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 Feb. 18, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review, the facility failed to provide care in a safe setting to all patients receiving psychiatric care at the facility as evidence by: not providing a ligature (points from furniture, envorionment that a patient can use as a means to potentially harm themselves) free enviroment, removal of equipment that can be used as a weapon or the ability to baracade themselves inside a room.

Please see Tag 0144
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on record review and interview, the facility failed to include the patient's representative in 1 (P#16) of 17 patients reviewed to make informed decisions regarding patients care. This failed practice does not allow the patient or their representative to request or refuse treatment.

The findings are:

A. Record review of "Informed Consent" policy dated 03/2018 revealed, "All patients who have a psychotropic medication ordered and guardian of patients who have a psychotropic medication ordered will be informed of the benefits and risks involved in taking prescribed medication. Consent to take medications will be given in writing and witnessed by a licensed nurse, physician or pharmacist. Except in emergency situations, informed consent will be obtained prior to administering psychotropic medications."

B. Record review of "Patients Rights" policy dated 04/2018 revealed, "except in emergencies, the consent of the patient, or their legally authorized representative, shall be obtained before treatment is administered."

C. Record review of Patient #16 (P#) medical chart revealed a court order dated 04/20/18 and expiring 04/19/19 appointing the patient's mother as the legal guardian for treatment.

D. Record review of "Psychiatric Progress Note" electronically signed by [name of nurse practitioner and name of medical doctor], dated 02/08/19 revealed PLAN: "I will discontinue the Depakote (used to treat various types of seizure disorders) and Aristada (used for the treatment of schizophrenia in adults) and these medications and changes were all approved by the treatment guardian.

E. Record review of P #16's medical record indicated no written consent signed by the legal guardian.

F. Record review of P#16's "Medication Information/Consent, Antipsychotic/Major Tranquilizers" form undated, revealed P#16 was prescribed Abilify (used to treat the symptoms of psychotic conditions such as schizophrenia and bipolar I disorder) and no signature from the patients Legal Representative and the RN (registered nurse) obtaining the consent.

G. On 02/12/19 at 9:43 am during interview, Director of PI (Performance Improvement)/Risk confirmed the legal guardian should have signed the consent form and the error should have been caught on the leadership audit tool (facility's method to evaluate the completeness of the medical record).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review, the facility failed to provide care in a safe setting to all patients receiving psychiatric care at the facility as evidence by: not providing a ligature free environment, removal of equipment that can be used as a weapon or the ability to barricade themselves inside a room. This failed practice has the potential to cause harm to patients at risk of suicide or patients who exhibit violent behaviors towards themselves or others.

The findings are:


A. Record review of "Proactive Patient Safety Risk Assessment" creation/revision date(s): October-December 2018 revealed, Electric Medical beds, safe and secure was rated 4 out 5. The "Risk score of 4-5, indicates further assessment will be required and if Action is required to indicate Yes or No", the assessment documented Yes (indicating the bed was not safe). "Most beds have been replaced with platform model beds. The remaining electrical beds have had the cords zip tied to the frame with heavy duty zip ties. Replacement on order."

B. Record review of "Levels of Observation and Special Precautions" policy dated 02/2018 revealed, "Special Precautions Suicide Precautions: All linens, drapes, and shower curtains are accounted for." "Aggression Precautions: All linens, drapes, and shower curtains are accounted for." "Staff Training, staff education and competence will address: the relationship between the degree and type of risk and the levels of observations and special precautions, recognition of environmental safety concerns, and mitigation (the action of reducing the severity, seriousness, or painfulness of something) of environmental risk."

C. Record review of "Safety Management Plan" dated 01/19 revealed, "promote a culture of safety to eliminate preventable patient harm by engaging, educating, and equipping patient-care staff, patients, and visitors to safe practices through identification of safety risks and the planning and implementing of processes to minimize the likelihood of those risk. The scope of the safety management plan defines the processes's which the Hospital utilizes to provide our patients, staff, and visitors with a physical environment free of hazards and manages activities proactively through risk assessment to reduce the risk of injuries to patients, staff, and other individuals coming to the hospital."

