directed, approved, or evaluated by the Governing Body.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on interviews and document reviews, the facility failed to maintain a comprehensive quality management program that showed measurable improvement in selected quality indicators, and demonstrated that the indicators resulted in improved health outcomes. Further, the facility failed to demonstrate the Governing Body specified the frequency and detail of data collection for its quality management program.

These failures resulted in incomplete quality management processes and missed opportunities to improve patient safety and health outcomes.

Findings:

POLICY

According to the policy, PI Performance Improvement, PI Function, the performance improvement department shall be responsible for planning, directing, and organizing the performance improvement (PI), risk management and staff development programs of the facility. Specific functions of the PI department are: prepare monthly analysis reports of aggregate data and submits to appropriate committees for review.

According to the policy, PI Performance Improvement, FOCUS-PDCA, is the method used to conduct performance improvement at (the facility). The facility will find opportunities to improve through the identification of problems, determination of goals, strategic planning, and other related processes. Once the performance measurement data has been collected, the information will be reviewed to identify problems and/or opportunities for improvement. This will occur by analysis of trends or patterns, changes in levels of performance, or any other unusual variance in operations. Leaders will determine organizational priorities in PI meetings and will communicate them to involved staff medical, professional staff, and the Board of Directors. A preliminary action plan is identified. Training needs are identified and implemented, as indicated by the team. After an action plan has been fully implemented than the following will take place: a review the effectiveness of actions, identifying any variations from the planned process, and conduct follow up measurements identify if the actions are going to be effective. Finalize the changes in the function or process, and prepare to fully implement the improvement cycle. Plan the improvement and data collection, do the improvement and data collection, check the results of the implementation, act to hold the gain and continue the improvement.


According to the document, (the facility's) Performance Improvement Plan, PI Performance Improvement, (pg. 9), data is systemically aggregated and analyzed on an ongoing basis. Appropriate statistical techniques are utilized to analyze and display data. Some tools include, but are not limited to: run charts, control charts, histograms, Pareto charts, cause-and-effect or fishbone diagrams.

According to the policy, Performance Improvement, Leadership, The Chief Executive Officer is responsible for the Performance Improvement process and the Director of Performance Improvement/Regulatory Compliance/Risk Management drives the process within the organization.

According to the document, (the facility's) Performance Improvement Plan, PI Performance Improvement (pg. 2),the performance Improvement Plan is dedicated to improving care, patient safety and value of service. The Governing Board/CEO has the ultimate authority and responsibility for adopting and organization-wide plan to assess and improve the quality of care provided.

According to the summary statement on the Director of Regulatory Compliance and Health Information Services (DOC) job description/evaluation, the DOC is responsible for performance improvement and quality assessment and responsible for directing and monitoring the actives of the overall hospital quality assessment and performance improvement process.

1. The facility's quality department failed to ensure implementation of a quality management program that demonstrated measurable improvement of its selected quality indicators used for a quality activity and project.

a) On 02/26/16 at 8:25 a.m., an interview was conducted with the Director of Regulatory Compliance and Health Information Services (DOC #2). The DOC stated s/he was in charge of performance improvement and quality assessment. The DOC stated the quality department had three quality improvement projects, which were patient falls, seclusions and restraints. The DOC stated the data for patient falls was collected through incident reports. S/he further stated the collected data for patient falls was discussed on a monthly basis at the quality council and on a quarterly basis at the Governing Board meetings. The DOC provided documented evidence of the data being collected for the patient falls but could not provide evidence that the Governing Board directed the frequency and detail of data collection, changes which were implemented, the evaluation of actions taken, quality project results, and how performance was tracked to ensure improvements were sustained by the facility.

No additional documentation regarding patient falls were received prior to exiting the facility on 02/26/16 at 12:26 p.m.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on interviews and document review, the facility failed to take actions aimed at performance improvement, analyze if the implemented actions were successful, and track performance to ensure that improvements were sustained.

This failure resulted in overlooked opportunities effecting health outcomes, patient safety, and quality, resulting in potential negative patient outcomes.

Findings:

POLICY

According to the policy and procedure manual, PI Function, specific functions of the PI department are: develops and coordinates implementation of goals and objectives for organization wide performance improvement programs.

