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.

CLEAR VIEW BEHAVIORAL HEALTH 4770 LARIMER PARKWAY JOHNSTOWN, CO Aug. 26, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.13, Patient Rights was out of compliance.

A-144- Standard: The patient has the right to receive care in a safe setting. The facility failed to ensure safe patient care was provided as evidenced by the failure to initiate and maintain patient fall precautions in 4 of 6 patients reviewed who required fall interventions (Patients #6, #16, #17 and #18). This failure resulted in a patient sustaining multiple falls while in the facility.

A-145- Standard: The patient has the right to be free from all forms of abuse or harassment. The facility failed to investigate and report abuse allegations. The facility failed to investigate an abuse allegation regarding Patient #6. This failure resulted in an allegation of abuse not being investigated and had the potential to affect all patients.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and document review the facility failed to ensure safe patient care was provided as evidenced by the failure to initiate and maintain patient fall precautions in 4 of 6 patients reviewed who required fall interventions (Patients #6, #16, #17 and #18).

This failure resulted in a patient sustaining multiple falls while in the facility.

FINDINGS

POLICY

According to Fall Risk Precautions all patients will be assessed for the potential to fall and will be placed on an appropriate prevention program upon admission. If a patient is assessed not to be at risk for falls, the patient will be reassessed anytime there is any indication a fall risk has developed (24 hour Nursing Assessment indicates need, significant change in mental status or change in physical health).

Nursing interventions would include: orient and re-orient patient/family members to surroundings, place yellow ID band on patient, wear non-slip footwear, determine alarms (bed or chair) to be initiated, instruct patient concerning toileting (calling for assistance to go to the bathroom), teach transfer techniques/use of assistive devices, maintain clutter free environment, reassess and observe every 2 hours after medication change or as condition worsens, communicate patient's "Fall Risk" during nursing shift report, place in room near nursing station, and identify the patient's "Fall Risk" on patient locator and nursing report.

According to Fall Reduction, the fall risk assessment will be completed by a Registered Nurse during the intake phase of admission. Fall risk categories will be assigned as follows: 1-5 equals low risk, 6-12 equals moderate risk, and 13+ equals high risk. All patients placed on the highest fall precaution level 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: review need for chair, bed, wheel chair alarm, fall mat and lap belt, yellow arm band placed on patient to identify a fall risk, appropriate signage placed at patient's doorway, reassessment of any patient with significant change in character or cognition, patients and families will be educated on the risk of falls and will be asked to participate in reduction of falls.

All patients will be encouraged to wear non-slip footwear or shoes at all times for transfers and/or ambulation; non-slip footwear will be colored in accordance with fall precaution level.
Any patient who displays a poor sitting balance will not be left alone on the toilet.
Reassessment as needed of any patients who start or change doses of high risk medications.
Ensure patient's clothing is well fitting and in good repair and does not present a fall hazard.
Front line staff is responsible for completing a safety checklist during each shift for patients on fall precautions. Any fall which would occur at facility will be reviewed for trending, prevention, and demographics.

1. The facility failed to ensure fall assessments were performed and fall prevention interventions were in place for patients who were identified at an increase risk of falls.

a) Record review revealed Patient #6 was admitted on [DATE] with a diagnosis of bipolar with psychotic features with poor insight, poor judgment and moderate impaired recent memory. Patient #6's Admission Fall Assessment revealed the patient was assessed as a moderate fall risk with a score of 10. Patient #6 had no fall precaution interventions documented on admission on 06/14/16 and the patient sustained a fall on 06/16/16.

A review of Patient #6's Daily Observation Logs revealed the facility failed to document fall precautions were in place for 20 of 51 days s/he received services at the facility. Additionally, Patient #6 did not have any documented fall prevention interventions on 49 of 51 days, during various shifts.

Subsequently Patient #6 experienced 6 falls while at the facility, two falls on 06/16/16 and one each on 06/17/16, 07/02/16, 07/07/16 and 07/10/16.

On 08/26/16 at 9:32 a.m., an interview was conducted with the Director of Nursing (DON #4) who stated fall precautions should be initiated upon admission and passed on from nurse to nurse during shift report. DON #4 stated the interventions included placing fall mats next to the patient's bed, patients wearing yellow non slip socks and wrist band and performing environmental checks. S/he stated the responsibility for preventing patient falls was the responsibility of all staff however the nurse had the overall responsibility.

b) Record review revealed Patient #17 was admitted on [DATE] with a diagnosis of suicidal ideation. Patient #17's Admission Fall Assessment revealed the patient was at a moderate fall risk. However, there was no documentation fall precautions or interventions were in place for 10 of 15 days of the patient's current hospitalization .