D. Record review of "Visitation" policy dated 01/2018 revealed, "Procedure, all individuals who visit patients will be required to sign the Visitors Sign-In log, at the Nurses Station. Staff will review all belongings brought to the hospital that are to be taken on the unit to ensure there are no prohibited items. Staff will document all belongings brought into the hospital."

E. On 02/11/19 at 2:30 pm during observation of patient's room (room#55) in the [name] unit, the patient's bed was not a secured-to-the-floor platform bed.

F. On 02/11/19 at 2:30 pm during observation of patient's rooms in the [name] unit, patient's linen on the bed (1 blanket and 1 sheet) was observed which does not follow the "Levels of Observation and Special Precautions" policy.

G. On 02/11/19 at 2:45 pm during interview, CEO confirmed being aware the bed should be secured to the floor and not having the bed secured could potentially cause patient harm.

H. On 02/11/19 at 2:55 pm during interview, CEO confirmed the BHTs try to make the beds during rounding. The CEO is aware of a safety concern with linens on the patients' bed and does not follow the "Levels of Observation and Special Precautions" policy.

I. Record review of [name of unit] visitor form dated 03/12/14 revealed the only visitor log that was included in the visitation binder was dated December 2018. No other documentation was found in the visitation binder to verify forbidden items brought by visitors to patients. Additionally, no other documentation was found in the visitation binder to demonstrate the facility staff safe-guarded the patients for prohibited items.

J. On 2/12/19 at 1:00 pm during interview, DON (Director of Nursing) confirmed the visitor log had not been completed since December [2018] and agreed this does not follow the policy for visitation.

K. Observation of unit on 02/11/19 reveals patients walk around freely in the unit with limited staff supervision.

L. On 02/11/19 at 3:00 pm during interview, BHT #6 reported the cameras in [name of unit] utilized to monitor the patients were not functioning.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on interview, observation, and record review, the facility failed to provide a safe environment free from neglect and potential abuse by not establishing a staffing system that is adequate for all shifts to take care of the individual needs of all patients. This failed practice has the potential to result in physical, harm or mental anguish to patients.
The findings are:



A. Record review of "Levels of Observation and Special Precautions" policy dated 02/2018 revealed, "Special Precautions Suicide Precautions: "Levels of Observation, Q15 Minute Checks, Assigned staff will make direct visual contact with patients and confirm they are in no danger or distress. Staff will be vigilant for potential risk factors identified for specific patients (types of precautions)."

B. On 02/11/19 at 3:00 pm during interview, BHT #6 was asked which patients on the unit were suicidal. BHT #6 responded the patient in room 4005 was suicidal and possibly 1 other patient on the unit was also suicidal. BHT #6 stated the assignment sheet/census sheet was not correct in identifying the SI patients on the unit and BHT #6 did not know which patients were suicidal. BHT #6 also stated that it did not matter because all patients were q15. In addition, BHT #6 reported the cameras in [name of unit] utilized to monitor the patients were not functioning.

C. On 02/12/19 at 7:00 am during observation of the television room, no staff was present in the room for 20 minutes. Approximately 10 patients were not in direct visual contact of the assigned staff person to confirm they are in no danger or distress per facility policy.

D. On 2/12/19 at 7:20 am during interview, Director of Clinical Services confirmed all patients should not be left alone and asked a staff member to go into the television room.

E. On 02/12/19 at 7:23 am during interview and observation in the dining room, one BHT (#3) was monitoring 16 patients during breakfast.

F. On 02/12/19 at 7:45 am during interview, BHT #3 was asked if it was normal to have one BHT monitor 16 patients during breakfast, BHT #3 confirmed it is usually one BHT in the dining room monitoring patients.

G. On 02/12/19 at 10:00 am during interview, the CEO confirmed the staff ratio of 1 BHT to 16 patients during breakfast does not adhere to the policy of BHT staff ratio of 1 to 5 patients . No staff ratio policy was presented as evidence.

H. Record review of "Abuse Reporting" policy dated 12/2018 revealed, "patients have the right to be free from mental, physical, sexual, and verbal abuse, neglect, and exploitation from anyone, including staff members, students, volunteers, other patients, visitors or family members."
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on record review and interview, the hospital failed to ensure that the Quality Assessment & Performance Improvement (QAPI) program showed measurable improvement in indicators that could improve health outcomes. This failed practice does not allow the facility to assess processes that have been implemented.