According to the policy and procedure manual, PI Measurement, measurement activities will occur at the beginning of an improvement process and at regular intervals to determine the effectiveness of the actions or plans implemented. A repeated measurement of functions or process over time provides an opportunity to evaluate stability, effectiveness, and quality.

According to document, (the facility) Performance Improvement Plan, PI Performance Improvement, (pg.11), the Performance Improvement Plan is reviewed and evaluated at least annually to ensure the program is comprehensive, shows minimal duplication of effort, is cost effective, maintains performance improvement principles, results in improved patient care outcomes and clinical performance. Outcomes from the analysis are integrated into the goals and the objectives the facility.

According to the document, Job Duties and Responsibilities of Director of Regulatory Compliance, quality assessment and performance improvement includes: review quality assessment (QA) findings, and assist in developing corrective action and monitors for effectiveness of actions. Collects trends and analyzes medical staff QA data and makes recommendations to the Medical Executive Committee/Quality Counsel for problem resolution.

1. The facility failed to implement a quality improvement program that effectively evaluated performance improvement, analyzed if the actions taken were successful and tracked performance to ensure improvements were sustained.

a) On 02/26/16 at 8:25 a.m., an interview was conducted with the Director of Regulatory Compliance and Health Information Services (DOC #2). S/he stated patient falls were one of the Quality Assessment Performance Improvement (QAPI) projects starting September 2015 to present.

Documentation for the QAPI project Patient Falls was requested on 02/26/16 at 8:30 a.m.

Specifically, the DOC was asked to provide documentation of changes that were implemented, evaluation of actions taken, and how performance was measured and tracked to ensure improvements were sustained, regarding the Patient Falls QAPI project.

No documentation that showed the facility measured the success of the chosen quality improvement project for patient falls, tracked performance to understand if improvements occurred, and ensured improvements were sustained, was received prior to exiting the facility on 02/26/16 at 12:26 p.m.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on interviews and document reviews, the facility's governing body failed to ensure the facility's Quality Assessment and Performance Improvement (QAPI) program involved all departments and services of the hospital including contract or arranged services.

This failure resulted in overlooked opportunities effecting health outcomes, patient safety, and quality by the quality department, resulting in potential negative patient outcomes.

Findings:

POLICY

According to the Job Duties and Responsibilities of Director of Regulatory Compliance, quality assessment and performance improvement includes: collects and tracks quality assessment data for each contract service.

According to the policy and procedure manual, PI Mandatory Reviews, (the facility) routinely collects Quality Control information regarding the service for which it contracts.

1. The facility failed to ensure contract or arranged services were involved in the Quality Assessment and Performance Improvement (QAPI) program.

a) On 02/26/16 at 8:25 a.m., an interview was conducted with the Director of Regulatory Compliance and Health Information Services (DOC #2). S/he stated laboratory, linen, bio-hazard and food services were contracted services utilized by the facility. The DOC further stated bio-hazard was the only contracted service discussed in Quality Council and Governing Body meetings.

The DOC could provide no documentation the QAPI program involved laboratory, linen or food services prior to exiting the facility on 02/26/16 at 12:26 p.m.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on interviews and document reviews, the facility's Governing Body failed to ensure the facility possessed a comprehensive quality program that demonstrated selected quality indicator improvement actions were directed, approved, and evaluated.

This failure resulted in the lack of ongoing Quality Assessment and Performance Improvement (QAPI) efforts not being directed, approved, or evaluated by the Governing Body.

Findings:

POLICY

According to document, (the facility) Performance Improvement Plan, PI Performance Improvement, (pg. 2),the performance Improvement Plan is dedicated to improving care, patient safety and value of service. The Governing Board/CEO has the ultimate authority and responsibility for adopting and organization-wide plan to assess and improve the quality of care provided.

According to the policy, Performance Improvement, Leadership, The Chief Executive Officer is responsible for the Performance Improvement process and the Director of Performance Improvement/Regulatory Compliance/Risk Management drive the process within the organization.

According to the policy and procedure manual, PI Committee, the PI Committee shall include, CEO, COO, Assistant Administrator, Compliance/Risk Management Director, Medical Director, Director of Clinical Services, Director or Nursing, Business Office Director, Director of Admissions, Director of Utilization Review, Director of Business Development, Director of Environment of Care, Director of Food Services, Medical Record Manager, Nutrition Manager, and the Safety Officer. The purpose of the committee is to review all improvement activities to assure improvement does occur, to preliminarily approve or determine improvement priorities.

