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PEAK VIEW BEHAVIORAL HEALTH 7353 SISTERS GROVE COLORADO SPRINGS, CO Dec. 13, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on the nature of standard level deficiency referenced to the Condition, it was determined the Condition of Participation 482.23, NURSING SERVICES, was out of compliance.

A-0395 - Standard: Registered Nurse Supervision of Nursing Care. The facility failed to initiate and maintain fall prevention measures for patients at risk for falls and failed to evaluate the effectiveness of interventions on an ongoing basis in 3 of 5 fall risk records reviewed (Patients #1, #2, and #3). The facility failed to conduct pain reassessments as required by facility policy in 5 of 7 records reviewed for pain management (Patients #1,#2, #5, #6 and #10). Additionally, the facility failed to provide hygiene and toileting assistance in 2 of 3 records reviewed for patients who required assistance (Patients #3 and #9). These failures resulted in patients experiencing multiple falls during their admissions. Further, the failures created the potential for inadequate pain management and for patient's personal care needs to go unmet.
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 initiate and maintain fall prevention measures for patients at risk for falls and failed to evaluate the effectiveness of interventions on an ongoing basis in 3 of 5 fall risk records reviewed (Patients #1, #2, and #3). The facility failed to conduct pain reassessments as required by facility policy in 5 of 7 records reviewed for pain management (Patients #1,#2, #5, #6 and #10). Additionally, the facility failed to provide hygiene and toileting assistance in 2 of 3 records reviewed for patient's who required assistance (Patients #3 and #9).

These failures resulted in patients experiencing multiple falls during their admissions. Further, the failures created the potential for inadequate pain management and for patient's personal care needs to go unmet.

FINDINGS

POLICY

According to the Fall Risk Evaluations policy, all patients will be evaluated for the potential of fall and will be placed on an appropriate prevention program upon admission. Nursing staff will evaluate and determine risk of adult patients with regards to falls utilizing the Fall Risk Evaluation Tool. Based on the score on the Fall Risk Evaluation Tool (Tool), patients will be placed on fall precaution.

Fall Interventions include, but are not limited to: orient patient/family members to surroundings; instruct patient concerning toileting, if needed; teach transfer techniques/use assistive devices, if needed; instruct patients to wear non-slip footwear; reevaluate and observe every 2 hours after medication change or as condition worsens; fall mats; bed alarms; wheelchair lap belts or clip alarms; increased observation status to line of sight or 1:1; yellow arm-band; falling star on doorway; call bells; place in room near the nursing station; communicate patient's "Fall Risk" during nursing shift changes.

According to the Fall Reduction Policy, the fall risk evaluation will be completed by a Licensed Nurse during the intake phase of the admission process. Fall risk categories will be assigned as 0-24 points equals a low fall risk (Green), 25-45 points equals a moderate fall risk (Blue), and 46 points or above equals a high fall risk (Red). Patients placed on the highest fall precaution level (Red) at admission will be reevaluated every 24 hours. After each reevaluation, the appropriate fall risk level will be initiated and appropriate actions will be taken.

The Pain Assessment policy philosophy of pain management is based upon the belief every person should have access to the best level of pain relief which may safely be provided. Optimal application of pain control methods depends on collaboration between different members of the healthcare team, the patient and their caregiver. To ensure the process occurs effectively, formal means must be used to assess pain and to obtain patient and caregiver feedback to gauge the adequacy of its control. Pain intensity and pain relief will be assessed and reassessed at regular intervals. Patients are assessed for pain using appropriate, reliable methods for adults, adolescents, and cognitively impaired adults. Patient assessments, reassessments, interventions, and response to interventions will be documented.

Reassessment should occur every 6 hours if pain is greater than 4 out of 10 on the numeric pain scale and more frequently if necessary.

The reference ranges for pain related to as needed (PRN) medication use are:
1-3= mild pain
4-7= moderate pain
8-10= severe pain

REFERENCE

According to the Fall Risk Scale on the Fall Risk Assessment document, interventions are listed according to the patients evaluated risk level. The highest fall risk (Red) level interventions include restroom assistance, never unattended on toilet, lap belt if in wheelchair, yellow bracelet, patient education, family notification/involvement, non-slip socks-red, fall mat beside bed and documentation on patient room board in red marker.

