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 May 11, 2017
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0431
Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.24 Medical Record Services, was out of compliance.

A-0454 - Standard: All orders, including verbal orders, must be dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient only if such a practitioner is acting in accordance with State law, including scope-of-practice laws, hospital policies, and medical staff bylaws, rules, and regulations. The facility failed to ensure all orders, including telephone orders, were entered, read back and authenticated promptly in 10 of 10 medical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10). Additionally, the facility failed to ensure all medical records were completed no more than thirty days after discharge of patients. These failures created the risk that incorrect medication and treatment orders would be carried out in the care of patients.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on interviews and record reviews the facility failed to ensure all orders, including telephone orders, within patient medical records were entered correctly and authenticated promptly by the prescribing practitioner in 10 of 10 medical records reviewed (Patients #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10).

The failure created the risk incorrect medications and treatments would be provided during care of a vulnerable patient population.

FINDINGS

POLICY

According to the policy Verbal/Telephone Orders and Test Results, due to he risk for medication errors associated with verbal/telephone communication of orders, all verbally communicated orders must contain all components of a valid written order. The listener must concurrently complete the order on an approved form and read the transcribed order back to the provider to ensure all communications was properly heard and understood. The transcriber must document "read back completed" next to the transcribed order.

REFERENCE

According to the facility Medical Staff Rules and Regulations, physician orders are required for admission, discharge, medications, treatments, therapeutic passes, and restrictions of patient rights. Telephone orders shall be countersigned by the practitioner within 48 hours and all medical record documentation shall be completed within 30 days following the patient's discharge.

1. The facility failed to ensure telephone orders were read back and promptly authenticated.

a) A review of 10 patient medical records was completed which revealed telephone orders had been transcribed without documentation to show the orders had been read back to verify accuracy and had not been countersigned by the prescribing practitioner in a prompt manner. As example:

Patient #1 was admitted to the facility from 3/9/17 to 3/12/17. Seven telephone orders were transcribed into the medical record with only one order documented as read back to the physician and none or the orders had been countersigned by the prescribing physician. Patient #1 had been prescribed several psychiatric medications by telephone communication. As of 5/8/17, two months after the patient's discharge, the record remained incomplete.

Patient #6 was admitted from 3/27/17 to 3/31/17 for psychiatric care. Review of the medical record revealed eight telephone orders had been transcribed into the medical record and none of the eight had been countersigned by the prescribing physician. On 5/10/17, 40 days after the patient's discharge, the medical record remained incomplete.

Patient #5 was admitted to the facility from 2/27/17 to 3/8/17 for psychiatric treatment. The medical record review revealed 12 telephone orders were transcribed with none of the 12 signed by the prescribing practitioner. On 3/8/17 a nursing discharge note was written at 3:08 p.m. which stated the patient had been released to his/her parent at discharge for transport to a new inpatient facility. There was no discharge order within the medical record to show the physician had approved the discharge.

Review of the remaining medical records for Patient's #2, #3, #4, #7, #8, #9 and #10 revealed similar omissions of order documentation and signatures.

b) An interview was conducted with an adolescent unit Registered Nurse (RN #6) on 5/10/17 at 1:23 p.m. According to RN #6 all orders required the signature of the prescribing practitioner and telephone orders were read back when transcribed by the nurse to ensure the accuracy of the order. Any patient, when discharged , required a discharge order from the practitioner even if it were an AMA (against medical advice) discharge.

c) On 5/10/17 at 4:33 p.m. an interview was conducted with RN #8 who stated a discharge order was required for every patient including patients who left AMA because the order was verifying the physician assessed the patient and the patient was safe to leave.

d) The Director of Nursing (DON #1) was interviewed on 5/11/17 at 7:54 a.m. During the interview DON #1 confirmed all orders required a physician signature and telephone orders were to be read back by the transcribing nurse then co-signed by the prescribing practitioner within 48 hours or the next time the practitioner was in the facility. Discharge orders were required to be completed by the physician, even if the patient left AMA, to show the physician decided it was safe for the patient to leave.

DON #1 added, nurses did not perform audits of the medical record occurred to ensure all telephone orders were read back and co-signed by the ordering practitioner and there was nothing within the facility system to trigger practitioners to review their telephone orders.

e) During an interview with the Medical Records Supervisor (Supervisor #5), on 5/10/17 at 12:41 p.m., s/he explained the medical records department performed audits on 10 open and 10 closed records each month. Supervisor #5 stated the audit was to verify each record contained physician history and physicals and to confirm nursing assessments were completed within the specific time frames, as well as looking at orders for completeness. Supervisor #5 stated s/he was under the impression a telephone order which had been read back was considered verified and did not know each required the ordering practitioners signature.