1. The facility's Governing Board failed to ensure that all improvement actions were evaluated.

a) On 02/26/16 at 8:25 a.m., an interview was conducted with the Director of Regulatory Compliance and Health Information Services (DOC #2). The DOC stated s/he was in charge of performance improvement and quality assessment. The DOC stated the facility's quality department had three quality improvement projects, which were patient falls, seclusions and restraints. The DOC stated data for patient falls was collected through incident reports. The DOC further stated the collected data for patient falls was discussed on a monthly basis at the quality council and on a quarterly basis at the Governing Board meetings. The DOC provided documented evidence of the data being collected for the patient falls but could not provide evidence that the Governing Board directed the frequency and detail of data collection, changes which were implemented, the evaluation of actions taken, quality project results, and how performance was tracked to ensure improvements were sustained by the facility.

No additional documentation regarding patient falls was received prior to exiting the facility on 02/26/15 at 12:26 p.m.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.23, NURSING SERVICES, was out of compliance.

In addition, due to the nature of the survey findings, an Immediate Jeopardy was declared on 02/25/26 at 9:47 a.m. related to the Condition of Participation 482.23, NURSING SERVICES. The facility failed to provide oversight of nursing services by failing to ensure services were provided by nursing staff who had been trained and had their competencies evaluated in completing high fall risk assessments and implementing high fall risk interventions.

A-0386 - Standard: Organization of Nursing Services. The facility failed to provide oversight of nursing services by failing to ensure services were provided by nursing staff who had been trained and had their competencies evaluated in completing high fall risk assessments and implementing high fall risk interventions resulting in negative patient outcomes.

A-0395 - Standard: Registered Nurse Supervision of Nursing Care. The facility failed to ensure fall risk assessments were performed by a Registered Nurse (RN) to meet the ongoing safety needs and ensure nursing services were provided to meet the pain management needs of patients in the facility.

A-0396 - Standard: Nursing Care Plan. The facility failed to ensure nursing staff developed, and kept current, a nursing care plan for each patient.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and document reviews, the Director of Nursing (DON) failed to provide oversight of nursing services within the facility by not ensuring 4 of 8 nurses, Registered Nurses (RN #6, RN #16, and RN #17) and Licensed Practical Nurse (LPN #8), were trained on completing fall risk assessments and implementing fall precaution interventions. Further, no nursing training files sampled contained competency testing for completing fall risk assessments and implementing fall precaution interventions, which included 2 of the 8 nursing staff members (RN #3 and LPN #10) who served to train newly hired nursing staff on fall risk assessments and fall precaution interventions.

These failures resulted in fall risk assessments and fall precaution interventions not being initiated and maintained according to facility policy and resulted in negative patient outcomes.

FINDINGS:

POLICY

According to policy, Fall Reduction, all staff will be educated in orientation, annually, and as needed on the fall reduction program. The Fall Risk Assessment will be completed by a Registered Nurse during the intake phase of the admission in accordance with the Morse Fall Scale. Fall risk categories will be assigned as follows: 0-24 points equals low fall risk (Green), 25-44 points equals moderate fall risk (Blue), and 45 point or above equal a high fall risk (Red). All patients placed on the high fall precaution level (Red) at admission, will be reassessed every 24 hours. After each assessment, the appropriate fall risk level will be initiated and appropriate actions will be taken.

According to policy, Fall Risk Precautions, nursing staff will assess and determine risk of adult patients with regard to falls utilizing the Fall Risk Assessment tool. Based on the score on the Fall Risk Assessment, the patient will be placed on Fall Precaution. Fall risk precaution nursing interventions included orienting patient/family members to surroundings, instructing patients concerning toileting, teaching transfer techniques, maintaining a clutter free environment, instructing patient to wear non-slip footwear, reassessing and observing every 2 hours after medication change or as condition worsened. Additional nursing interventions included: re-orient patients to surroundings, reminding patients to call for assistance to go to the bathroom at night, encouraging use of as needed assistance devices and when walking or transferring patients, communicating patient's "Fall Risk" during nursing shift report, placing personal items within reach, place in room near the nursing station, and identifying the patient's "Fall Risk" on the patient's care board.