According to the daily schedule in the admission folder and posted in each unit, personal hygiene was scheduled twice each day.

1. The facility failed to ensure patients at the Blue and Red level fall risk had interventions implemented to prevent falls.

a) An interview was conducted with Nurse Manager (Manager) #1 on 12/13/17 at 3:23 p.m. Manager #1 explained, the fall risk level categories were assessed and determined first by the admission nurse and were added to the Treatment Plan. The fall risk was then reevaluated at intervals based on the patient's identified fall risk level. In the case of red level fall risk, patients were reevaluated every 24 hours. The assigned nurse was expected to implement the appropriate fall prevention interventions based on the patient's fall risk category. According to Manager #1 interventions listed on the Fall Risk Assessment form were a guideline for staff to know what was available to put in place.

b) Review of facility incident reports and Patient #2's medical record revealed s/he experienced 4 falls since his/her admission on 12/04/17. Patient #2 had a history of developmental delays which presented as challenges with non-verbal communication and awkward body movements.

The Nursing Assessment, dated 12/04/17 at 3:57 p.m. and completed by Registered Nurse (RN) #16, documented Patient #2 was in a wheelchair, was unsteady while standing and needed a 2 person assist. The patient's Functional Screen noted s/he had problems with coordination and balance. According to the Fall Risk Assessment completed by RN #16, Patient #2 had a total score of 65 and a "Red" fall risk level.

A second Fall Risk Assessment, dated 12/04/17 completed by Licensed Practical Nurse (LPN) #17, documented Patient #2 had an impaired gait and "overestimates or forgets limitations." LPN #17 documented the patient's fall risk score as 65 and his/her level as "Red."

Review of the initial Treatment Plan, dated 12/04/17, for nursing identified the patient was at risk for falls related to limited mobility. Interventions identified were the patient would wear appropriate non-skid footwear, staff would assist with personal care and transfers, the patient would have a fall mat and call bell at bedside when in bed and an alarmed lap belt while in his/her wheelchair.

An incident report, dated 12/08/17 at 4:10 p.m. was completed by RN #18. According to RN #18, Patient #2 experienced a fall at 3:10 p.m. on 12/08/17 while attempting to transfer independently from his/her wheelchair to the bed. A nursing progress note, completed by RN #18 on 12/08/17 at 4:16 p.m., documented the patient's brother was contacted to inform him of the fall. During the notification, the brother informed RN #18 the patient was supposed to have on a foot brace to improve the stability of Patient #2's leg. The brother stated he would bring the brace to the facility. The new fall risk intervention to be implemented, according to the incident report, was an alarmed lap belt.

However, although the initial treatment plan, completed prior to the patient's fall, identified Patient #2 would wear an alarmed lap belt while in his/her wheelchair, s/he did not have the intervention in place during his/her first fall on 12/08/17.

Subsequently, Patient #2 experienced a second fall from his/her wheelchair on the same date, 12/08/17 at 7:00 p.m. According to the incident report for the second fall, completed by RN #19 on 12/08/17 at 8:00 p.m., Patient #2 attempted to self-transfer from the wheelchair to the bed again. The Fall Risk Evaluations, completed by RN #19 on 12/08/17, before and after the second fall, showed Patient #2 was not wearing the alarmed lap belt while in his/her wheelchair.

There was no documentation why the previously identified interventions to reduce Patient #2's fall risk were not implemented.

Documentation in the Director of Nursing section of the incident reports for each fall, on 12/08/17, noted the patient had a lap belt implemented and all documentation, completed by the nurse, identified all necessary interventions were implemented to prevent Patient #2 from falling. However, there was no consistent documentation Patient #2 had an alarmed lap belt in place until 12/10/17.

An interview with Manager #1 was conducted on 12/13/17 at 3:23 p.m. S/he stated, the fall risk interventions identified on the treatment plan should be implemented upon admission and could be added to as needed. Manager #1 stated it was up to the nurse to use their professional judgement to decide what fall prevention interventions were to be implemented on the patient from shift to shift. Manager #1 stated there was no physician order required to put an alarmed lap belt on a patient. The manager stated Patient #2 should have had an alarmed lap belt on prior to his/her fall on 12/08/17.