The findings are:


A. Record review of the hospitals QAPI minutes for November 2018, December 2018, and January 2019 reveals no identification of issues, plan of correction, who was assigned and resolved date and there no documentation of measurable improvement, re-evaluation, sustain positive patient health outcomes, patient safety, or quality of care improvement.

B. On 2/11/19 at 3:00 pm during interview the PI/Risk Director confirmed that the facility tracks identified issues, plan of correction, person assigned to correct issue and date resolved but does not track outcomes or re-evaluations.

C. Record review of the hospitals QAPI minutes for November 2018 the matter of "Look alike/sound alike medications" was on the agenda and was deferred until the December 2018 meeting. The December 2018 agenda did not have the subject of "Look alike/sound alike medications" but the minutes for this month had this subject as part of new business. The subject of "Look alike/sound alike medications" in the December 2018 minutes did not have any documentation showing any action being done in regards to this subject. The following month (January 2019) QAPI minutes and agenda do not have the subject of "Look alike/sound alike medications" documented.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on record review and interview the facility failed to conduct and document performance improvement projects as part of the Quality Assessment & Performance Improvement (QAPI) program. This failed practice has the potential to affect health outcomes, patient safety, and quality of care by not identifying opportunities for improvement and implementing changes that will lead to improvement.
The findings are:


A. Record review of the hospital QAPI program and training binder 2018, reveals no documented performance improvement projects.

B. On 2/11/19 at 3:00 pm during interview the PI/Risk Director confirmed that the QAPI binder and training binder has no performance improvement projects documented.
VIOLATION: MEDICAL STAFF CREDENTIALING Tag No: A0341
Based on record review and interview, the facility's Governing Body failed to assure that the Medical Staff bylaws for granting medical privileges were followed for 2 (Medical Doctor [MD]#1 and Doctor of Nursing Practice [DNP]) of 4 (MD#1, DNP, [pharmacist]Pharm #2, [physican's assistant] PA #1) Medical Staff. This deficient practice precludes the hospital from fully assessing the practitioner's competence to perform the tasks that he/she was requesting in his/her request for privileges. The findings are:

A. Record review the facility's Clinical Privileges Plan, last approved on 01/2018 revealed, "Basic Qualifications, two letters of reference from professional peers with or for whom the applicant has worked in the last five years."

B. Record review of Medical Staff Rules and Regulations of [name of facility] last approved on 08/2018 revealed, "Criteria for Delineation of Privileges, A. Basic Qualifications, 6, Two letters of reference from professional peers with or for whom the applicant has worked in the last five years, indicating the competency and ethical character of the applicant to fulfill responsibilities of a practitioner at [name of facility] behavioral hospital."

C. Record review of Doctor of Nursing Practice (DNP)'s personnel file revealed the following: 1) Date of Hire (DOH) 08/20/18, 2) Application for Delineation of Privileges made by DNP on 09/18/18. There were two Application for Delineation of Privileges one that was signed off as approved on 09/18 (illegible)/18 and another signed off as approved 10/11/18. There was no letter in the file from the CEO stating that the Governing Board (GB) had reviewed the application and granted privileges. On 02/12/19, a letter was placed in his file, granting DNP privileges as of 09/28/18, and 3) Two references dated after the DOH and one dated after the Granting of Privileges: 09/25/18 and 10/01/18.

D. Record review of Medical Doctor (MD)#1's personnel file revealed the following: 1) Date of Hire 05/31/018, 2) Application for Delineation of Privileges made by MD#1 on 05/17/18. On 05/31/18, MD#1 was approved for privileges. There was a letter in the file to MD#1 from the CEO dated 05/31/018 stating that the GB had reviewed the application and unanimously granted the request for initial appointment and granted Active Medical Staff Privileges as delineated in the application and 3) Two references dated after the DOH and the Granting of Privileges: 07/23/18 and 08/23/18.