1. The Director of Nursing (DON #1) failed to ensure nursing services were provided in a safe and effective manner by trained, competent and qualified staff.

a) Training file review showed nursing staff members were not trained on completing fall risk assessments and implementing fall precaution interventions, which was required by facility policy. Further, none of the nursing training files contained competency testing for completing fall risk assessments and implementing fall precaution interventions.

b) Record review revealed Patient #1 was admitted on [DATE] with a diagnosis of Major Depressive Disorder with poor recent memory, poor judgment, poor insight, and s/he was not oriented to the current date, time, his/her location, or the reason s/he was in the facility.

Patient #1's admission Fall Risk Assessment revealed the patient had more than one medical diagnosis, used an ambulatory aid, had a weak gait, and overestimated or forgot his/her limitations. These factors placed the patient in the highest fall risk category with a score of 55, which was the Red category.

However, Patient #1 had no fall precaution interventions documented on admission on 12/31/15 and the patient sustained a fall on 01/01/16 which resulted in a right arm fracture at the facility.

Record review revealed RN #6 completed Patient #1's admission Fall Risk Assessment on 01/01/16 without implementing and documenting any fall precaution interventions and the patient subsequently fell on [DATE]. Training file review revealed RN #6's file did not contain any evidence s/he had completed fall risk assessment or fall precaution intervention training, which was required by facility policy.

c) An interview with the DON was conducted on 02/25/16 at 1:27 p.m. The DON reviewed the lack of Patient #1's fall interventions upon admission on 12/31/15, despite the patient's high fall risk score. The DON stated staff would be educated regarding the topic of falls and facility expectations were not being met by the example. Further, s/he acknowledged nursing staff did not have documented education or competencies in their training files around the topic of fall risk assessment or fall precaution interventions, nor did nurses who trained newly hired nursing staff receive any specific training on how to assess competency of new staff on fall assessments or fall interventions.

d) Record review revealed Patient #12 was admitted on [DATE] with a diagnosis of Schizoaffective disorder with impulsive behavior, poor judgment, poor insight, and s/he was not oriented to the current date, time, his/her location, or why s/he was in the facility. Charting completed by LPN #8 did not have fall precaution interventions in place on 02/04/16, or 02/05/16, and the patient subsequently sustained a fall on 02/05/16. The fall resulted in the patient hitting his/her head and leaving a "big bump" per the facility Fall Log.

Charting completed by LPN #8 did not contain any fall interventions for Patient #12 on 02/09/16 or 02/10/16. The patient subsequently fell at the facility a second time on 02/12/16. The facility did not maintain fall risk assessments or implement fall precaution interventions for Patient #12, which may have contributed to subsequent falls while the patient remained under the care of the facility.

Training file review revealed LPN #8's file did not contain any evidence s/he completed fall risk assessment or fall precaution intervention training, which was required by facility policy.

e) An interview with the DON was conducted on 02/24/16 at 8:21 a.m. The DON stated Patient #12's fall risk assessments and fall interventions did not meet facility expectations, and that s/he needed to reeducate LPN #8 and other staff on completing fall risk assessments and implementing fall precaution interventions.

f) Record review revealed Patient #13 was admitted on [DATE] with a diagnosis of Impulsive Disorder with impaired concentration and attention span, impaired recent memory, and s/he was not oriented to the current date, time, his/her location, or why s/he was in the facility.

Patient #13 had a witnessed fall in a patient room on 01/26/16 at 6:15 a.m., hitting his/her right hip. No Fall Risk Assessment was completed or fall interventions implemented after the fall, and subsequently the patient sustained a second fall in the dining room, falling to the floor on 01/26/16 at 1:30 p.m. Again, no Fall Risk Assessment or fall interventions were documented on 01/26/16 or 01/27/16. On 01/28/16 at 5:15 p.m., Patient #13 sustained a third fall while walking in the facility cafeteria, falling to the floor.

No Fall Risk Assessments or fall interventions were completed during the patient's stay in the facility between 01/16/16 through 02/06/16 despite the patient sustaining three falls in the facility during that timeframe. The patient subsequently fell a fourth time on 02/06/16 at 6:50 p.m. and was found on the floor after hitting his/her head.