Record review revealed Patient #2's fall risk level remained at a red level. Documented interventions included combinations of non-slip footwear, fall mat at bedside, bed alarm in place, a yellow bracelet on the patient and patient education. There was no documentation Patient #2 had a lap belt in place while in his/her wheelchair, as specified by the Treatment Plan, for 4 days leading up to his/her first fall on 12/08/17 at 3:10 p.m.

Subsequently, Patient #2 experienced 2 falls from his/her bed. According to the nurses note, completed by LPN #22 on 12/11/17 at 2:04 p.m., Patient #2 was less oriented than his/her previous baseline, after rolling out of bed at 12:45 p.m., and was sent to an outside hospital for a neurological evaluation. Upon his/her return to the facility on [DATE] at 7:30 p.m., there were no additional fall risk interventions documented for Patient #2.

Patient #2 experienced a second fall from his/her bed on 12/12/17 at 5:30 a.m. After the fourth patient fall during his/her admission, an order was placed for Patient #2 to have one-to-one observation by a staff member present at all times.

During the interview, on 12/13/17 at 3:23 p.m., Manager #1 stated, s/he did not make direct observations of patients under the "Red" and "Blue" level fall risk categories when completing fall risk audits. S/he expected the nurse to document all interventions implemented based on their judgment and evaluation of the patient. The expectation was to have least one intervention documented for the "Red" and "Blue" fall risk category patient.

Manager #1 stated, Patient #2 should have had an alarmed lap belt in place on 12/08/17. S/he confirmed lipped mattresses were available for use with a physician order to decrease the risk of falls from bed; however, Patient #2 would have one on one observation beginning 12/12/17. Manager #1 stated fall prevention was an ongoing struggle which could always be improved upon.





c) A review of Patient #3's medical record revealed s/he had 2 falls while at the facility. Patient #3 was admitted to the facility on [DATE]. According to the history and physical (H&P), dated 11/26/17, the patient had a history of falls, memory deficits, confusion, and was only oriented to person.

Review of the Patient Falls Analysis, signed as reviewed on 12/03/17, noted Patient #3 fell on Saturday, 12/02/17 at 4:45 p.m., and obtained a skin tear to his/her right elbow and on top of his/her right hand.

According to the General Note, dated 12/02/17 and completed by RN #19, Patient #3's fall was unwitnessed and reviewed by video. The video revealed, the patient was leaning too far forward while propelling in his/her wheelchair (w/c) and fell to the floor.

Review of the Incident Report, dated 12/02/17 and completed by RN #19, documented Patient #3 would be reeducated to ask for assistance and an alarmed lap belt for safety would be implemented.

However, review of the Treatment Plan, dated 11/26/17, completed on admission by RN #24 identified the need to attach a clip alarm and alarmed lap belt to Patient #3 when in his/her wheelchair. On 12/02/17 at 5:31 p.m., after the fall occurred, an order was obtained by RN #24 for Patient #3 to have a clip alarm and lap belt in place when in w/c. It was not evident why the physician's order for a clip alarm and lap belt was not obtained until 12/02/17 at 5:31 p.m. after the fall occurred, when the need had been identified 6 days prior.

Subsequently, Patient #3 experienced a second fall on Sunday, 12/10/17 at 8:50 p.m., and obtained a skin tear to his/her left elbow. According to the Incident Report, dated 12/10/17, Patient #3 had an unwitnessed fall from the w/c in his/her bedroom with an alarm in place.