On 5/11/17 at 9:45 a.m. a second interview was conducted with Supervisor #5 in which s/he verified 3 out of 5 medical records provided were missing discharge orders and s/he could not verify the complete medical record had been provided. Supervisor #5 further confirmed record requests made by patients and other facilities would yield the same incomplete content.

f) On 5/9/17 at 1:55 p.m. an interview was conducted with the Director of Compliance (Director #2) who stated all patients must have a written discharge order from a licensed practitioner even if the patient left the facility against medical advice (AMA).

g) An interview was conducted with Physician #9 on 5/11/17 at 10:13 a.m. in which s/he confirmed all orders, including telephone orders, must be signed by the prescribing practitioner and no patient could be discharged without a discharge order from a physician. S/he stated receipt of an incomplete medical record would not provide all information needed for continuity of care of the patient.
VIOLATION: INFECTION CONTROL Tag No: A0747
Based on the manner and degree of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.42 Infection Control, was out of compliance.

A-0749 - The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. The facility failed to maintain appropriate infection control processes when serving and storing food intended for patient consumption. This failure created the potential for patients to experience illness due to exposure to food borne pathogens.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interviews and document review, the facility failed to maintain appropriate infection control processes when serving and storing food intended for patient consumption.

This failure created the potential for patients to experience illness due to exposure to food borne pathogens.

FINDINGS:

POLICY

According to the policy, Department Responsibility for Infection Control, Food Services are responsible for maintaining sanitary work areas, storage areas, and equipment for the handling of supplies in accordance with local and State Health Department Standards.

REFERENCE

According to an In Service Training Lecture titled Foodborne Illness, it is important to limit the time to 2 hours for any food held between 41 and 140 degrees Fahrenheit . In this temperature range microorganisms grow rapidly. To prevent time-temperature abuse: hold and store food at appropriate temperatures. Always keep food covered and at the correct temperature.

According to the U.S. Food and Drug Administration (FDA), Serving Up Safe Buffets, January of 2017: Hot foods should be kept at an internal temperature of 140 degrees Fahrenheit or warmer. Make sure the food warmer has the capability to hold foods at 140 degrees Fahrenheit or warmer. This is the temperature that's required to keep bacteria at bay.

Cold foods should be kept at 40 degrees Fahrenheit or colder.

1. The facility failed to ensure food was stored at temperatures required for reducing bacterial growth.

a) On 05/08/17 at 9:53 a.m., a tour of the kitchen and cafeteria was conducted with the Director of Food Services (Director #10). At 9:57 a.m., observation of the buffet food warmer revealed a metal container of uncovered meatballs. At 10:20 a.m., the meatballs were still uncovered. Director #10 obtained a temperature of the meatballs, which revealed a temperature of 98 degrees Fahrenheit. Director #10 stated the meatballs should have been at a temperature of 140 degrees or higher.

At 11:32 a.m., an additional tour of the cafeteria was conducted with Director #10. The temperature of the meatballs was tested again by Director #10, which revealed a temperature of 93.4 degrees Fahrenheit. The temperature of a metal container of red sauce also stored on the buffet food warmer revealed a temperature of 110 degrees Fahrenheit. Director #10 verified the buffet food warmer was turned up to the maximum temperature and stated the meatballs needed to be stirred in order for all of the meat to be exposed to the correct temperature. Director #10 then stated any meatballs stored below the acceptable temperature of 140 degrees or higher needed to be discarded.

At 10:27 a.m., a large, clear, zip lock bag filled with cooked bacon and grease was observed on the bottom shelf of a storage rack. Further observation of the bag revealed no date of when the bacon was cooked or how long it had been stored at room temperature. At 11:37 a.m. the bag of bacon was again observed, this time with a date of 5/6 written on the bag. Cook #21 was present during the observation and stated s/he did not think cooked bacon needed to be refrigerated; however, the bacon did not look good and should have been discarded.

At 11:45 a.m., observations conducted outside of the facility's kitchen exit revealed a large cooling unit. The cooling unit was unlocked and located outside with no measures of securing the items stored inside from unauthorized access. Further observation revealed a thermostat on the outside of the unit, which indicated the temperature of the unit was 42 degrees Fahrenheit. Inspection of the inside the cooler revealed a sour odor and clear and white liquid was observed at the bottom and sides of the cooler. The cooler stored 2 milk crates filled with small containers of milk and 4 gallon containers of milk. Cook #21 was present during the observation and stated milk stored at temperatures above 40 degrees Fahrenheit should have been discarded due to the increased risk of the consumers of the milk becoming ill. Cook #21 stated the cooler was cleaned weekly; however, the small cartons of milk continuously leaked. Cook #21 further stated s/he did not know how to decrease the temperature of the cooler.