No fall interventions were implemented and documented on 02/07/16, 02/08/16, or by LPN #8 the day the patient discharged from the facility on 02/09/16. The facility's failure to conduct ongoing fall risk assessments and implement fall interventions for Patient #13 contributed to the patient sustaining multiple falls while the patient remained under the care of the facility.

g) Record review revealed Patient #14 was admitted on [DATE] with a diagnosis of Major Depressive Disorder and problems with activities of daily living, poor judgment, and poor insight.

Patient #14 had an unwitnessed fall to the floor on 01/26/16, but no fall risk assessments were completed or fall precaution interventions implemented between 01/27/16 until 02/05/16.

Patient #14 sustained a second fall to the floor on 02/05/16, after which, no fall interventions were documented in the patient's medical record for that date. The patient didn't have a fall risk assessment until two days later on 02/07/16 and fall interventions were not implemented until 02/08/16. Patient #14 sustained a third fall at the facility on 02/09/16 in his/her patient room while assigned to LPN #8. According to the facility Fall Log, the patient "bumped" his/her head, and was given ice for treatment.

After Patient #14 sustained the third fall at the facility, the patient didn't have fall interventions in place the following day on 02/10/16, and didn't have a fall risk assessment or fall interventions in place on 02/11/16.

The patient sustained a fourth fall at the facility when s/he was found on his/her bathroom floor on 02/11/16. The patient did not have any fall risk assessments or fall interventions documented for the next 10 out of 12 days until the beginning date of the survey. The facility did not maintain fall risk assessments and continue to implement fall precaution interventions for Patient #14, which may have contributed to subsequent falls while the patient remained under the care of the facility.

An interview with the DON was conducted on 02/24/16 at 8:21 a.m. The DON stated Patient #14's fall risk assessments and fall interventions did not meet facility expectations.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record reviews, the facility failed to ensure fall risk assessments were performed by a Registered Nurse (RN) to meet the ongoing safety needs of patients in 3 of 17 records reviewed (Patients #12, #13, and #14).

This failure created an unsafe patient environment and negative patient outcomes.

FINDINGS:

POLICY

According to the document, Registered Nurse Position Description, a Registered Nurse (RN) is responsible for providing direct patient care to inpatients and supervising care provided by Licensed Practical Nurse (LPN) and Certified Nurse Assistant (CNA) staff assigned to patient care. The Registered Nurse is also responsible for assessment and reassessment of patients.

1. The Director of Nursing (DON #1) failed to ensure a RN supervised and evaluated the nursing care for each patient in the facility.

a) Record review revealed patients' fall risk assessments were conducted by a Licensed Practical Nurse (LPN #8) without RN supervision or evaluation to ensure the assessments were performed correctly. The assessments completed by LPN #8 did not contain any fall risk interventions, nor were any fall interventions implemented by a RN for patients who sustained multiple falls at the facility.

b) Record review revealed Patient #12 had fall risk assessments performed by LPN #8 on 02/04/16 and 02/05/16 and not by a RN, as required by policy. The assessments did not contain any fall precaution interventions, and the patient subsequently sustained a fall with injury on 02/05/16. LPN #8 also completed fall risk assessments, rather than a RN, on 02/09/16 and 02/10/16. The assessments were missing fall interventions. The patient fell at the facility again on 02/12/16.

The facility did not ensure fall risk assessments were completed by a RN or continue to implement fall precaution interventions for Patient #12, which may have contributed to subsequent falls while the patient remained under the care of the facility.

c) An interview with the DON was conducted on 02/24/16 at 8:21 a.m. The DON stated Patient #12's lack of fall risk assessments and fall interventions did not meet facility expectations, and s/he planned to reeducate LPN #8 and other staff on completing fall risk assessments and implementing fall precaution interventions. The DON stated a LPN was allowed to independently perform fall risk assessments in the facility, which was inconsistent with facility policy.

d) Record review revealed Patient #13 was admitted on [DATE] with a diagnosis of Impulsive Disorder with impaired concentration and attention span, impaired recent memory, and s/he was not oriented to the current date, time, his/her location, or why s/he was in the facility.