A Patient Fall Analysis, completed by LPN #17 on 12/10/17 at 8:50 p.m., noted under the section, "After this fall, what additional precautions were taken to prevent another fall" that Patient #3 was to have a a lap belt when in his/her wheelchair. There was no documentation as to why the LPN implemented an intervention that had already been identified in the Treatment Plan and ordered by a physician prior to the fall.

d) Patient #1 was admitted to the facility on [DATE]. The Nursing Assessment completed on 10/20/17 by RN #18, documented Patient #1 had decreased endurance, an unsteady gait, required transfer assistance and used a wheelchair for mobility. S/he had a fall risk score of 85, which placed Patient #1 at the Red level. The Treatment Plan, dated 10/21/17, identified Patient #1 as a risk for falls due to having an unsteady gait and a history of falls. The goal was for the patient to have no falls which s/he was at the facility. The interventions identified to prevent falls included having a fall mat at the bedside, along with a lipped mattress, bed alarm and call bell while in bed. Additional interventions included 1:1 observation status and staff assisting him/her with Activities of Daily Living (ADLs) and mobility. Patient #1 should also wear non-slip footwear and have a lap belt and a clip tab alarm when in his/her w/c.

According to the General Note, written by RN #14 on 10/26/17 at 4:18 a.m., Patient #1 was found lying on the floor on his/her stomach and had swelling and redness to the right eyebrow area. The on call physician was notified and the patient was sent to an acute care hospital for an evaluation of his/her injury. There was no documentation a lipped mattress was in place or that Patient #1 was on 1:1 observation as an intervention identified in the Treatment Plan to prevent falls.

Furthermore, physician orders for the one-to-one observation were not obtained until 10/26/17 at 12:45 p.m., 6 days after admission and almost 12 hours after the patient fell from bed. On 10/29/17 additional physician orders were obtained for the lipped bed mattress while in bed, alarmed lap belt, and a clip alarm attached to the patient while s/he was in the wheelchair, 3 days after the patient's fall.

e) An interview was conducted with LPN #4 on 12/13/17 at 2:23 p.m. LPN #4 stated patients would be considered high fall risks for reasons such as an unsteady gait, falling out of bed, or anyone who had the potential to lose their balance. LPN #4 stated it was the responsibility of the assigned nurse to ensure the necessary fall risk interventions were implemented for the patients.

The facility failed to establish minimal requirements for fall risk interventions to meet the needs of patients at the "Red" and "Blue" level fall categories. Furthermore, the facility failed to evaluate specific interventions were in place and the effectiveness of new interventions that could have possibly prevented additional falls.

f) The facility's failure to have a standard process for initiating and maintaining fall prevention measures resulted in patients experiencing multiple falls during their hospital admission.

2. The facility failed to ensure pain reassessments were performed as required to ensure patients had obtained adequate pain relief.

a) Patient #1 was admitted to the facility with a diagnosis of fibromyalgia which required pain medication for pain management. Orders for Gabapentin 100 mg three times a day and Norco 5mg/325mg as needed (PRN) for pain relief were present in the medical record. Patient #1 had a positive pain screening on 3 occasions in which no reassessments were completed within the time frame outlined according to facility policy.

On 10/25/17 at 9:00 a.m., LPN #22 documented in the Nursing Evaluation, Patient #1 had foot and knee pain scored as 9 out of 10 and had received a PRN dose or Norco and the "patient reported it was effective." According to the Medication Administration Record (MAR), Patient #1 had received a dose Norco (a narcotic pain medication) at 7:40 a.m. with no pain assessment documented. According to the Nursing Evaluation, Patient #1's pain was not reassessed until 10/25/17 at 11:18 p.m., 14 hours later.

On 10/28/17 at 10:09 p.m., RN #28 documented Patient #1 had neck pain with a pain score of 7 out of 10. According to the MAR, Norco was given at 9:29 p.m. The next pain re-assessment was completed 10/29/17 at 2:39 p.m., 16.5 hours later.

On 10/30/17 at 9:00 a.m., LPN #22 documented Patient #1 had 8 out of 10 pain in his/her legs. The MAR showed Norco was given at 9:13 a.m. According to the pain evaluation, the patient reported effective relief the same time the medication was administered. However, the next pain assessment was not completed until 10/30/17 at 8:41 p.m., 11 hours and 45 minutes later.

b) Patient #5 was admitted to the facility with a history of chronic pain which required medication management. Patient #5 had orders for Gabapentin 200 mg twice daily, Mobic 15 mg daily, Tramadol 50 mg PRN (as needed) and Tylenol 650 mg PRN. Documentation in the medical record revealed Patient #5 received pain medication on several occasions but was not reassessed for pain as stipulated by facility policy. For example:

On 12/03/17 at 4:36 p.m., a pain score of 6 out of 10 was documented by LPN #21 for pain to the patient's back and hips Patient #5 received a scheduled dose of Gabapentin at 8:50 p.m. to treat the pain. There was no documented pain reassessment. The next pain assessment did not occur until 12/04/17 at 10:13 a.m., more than 17 hours later.