E. On 02/12/19 at 7:30 am during interview, Human Resources Director (HRD) stated the last HRD left the facility at the end of August 2018 and medical personnel have rotated to help with HR tasks until HRD was hired in December of 2018. HRD stated, "Credentialing is new to me." HRD confirmed that MD#1 and DNP became a part of Medical Staff without all references being checked.
VIOLATION: CONTENT OF RECORD Tag No: A0449
Based on record review and interview the hospital failed to ensure the medical record contained information to describe the patient's progress and response to medications and services including assessments and laboratory work provided for 4 (P# 4, 8, 10, and 18) of 5 patients patients sampled. This deficient practice does not allow the medical provider to review the entire record for patient's progress or degree of changes which could result in harm or death. The findings are:


A. Record review indicated in 4 (P# 4, 8, 10, and 18) of 5 patients the physician did not complete and document a history and physical within 24 hours of admission as required by hospital policy.

B. Record review of facility policy "Assessment/Reassessment" dated 11/17/18 revealed, "Within the first twenty-four (24) hours of the patient's admission, a physician will complete a history and physical."

C. Record review of 3 (P#4, 7, and 18) revealed no evidence of lab results and treatment reports were not reported to the physician or practitioner.

D. On 02/14/19 at 9:30 am during interview, the CEO confirmed the current process of communication with the physician or practitioner is not effective.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and interview, the facility failed to ensure that all verbal orders were dated, timed and authenticated promptly per facility policy, scope of practice laws, and hospital policies for 1 patients (P# 4) of 3 (P# 4, P# 5 and P# 6) patients sampled. This failed practice has the potential to have all verbal orders not appropriately reviewed and verified by a physician for correctness and appropriateness for all patients at the facility, which could result in harm to a patient by missed or inappropriate treatments/therapies, potential medication errors and lab draws not being obtained.
The findings are:

A. Review of facility policy "Written and Verbal Orders" policy ID: 02, last approved and revised 08/2018 revealed: "Only telephone orders from an approved licensed independent practitioner (LIP) will be taken. The order will be written on the physician order sheet, represented as a telephone order, and include the receiver's name and title. The Prescriber shall co-sign the order within 24 hours. After confirming the order through 'read back', the receiver will sign and use the initials 'RBV' (Read Back and Verified) to designate completion of order."

B. Record review of P# 4's chart revealed the "Physician's Certificate for Emergency Detention" was taken as a verbal order from a provider, the signature of the ordering physician was hand printed and not countersigned by the receiving Registered Nurse # 6. The ordering physician (MD# 1) did not co-sign the document within the 24 hour time frame per facility policy. Further review of the chart revealed that the physician's signature was not obtained from date of admission (02/07/2019) to day of chart review (02/13/2019).

C. Record review of P# 4's chart revealed the "Admission Orders" Sheet dated 2/7/19 [sic] at 22:00 (10:00 pm), Legal Status was checked "Involuntary".

D. Record review of P# 4's chart revealed the patient was involuntarily admitted on [DATE]. The "Notification of Rights to Involuntary Patients - This form must be read and explained to every new involuntary patient when he/she is put on an involuntary hold. Try to obtain the patient's signature. If the patient does not sign, state why below" was not signed by the patient or by their Power of Attorney (POA)/representative and neither the 5 day nor the 7 day involuntary hold boxes were checked. Further review of this form revealed no explanation as to why the patient could not or would not sign the document.

E. Record review of P# 4's chart revealed "Psychiatric Evaluation" dated 02/08/2019 [sic] no time listed, Doctor of Medicine (MD) #1 dictated and electronically signed the Psychiatric Evaluation form with "Legal Status: Verbal Consent, voluntary."

F. Record review of New Mexico Administrative Code (NMAC): Title 16: Occupational and Professional Licensing, Chapter 10: Medicine and Surgery Practitioners, Part 15: Physician Assistants: Licensure and Practice Requirements, Section 11: "Supervision of a Physician Assistant: Supervision of a physician assistant must be rendered by a licensed supervising physician."