Patient #13 had a witnessed fall in a patient room on 01/26/16 at 6:15 a.m., hitting his/her right hip. No fall risk assessment was completed or fall interventions implemented after the fall, and the patient sustained a second fall in the dining room on 01/26/16 at 1:30 p.m. Again, no fall risk assessment or fall interventions were documented on 01/26/16 or 01/27/16. On 01/28/16 at 5:15 p.m., Patient #13 sustained a third fall while walking in the facility cafeteria, falling to the floor.

No Fall Risk Assessments or fall interventions were completed during the patient's stay in the facility between 01/16/16 through 02/06/16 despite the patient sustaining three falls in the facility during that timeframe. The patient subsequently fell a fourth time on 02/06/16 at 6:50 p.m. and was found on the floor after hitting his/her head. Patient #13 had a fall risk assessment performed by LPN #8 on 02/09/16 and not by an RN, as required by policy. Additionally, the assessment did not contain any fall precaution interventions, despite the patient scoring a high fall risk score, having a history of falls, more than one medical diagnosis, the patient requiring the use of a walking aid, a weak gait, and the patient overestimated or forgot limitations.

The ongoing safety needs for Patient #13 were not supervised or evaluated by a RN which created an unsafe patient environment and increased the likelihood of additional negative patient outcomes.

e) An interview was conducted with the House Supervisor (RN #3) on 02/25/16 at 11:01 a.m. The House Supervisor stated it was not mandatory in the facility for RNs to oversee LPNs fall risk assessments or fall risk interventions, which was not consistent with the facility policy regarding assessments needing to be completed by a RN.

f) Record review revealed Patient #14 was admitted on [DATE] with a diagnosis of Major Depressive Disorder and problems with activities of daily living, poor judgment, and poor insight.

Patient #14 had an unwitnessed fall on 01/26/16, but no fall risk assessments were completed or fall precaution interventions implemented between 01/27/16 until 02/05/16. Patient #14 sustained a second fall on 02/05/16, after which, a Fall Risk Assessment was completed by LPN #8, and not a RN, as required by facility policy.

Further, no fall interventions were documented in the patient's medical record for that date. The patient didn't have a subsequent Fall Risk Assessment or fall interventions completed two days later on 02/07/16, and fall interventions also were not implemented the next day on 02/08/16. Patient #14 sustained a third fall at the facility on 02/09/16 in his/her patient room. According to the facility Fall Log, the patient "bumped" his/her head, and was given ice for treatment.

After Patient #14 sustained the third fall at the facility on 02/09/16, the patient only had a Fall Risk Assessment completed by LPN #8, and didn't have RN fall risk assessments completed on 02/09/16 or 02/10/16. Both assessments did not have any fall interventions documented. Additionally, the patient didn't have a Fall Risk Assessment or fall interventions in place on 02/11/16.

The patient sustained a fourth fall at the facility when s/he was found on his/her bathroom floor on 02/11/16. The patient did not have any Fall Risk Assessments or fall interventions documented for the next 10 out of 12 days until the beginning date of the survey. The facility did not ensure fall risk assessments were completed by an RN or continue implementing fall precaution interventions for Patient #14, which may have contributed to subsequent falls while the patient remained under the care of the facility.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on interviews and record reviews, the facility failed to ensure nursing staff developed, and kept current, a nursing care plan to address the pain management needs of a patient in 1 of 10 records reviewed (Patient #2).

This failure created an increased risk of negative patient outcomes by patient care needs possibly not being met by facility staff.







FINDINGS

POLICY

According to the policy, Clinical Service, each patient admitted to the psychiatric unit shall have an individualized treatment plan which is based on interdisciplinary clinical assessments.

According to the policy, Pain Assessment, pain intensity and pain relief will be assessed and reassessed at regular interval, and will contribute to the choice of appropriate therapeutic intervention. Every patient will be assessed for pain at least once per shift, more often as indicated. Reassessment should occur at least every 4 hours for the first 24 hours and every 6 hours thereafter. More frequent assessment is necessary if pain is controlled poorly.

1. The facility failed to ensure the pain management needs of the patient were met.

a) Patient #2 had two separate admissions. Review of Patient #2's medical record for the first admission from 12/03/15 to 01/10/16 was conducted. The facility used a document titled "General note" which revealed:

On 12/03/15 at 7:48 a.m., a pain assessment sheet revealed a pain level of 0, which indicated no pain. No other pain assessments were documented in the patient's medical record nor was a pain management care plan developed when Patient #2 began experiencing pain.

