The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HAVEN BEHAVIORAL HOSPITAL OF ALBUQUERQUE 5400 GIBSON BOULEVARD SE, 4TH FLOOR BOX# 8 ALBUQUERQUE, NM 87108 May 14, 2015
VIOLATION: QAPI Tag No: A0263
Based on record review and interview, the hospital failed to analyze adverse patient falls for 8 (Patient #1 through 6, 8, and 9) of 9 (Patient #1 through 9) sampled patients with falls (refer to A-286.) Patients #1, 2, 3, 4 and 8 had falls with injuries or injuries of unknown origin. An analysis of the cause was completed for Patient #8 only after outside agencies (the accreditation organization and an insurance company) asked for the analysis to be completed. The cumulative effect of this deficient practice could result in continued falls with injuries to patients and the hospital not knowing what caused the falls and how to stop them from occurring again.
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the hospital failed to analyze adverse patient falls for 8 (Patient #1 through 6, 8, and 9) of 9 (Patient #1 through 9) sampled patients with falls. Patients #1, 2, 3, 4 and 8 had falls with injuries or injuries of unknown origin. An analysis of the cause was completed for Patient #8 only after outside agencies (the accreditation organization and an insurance company) asked for the analysis to be completed. This deficient practice could result in continued falls with injuries to patients and the hospital not knowing what caused the falls and how to stop them from occurring again. The findings are:

A. Record review of Patient #1's clinical record revealed the following:
1. The Nursing assessment dated [DATE] at 4:40 pm indicated the presence of a bruise around the patient's left eye. The documentation did not state when or how the injury occurred.
2. The hospital's incident reporting log made no mention of the injury of Patient #1.

B. On 05/13/15 at 3:30 pm during an interview, the Director of Risk/Performance Improvement confirmed that no analysis was done to determine the cause of the bruise around Patient #1's left eye.

C. Record review of Patient #2's clinical record revealed the following:
1. A Risk Incident Report (RIR) dated 04/14/15 for Patient #2 indicated that the patient was found about 8:00 am by the Behavior Health Tech (BHT) in her room without a Merry Walker (assistive device) which the patient required for ambulation. The BHT went to retrieve the Merry Walker for the patient and found her down on the floor bleeding from an injury to her forehead (left side front).
2. Further review of the incident report revealed the patient was assessed as a moderate fall risk upon admit on 04/10/15.
3. Further review of the incident report revealed no analysis of the reason for fall.

D. Record review of Patient #3's clinical record revealed the following:
1. Nurses Progress Notes dated 01/06/15 at 2:40 am indicated that after Nurse #1 heard a "thud" in the hallway, Patient #3 was found lying down in the hallway with a "small hematoma at the back of the patient's head."
2. An RIR dated 01/06/15 for Patient #3 revealed no analysis of the reason for the fall.

E. Record review of Patient #4's clinical record revealed the following:
1. Nurses Progress Notes dated 05/05/15 at 7:31 pm revealed Patient #4 was found on the floor at 4:00 pm. She had a swollen, bruised raised area above her left eyebrow.
2. An RIR dated 05/05/15 for Patient #4 revealed no analysis of the reason for the fall.

F. Record review of an RIR dated 03/13/15 for Patient #5 revealed the patient had an unwitnessed fall. Further review of the RIR revealed no analysis of the reason for the fall.

G. Record review of Patient #6's Nursing Progress Notes dated 01/19/15 revealed the patient had a fall.

H. When an RIR regarding Patient #6's fall was requested from the Director of Risk/ Performance Improvement on 05/13/15, an RIR could not be located for the incident and no analysis of the fall could be found.

I. Record review of Patient #8's clinical record revealed the following:
1. Nursing Progress Notes dated 01/07/15 at 11:30 pm indicated that Nurse #2 heard a yell for help and found Patient #8 on the floor next to the bathroom. The patient has a small skin tear on her elbow and a hematoma on her right side forehead.
2. The RIR for the incident revealed the patient was assessed as a high fall risk and was legally blind, but no interventions were documented.
3. The analysis reported to the accreditation organization revealed the hospital failed to complete the analysis at that time due to staff turnover in administration.

J. Record review of an RIR dated 02/07/15 revealed Patient #9 had a fall without injury when she was found in her bathroom.
1. Further review of the RIR revealed the patient was assessed as having a high risk for falls.
2. Further review of the incident report revealed no analysis of the reason for fall.

K. On 05/13/15 at 3:30 pm during an interview, the Director of Risk/Performance Improvement stated she did not know she needed to complete an analysis of each incident to determine the cause.