On 05/09/17 at 11:55 a.m., a tour of the outpatient cafeteria, located in a separate building, was conducted. Observations of the buffet food warmer revealed a metal container of chicken cacciatore. Temperature of the chicken cacciatore revealed a temperature of 104 degrees Fahrenheit. Further observation revealed a buffet food cooler with salad items. Temperatures of metal containers of cottage cheese and Ranch dressing were 42 degrees Fahrenheit.

After the observation of the outpatient cafeteria, Director #10 was interviewed. Director #10 confirmed the expectation was for cold food to be stored at temperatures below 40 degrees Fahrenheit and hot food at temperatures above 140 degrees Fahrenheit in order to prevent patients from becoming ill. Director #10 stated s/he tested temperatures of the food in the main cafeteria and did not have any issues with temperatures falling out of range. Director #10 further stated s/he did not check temperatures of the food served in the outpatient cafeteria. Director #10 stated s/he did not think it was his/her responsibility because it was considered a separate entity. Director #10 confirmed the food served at the outpatient cafeteria came from the same kitchen that supplied the food for the main cafeteria.

b) On 05/11/17 at 7:54 a.m., an interview with the Director of Nursing (DON #1) was conducted. DON #1 stated the staff member in charge of the infection control program was not available but DON #1 confirmed s/he covered for him/her when absent. DON #1 stated serving food at temperatures outside of a safe and acceptable range could possibly cause illness due to bacteria being present. DON #1 stated oversight of the kitchen's infection control process was minimal and consisted of quarterly audits.

c) On 05/11/17 at 9:03 a.m., an interview with the Director of Quality and Compliance (Director #2) was conducted. Director #2 stated the facility rounded in the kitchen weekly to assess for infection control issues. Director #2 further stated s/he did not check the temperatures of the food prior to it being served to patients and that s/he was not aware of an issue with food being stored outside of temperature parameters considered unsafe for consumption.
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.43 Discharge Planning, was out of compliance.

A0821 - Standard: The hospital must reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan. The facility failed to reassess discharge plans for changes which warrant adjustment to the plan. Specifically, a patient legally certified to be a danger to themselves was allowed to leave the facility against medical advice while under short-term certification (Patient #1). The failure created the potential the patient would be discharged into an environment which did not address their physical and psychological safety needs.
VIOLATION: REASSESSMENT OF A DISCHARGE PLAN Tag No: A0821
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and record review the facility failed to reassess discharge plans for changes which warrant adjustment to the plan. Specifically, patients legally certified to be a danger to themselves were allowed to leave the facility in 1 out of 1 short-term certified (STC) patient records reviewed (Patient #1).

The failure created the potential the patient would be discharged into an environment which did not address their physical and psychological safety needs.

FINDINGS

POLICY

According to the policy Discharge and Continuing Care Planning, discharge planning is an organized and coordinated process involving the care team, patient and family. Discharge planning is an ongoing process which continues throughout the patient's hospitalization and is continually assessed and re-evaluated for appropriateness. Family involvement and teaching are important to support of the patient after discharge. The family must be taught what changes to look for, who to call for help, what medications the patient needs and to whom the patient is being referred.

According to the policy New Format/AMA (Against Medical Advice) Intervention Plan, many AMA's can be prevented through active and caring intervention. The motivation behind any AMA intervention must be the welfare of the patient. Family involvement in treatment may be a critical indicator of how motivated the patient is to complete treatment. Separation from family may cause extreme anxiety and every staff member must be prepared to deal with the potential AMA. If a potential AMA escalates, arrange for a special meeting with the treatment team and family support to discuss the potential consequences of leaving prior to treatment completion.

1. The facility failed to prevent the discharge against medical advice of a patient legally certified as a danger to themselves.

a) The medical record of Patient #1 was reviewed and revealed a [AGE] year old was placed on a mental health hold (M-1) for thoughts of suicide expressed in a written note. The M-1 hold was initiated on 3/9/17 and set to expire 72-hours later on 3/12/17. Continued review of therapist notes within the medical record showed telephone discussions with the parent of Patient #1 related to the desire to end treatment once the 72-hour legal hold was completed and concerns Patient #1 had not received enough therapy to ensure s/he had the coping skills to leave the inpatient facility safely.

According to a therapy note, dated 3/11/17 (Saturday), a telephone discussion occurred with the parent of Patient #1 in which the therapist expressed concern for the safety of Patient #1 and the possibility s/he would carry out the planned suicide and the possibility of placement of continued involuntary treatment (STC) for up to 90-days could be instituted. The parent of Patient #1 was documented to state unless written evidence was produced to support the need for a continued involuntary hold, s/he would take Patient #1 home on 3/12/17.