On 12/04/17 at 10:13 a.m., RN #27 documented a pain score of 7 out of 10 for low back and hip pain. Review of the MAR revealed Patient #5 did not receive a PRN dose of medication to relieve documented pain. Another pain reassessment did not occur until 12/04/17 at 9:29 p.m., 11.5 hours later.

This pattern occurred on 8 other occasions during Patient #5's stay in the facility. Reassessment times were not completed during the time frame indicated in the facility policy.

c) Patient #2 was admitted on [DATE] and had a history of major depression and Aspergers (a developmental disorder). Patient #2 verbalized "my head hurts" during a session with Nurse Practitioner #15 on 12/09/17 at 7:24 a.m. According to the MAR, Patient #2 was provided Tylenol at 8:33 a.m. on 12/9/17 but was not reassessed for effectiveness of pain relief. Patient #2 was not reassessed for pain until 12/10/17 at 12:59 a.m. There was no documentation to show the patient was re-assessed for pain by a nurse after administration of the medication as to evaluate the effectiveness of the medication.

d) On 12/02/17, Patient #6 was admitted with a diagnosis of chronic back pain, and swelling on his/her right calf and left forearm. The pain medications, Mobic 7.5 mg (anti-inflammatory) daily, Baclofen 10 mg (a muscle relaxant) three times a day, Percocet 5 mg/325 mg (a narcotic for moderate-severe pain) and Acetaminophen 650 mg (for minor pain and fever) PRN for pain relief were ordered. The following day, an order for Voltaren 1% (a topical anti-inflammatory gel) twice a day was added.

Patient #6 had a positive pain screening on 7 occasions in which no re-assessments were completed within 6 hours, as specified in facility policy. For example:

On the day of admission, 12/02/17 at 4:20 p.m., LPN #21 documented Patient #6 reported a right calf pain score of 10 out of 10 and a left forearm pain score of 8 out of 10. According to the MAR, Patient #6 received a dose of Baclofen at 4:56 p.m. and 8:19 p.m., and Percocet at 8:35 p.m. Patient #6's pain was not reassessed until 12/03/17 at 1:24 a.m., 9 hours later.

On 12/05/17, more than 12 hours lapsed between a documented pain score of 5, reported by Patient #6 at 12:13 p.m., and the re-assessment score of 4 on 12/06/17 at 1:09 a.m. Pain medication was administered twice during this period, at 2:32 p.m. and 9:37 p.m., with no associated pain assessments documented.

e) Patient #10 was admitted on [DATE] and had a history of depression and a traumatic brain injury. According to the Nursing Evaluation on 4/22/17 at 10:14 a.m., RN #18 documented Patient #10 complained of 8 out of 10 back pain and did not request pain medication at that time. Review of the MAR revealed Patient #10 was not given medication to relieve pain. Patient #10 was not reassessed for pain until 4/24/17 at 11:08 a.m., 49 hours later . Patient #10 did not complain of pain at that time.

f) An interview was conducted with LPN #4 on 12/13/17 at 2:23 p.m. LPN #4 stated pain evaluations were expected to be documented daily using verbal or nonverbal assessments tools. LPN #4 stated pain should be reassessed one hour after receiving pain medications to evaluate the effectiveness of the medication. S/he stated there should be documentation for every pain intervention in the patient chart. According to LPN #4, it was difficult to document pain reassessments because there was no way to re-enter the Pain Evaluation form in the electronic health record (EHR) once the first evaluation was completed.

g) On 12/12/17 at 8:00 a.m., an interview with RN #5 was conducted. S/he stated patient pain was assessed during nursing rounds or when the patient notified the nurse of pain. Once a pain intervention was implemented, it was RN #5's practice to reassess their pain level within a 1-hour timeframe. RN #5 stated it was not possible to document pain reassessments on the MAR. Although it was possible to document the reassessment in the Nursing Assessments section of the EHR, s/he did not routinely perform this action.