G. On 02/14/19 at 11:50 am during interview DON confirmed RN# 6 did not follow facility policy when taking a telephone order from a provider for both P# 4 and P# 5's orders.
VIOLATION: CONTENT OF RECORD - INFORMED CONSENT Tag No: A0466
Based on record review and interview, the facility failed to obtain a properly executed informed written consent for 1 (P# 5) of 3 (P#4, P# 5 and P# 6) patient charts reviewed. This failed practice has the potential to have the patient and his/her representative to not be involved in their care planning and treatment and not being able to request or refuse treatment.
The findings are:

A. Record review of P# 5's chart revealed no signature on any consents for treatment or admission paperwork. It further reveals a note from hospital personnel "Pt (sic) too tired/sedated to sign" with a date, time and staff signature (unidentifiable) following the handwritten notation.

B. Record review of [Name of facility] policy "Admission/Registration Documents" policy ID: 72, revised 07/2016, last reviewed 02/2018 revealed, "Procedure: Conditions of Admission must be signed by each participant/guarantor entering the facility for treatment, regardless of level of care. The Business Office Manager is responsible for having the patient/guarantor complete the remainder of the admissions paperwork. The Business Office Manager and/or (Chief Executive Officer) CEO should ensure that appropriate processes are in place to review the Admission/Registration Checklist for each day's admissions/registrations and follow up on missing or incomplete records. The checklist will be used to provide a guideline to perform future Quality Assurance reviews of data collected and to ensure compliance on completion of required forms."

C. Record review of undated [Name of facility] Leadership Chart Audit Tool revealed "Providers have timely signed TORB's [Telephone order read back]" is checked "No" with handwritten notation of "flagged" noted in "Corrections" box.

D. On 02/14/19 at 10:30 am during interview, the Director of Social Services (DSS) stated, "There is an expectation that there are 3 attempts to be made to get a patient to sign their consents within 72 hours of admission." DSS confirmed patient consent signatures were not obtained.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on record review and interview the medical staff is responsible for developing policies and procedures that minimize drug errors and delegated these policies and procedures to the pharmaceutical service. The pharmaceutical staff failed to follow these policies and procedures. This deficient practice has the potential to cause harm or be fatal to a patient. The findings are:

A. Record review of the hospitals' policy on Medication Administration, the policy states the number and amount of narcotics and hypnotics will be counted and verified by a licensed nurse going off shift and a license nurse coming on shift at the change of each shift. Any discrepancies are to be reported to the Nursing Director and the Pharmacist.

B. On 2/14/19 at 11:00 am during an interview with S #5 Pharmacist, it was confirmed that the staff performs a narcotic count once a week (Sunday) and not on each shift as required by policy.

C. On 2/14/19 at 12:00 pm during an interview with S #1 Director of Nursing, it was confirmed that the staff performs a narcotic count once a week (Sundays) and not on each shift as required by policy.

D. Record review of the hospitals' Medication Variance Log for the fourth quarter of 2018, revealed 57 medication errors on the log.

E. Record review of an incident report on 11/20/18, Duloxetine (a medication used to treat major depressive disorder, generalized anxiety disorder, fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues) and neuropathic pain (pain by damage or disease affecting the somatosensory nervous system) was administered to the wrong patient.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and interview, the facility failed to ensure the contracted housekeeping service was qualified to provide services permitting the hospital to comply with the applicable federal regulations. This failed practice puts all current and future patients at risk of not having a clean and safe environment resulting in unmet patient needs.
The findings are:

A. On 02/11/19 at 2:05 pm observation of the facility during the tour of the facility revealed the the "Quiet Room"/Seclusion room was dirty. The mat that sits on top of the bed appeared to have large white streaks and splatters of unidentifiable matter. On the wall next to the door at eye level, there were dark reddish brown stains.

B. On 02/12/19 at 2:05 pm during interview, the DON confirmed the room was dirty and observed the matter on the wall acknowledging that it should have been cleaned. The CEO stated, "This is not normal."

C. On 02/12/19 at 2:00 pm during the tour, the CEO confirmed the last seclusion event occurred on 02/08/19 and the room had not been cleaned since.

D. On 02/11/19 at 2:00 pm the tour of the facility revealed the overall appearance of the facility was dirty and unkempt. Handrails were sticky, windowsills, cabinets, furniture, and countertops were dusty. The hallways smelled of urine.

E. On 2/11/19 at 2:15 pm during interview on the tour, the CEO stated, "we have been having problems with Housekeeping not doing what we ask."