c) Record review revealed Patient #16 was admitted on [DATE]. Review of the Fall Assessment showed Patient #16 was a moderate fall risk. However, there was no documentation fall precautions or interventions were implemented for numerous shifts over the 6 days since the patient's admission to the facility.

d) Record review revealed similar findings for Patient #18 who had been identified as a fall risk by the facility; however, there was no evidence fall precautions and interventions were consistently implemented and maintained.

e) On 08/25/16 at 12:22 p.m., an interview was conducted with Registered Nurse #6 (RN) who stated fall assessments were to be completed when a patient fell , upon admission or when a patient became unsteady. RN #6 stated fall prevention interventions should include moving a patient closer to the nurse's station, placing chair and bed alarms, keeping the bed in low position with a fall mat in place, placing a yellow wrist band and reminding patients to call for assistance.

RN #6 stated patients identified as a fall risk should be identified on the daily census under precautions. RN #6 confirmed the census sheet, dated 08/25/16, did not indicate any patients were on fall precautions for the unit. RN #6 stated both Patients #17 and #18 should have been identified on the census sheet and Locator and Patient Observation Record.

f) On 08/26/16 at 9:32 a.m., an interview was conducted with DON #4 and the Chief Executive Officer (CEO #1) who stated documentation of fall interventions had been inconsistent and when they were not documented, they weren't done. The CEO stated patients were at a risk of falls if staff did not follow policy.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interviews and document review the facility failed to investigate an abuse allegation regarding Patient #6.

This failure resulted in an allegation of abuse not being investigated and had the potential to affect all patients.

FINDINGS

POLICY

According to Patient Abuse and Neglect, anyone who receives or witnesses an incident of patient abuse or neglect must report the incident to his/her immediate supervisor or to the Patient Advocate. A complaint may be received from any of the following: the patient who thinks he/she has been a victim, a family member of the patient, a patient who may have witnessed the incident, a staff member who witnessed the incident or any responsible citizen who may have witnessed the incident. The employee is to inform the patient of the availability of the Patient Advocate who will then contact the complainant. The administrator will be notified and will initiate an investigation.

According to Completion of Incident Reports, incident reports must be completed by the staff member who witnessed/had first-hand knowledge of the incident at the time of occurrence. Incident reports should be completed prior to the end of the shift on which they occurred. Forward the report to your Department Head and then to Risk Management within 24 hours of the incident occurring. The Risk Manager reviews all Incident Reports, categorizes the incident report, conducts an investigation and follow up occurs as necessary.

1. The facility failed to investigate an allegation of abuse reported by patients.

a) Review of Patient #6's nursing notes, dated 06/17/16 at 3:00 p.m., revealed two females had reported Patient #6 was sexually inappropriate with them; one patient stated Patient #6 had touched his/her breast.

Review of Patient #6's Recreation Therapy Notes, dated 06/17/16 at 3: 30 p.m., revealed Therapist #3 reported Patient #6 maintained inappropriate boundaries with patients by comments and touching. Patient #6 reportedly had inappropriately touched a patient's breast as reported by a patient.

After reviewing the facility's Incident Report Log, from 06/01/16 through 07/29/16, the documentation revealed no incidents involving inappropriate touching had been documented and investigated.

On 08/25/16 at 12:22 p.m., an interview was conducted with Registered Nurse (RN) #6 who stated any inappropriate touching between patients had been documented in the nurse's progress notes, an incident report was completed and the Unit Manager or Risk Manager had been contacted. Upon reviewing Patient #6's medical record, RN #6 stated s/he received notification of the situation from Therapist #3 and thought Therapist #3 had completed an incident report. RN #6 stated s/he did not remember if s/he had reported the allegation to a member of the management team; however, RN #6 believed an investigation was completed.

On 08/25/16 at 1:36 p.m., an interview was conducted with Therapist # 3 who stated after group therapy, on 06/17/16, a patient approached him/her alleging Patient #6 had inappropriately touched his/her chest. Therapist #3 stated s/he informed a mental health technician of the allegation. Therapist #3 did not complete an incident report but acknowledged one should have been completed.

On 08/25/16 at 2:09 p.m., an interview was conducted with Psychiatrist #9 who stated there were multiple notes in Patient #6's medical record stating s/he had touched a female patient's breast. Psychiatrist stated a review of the monitoring tapes for that day would have been helpful with an investigation of the allegation.

On 08/26/16 at 10: 11 a.m., an interview was conducted with the Chief Executive Officer (CEO #1) and Director of Nursing (DON #4) who stated any inappropriate touching should have been communicated to the supervisor and administrator. The CEO and CNO stated they were unaware of the documentation in Patient #6's medical record indicating inappropriate touching had occurred. CEO #1 stated there should have been an incident report and investigation completed.