h) An interview with RN #6 was conducted on 12/12/17 at 8:05 a.m. RN #6 stated that pain assessments were documented on the Nursing Assessment page of the EHR using a numeric rating scale and should be reassessed within a 1-hour timeframe of the patient receiving pain medication.

i) On 12/13/17 at 3:23 p.m., an interview with Manager #1 was conducted. S/he stated pain was assessed once per shift as a standard of practice at the facility. The expectation was to document a pain reassessment within a couple of hours after a pain medication was administered Manager #1 stated nurses were expected to reevaluate the effectiveness of scheduled pain medications in accordance with nursing standards and facility policy. According to Manager #1, nurses could document pain reassessments on the pain assessment tool or a nursing note. S/he was unaware if the facility utilized a specific nursing guideline for the provision of care.






3. The facility failed to provide ongoing hygiene assistance in order to meet the basic care needs of patients.

a) A review of Patient #3's medical record revealed the patient was admitted to the facility on [DATE] for a mental health crisis. An initial nursing assessment was conducted on 11/26/17 which reported the patient was incontinent, had decreased endurance, problems with coordination and balance, used a wheelchair, and needed assistance with transfers, bathing, dressing and grooming.

The medical record revealed an inconsistent routine for changing the patient's briefs. For example, a bowel movement and change was documented at 9:30 a.m. on 12/01/17. The next change of briefs was documented the following day on 12/02/17 at 9:30 p.m., 36 hours later. Similarly, the medical record revealed the briefs were changed on 12/07/17 at 9:00 a.m. and not again until more than 20 hours later, on 12/08/17 at 5:45 a.m. In addition, there was no record the patient's clothes were changed during the entire 16 day hospital stay.

b) A review of Patient #9's medical record revealed the patient was admitted to the facility on [DATE] for a mental health crisis. The initial nursing assessment indicated the patient was constipated but did not indicate the patient was incontinent; however, much of the nursing assessment was not able to be completed due to the patient's confusion. According to the nursing evaluation from the following day, on 3/30/17, Patient #9 urinated on the floor twice, including once on another patient. The patient continued to urinate on the floor the next day due to confusion, according to a nursing evaluation on 3/31/17. Two days later, on 4/02/17, the patient was noted as incontinent.

Despite the patient's need for assistance with toileting, the medical record revealed inconsistent assistance was provided. For example, patient care flowsheets completed by the mental health technicians (MHTs) revealed:

On 3/30/17, the patient self-toileted.
On 3/31/17, the patient was changed 3 times.
On 4/01/17, there was no documentation of the patient's elimination or if the patient was changed.
On 4/02/17, the patient was changed once, and noted as combative with changes. This was more than 46 hours after the last change documented on 3/31/17.
On 4/03/17, the patient was changed once. Twenty-six hours passed until the next change the following day.
On 4/04/17, the patient was changed twice.
On 4/05/17, the patient was changed once at 12 p.m., which was 21 hours since the previous change on 4/04/17.

In addition, there was no record the patient's clothes were changed during the 8 day hospital stay.

c) An interview was conducted on 12/13/17 at 12:34 p.m. with Lead Mental Health Technician (MHT) #12. S/he stated MHTs were required to check the briefs of incontinent patients every 2 hours to see if a change was required. MHT #12 stated documentation to support this would not be found within facility records.

d) An interview was conducted on 12/13/17 at 3:22 p.m. with Nurse Manager (Manager) #1, who reviewed the flowsheet for Patient #9, and stated it looked like this patient required assistance with changes. S/he stated the number of brief changes documented was not appropriate and understood why this was a concern. S/he expected every patient who needed assistance to have the assistance documented in the medical record. Clothing changes were a part of the facility's daily process, and the MHT should have documented in the medical record if a patient was confused and refused a clothing change. Manager #1 stated s/he did not know if the MHTs had a specific place to document every time a patient's clothes were changed or incontinent briefs were checked.