A second note written by the therapist, dated 3/12/17, documented a telephone conversation with Patient #1's parent regarding the continued concern of the treatment team for the safety of Patient #1 should s/he be removed from treatment after only 72-hours. Patient #1's parent was questioned regarding his/her ability to prevent a potential suicide attempt by Patient #1 to which the parent replied there was no guarantee anyone could prevent a person from making a suicide attempt.

On 3/12/17 at 9:00 a.m. a short-term certification (STC) was initiated for Patient #1 by Physician #9 which stated the patient was high risk and continued to present a danger to him/herself.

b) According to a General Note written by the therapist on duty, on 3/12/17 at 3:00 p.m., a family meeting occurred. Patient #1's parents arrived to take the patient home and were presented with the STC paperwork. Both parents verbalized disagreement with the plan of care and their insistence on removing the [AGE] year old patient from the facility based on their belief there was not sufficient legal evidence for Patient #1 to remain in the facility. The note further stated the Nurse Manager on duty on 3/12/17 attempted to contact the assigned psychiatrist, but there was no documentation to show if, or which psychiatrist was contacted. Upon the Nurse Managers return to the room a discussion began surrounding an AMA discharge which the parents agreed to pursue.

c) A Discharge Note written by the on duty therapist on 3/12/17 at 5:15 p.m. stated the Nurse Practitioner (NP) present in the facility spoke with Patient #1 to assess the risk level of the patient and rated the patient as low-risk for self-harm but remained at a moderate risk for vulnerability to suicidal thoughts. The therapist further noted Patient #1 had not attended group therapy due to personal illness for 2 of 3 days in the care of the facility. Additionally, a safety plan had not been established with Patient #1 prior to departing the facility.

d) Review of the Nurse Practitioner (NP) progress note, dated 3/12/17 at 8:46 a.m., confirmed Patient #1 had spent the last 48 hours of his/her stay in bed ill and had not participated in group therapy. Patient #1 was described to have been minimizing the severity of the suicide note in a likely attempt to be released to complete the suicide plan and was unpredictable because s/he was providing the treatment team with what they wanted to hear.

According to the progress note the NP consulted with Physician # 9 to obtain the STC to maintain the legal detainment of Patient #1 for safety and further treatment with re-evaluation by Physician # 9 the following day (3/13/17).

e) The Discharge Summary signed by the NP on 3/14/17 at 3:01 p.m. showed Patient #1 had been discharged on [DATE]. Documentation in the Treatment Course section described Patient #1 as having participated in multiple therapies which addressed the psychosocial components of the diagnosed illness, had tolerated medication changes, and was not at imminent risk or gravely disabled and safe to discharge. Within the Discharge Condition section of the summary the NP documented Patient #1 as stable and improved and that s/he had reached the maximum benefit of treatment. This was in contrast to the note written earlier on 3/12/17 at 8:46 a.m. There was no mention Patient #1 had been released AMA.

f) A nursing progress note titled AMA was documented on 3/12/17 at 5:38 p.m. which stated the patient was off the unit for discharge at 5:00 p.m. with parent by AMA. "STC to be dropped tomorrow".

g) On 5/09/17 at 11:17 a.m. an interview was conducted with the Clinical Director (Director # 3) responsible for supervision of all therapists. According to Director # 3, a therapist did not have the authority to release a patient by AMA once a legal hold (STC) had been instituted. A STC could only be removed by a psychiatrist.

h) An interview was conducted on 5/11/17 at 11:47 a.m. with Patient #1's admitting psychiatrist (Physician # 9). According to Physician # 9, s/he was not on duty on 3/12/17, but had made a special trip to initiate the STC (legal hold) on Patient #1 and was unaware the patient had been discharged AMA until his/her return to duty on 3/13/17. Physician # 9 stated s/he had not submitted paperwork to remove the STC of Patient #1 on 3/12/17 because s/he was not available to do so. According to Physician #9 the institution of a STC, followed by the release of a legal hold within several hours would not make any sense. The STC was stating the patient required further therapy in a controlled setting even if they were not an imminent danger or gravely ill. Once the STC was implemented the child should not have been allowed to leave with the parents.

Physician #9 confirmed s/he had not completed the Notice of Termination of Involuntary Treatment (M-10) to release the legal hold until Monday 3/13/17 when s/he was informed Patient #1 had left the facility against medical advice. Review of the M-10 form revealed Physician #9 had dated the signed form for the day of discharge (3/12/17) because s/he felt there was no other choice except to back date the legal document.