On 01/08/16 at 1:53 p.m., it was documented Patient #2 had right sided jaw swelling and swelling to lower legs. However, there was no documentation the patient was assessed for pain associated with the change in condition.

On 01/08/16 at 5:53 p.m., it was documented the patient had swelling to the right side of his/her mouth with constant drooling. There was no pain assessment or other assessment completed.

On 01/09/16 at 9:00 a.m., a progress note revealed the patient had reported bleeding and foul smelling breath and draining of puss like material down face. There was no documented assessment of the patient's pain level or documentation the facility took measures to address the patient's change in condition.

On 01/09/16 at 9:14 p.m., documentation showed Patient #2 appeared to have had major mouth pain due to apparent swelling and abscess of tooth and lower jaw. However, there was no documentation the facility addressed the patient's pain and took interventions to address his/her change in condition.

On 01/09/16 at 5:55 p.m., patient refused hard foods due to abscess in mouth.

On 01/10/16 at 09:28 a.m., almost 2 days after Patient #2 experience a change in condition, the patient's spouse stated the patient verbalized a high level of pain from his/hers feet all the way to his/her head. Both feet and ankles were swollen and the patient continued to have a large swollen abscess to cheek. The facility received an order to transfer the patient to a higher level of care.

The plan of care developed during Patient #2's first admission. A care plan for fall prevention and mental health services was present; however there was no documentation the facility developed a nursing care plan to address the pain management needs or other patient needs associated with his/her change of condition.

On 02/25/16 at 1:27 p.m., an interview was conducted with the Director of Nursing (DON #1). S/he stated the facility expected nursing staff to have assessed a patient's pain once or twice a shift, and more often if needed. S/he stated nursing staff should have used the numeric pain scale to assess a patient's pain and the pain assessments should have been documented in the nursing notes. DON #1 stated nursing staff did not meet the facility's expectation by failing to assess the patient's pain or offering pain medications. DON #1 stated there had not been any staff training regarding pain assessments, re-assessments or pain control. S/he further stated there had not been any annual training regarding pain control for patients.

b) On 01/23/16 a review of Patient #2's medical record for the second admission from 01/12/16 to 02/08/16 was conducted. The facility used a document titled "General note" which revealed:

On 01/12/16 at 10:22 p.m., a pain assessment sheet revealed the patient had a pain level of 0, which meant no pain. No other pain assessments were documented in the patient's medical record nor was there a pain management care plan developed during Patient #2's admission.

On 01/27/16 at 4:00 p.m., Mental Health Technician #17 (MHT) wrote, patient was sobbing due to pain in his/her genitals.

The plan of care developed during the second admission for Patient #2 was reviewed. A care plan for fall prevention and mental health services was present; however staff failed to develop a nursing care plan to address the pain management needs of Patient #2.

c) On 02/24/16 at 9:55 a.m., an interview was conducted with the DON. S/he stated MHT #17 who examined the patient should have notified the nurse that the patient was having pain in his/her genitals. DON stated MHT #17 did not meet the expectation of the facility by not reporting the patient's pain to the nurse.

d) On 02/24/16 at 11:01 a.m., an interview was conducted with Licensed Practical Nurse (LPN #10). S/he stated pain assessments should have been done on admission and then every shift if the patient did not have complaints of pain. S/he further stated if a patient had complaints of pain then a pain assessment should have been done more frequently. S/he stated when assessing pain, staff were to use the pain scale or visual cues by assessing the patient's face. LPN #10 stated the pain assessment should have been documented in the patient's chart in either nursing notes or in the pain assessment section. LPN #10 stated a nurse could call the doctor to obtain an order for pain medication if needed.

e) On 02/24/16 at 10:54 a.m., an interview was conducted with LPN #9. S/he stated pain should be assessed on admission, as needed and when a patient complains of pain. LPN #9 stated pain should be assessed by having the patient rate his/her pain on a scale and pain could be assessed by observing a patient's visual cues. S/he stated a patient's pain should be documented in either the general notes or under pain assessments section in the chart.