Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION DATE SURVEY 3UILDING: COMPLETED 1 01071201 3 NAME OF PROVIDER OR SUPPLIER BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 in SUMMARY STATEMENT OF In PROVIDERS PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE DEFICIENCY) 000 Initial Comments 8 000 An unannounced on?site complaint investigation was conducted on 09/16/13 through 10/7/13. The survey was generated by CO 14978 and CO 14979. Nine De?ciencies were Cited. A plan of correction is required. 8 002 Survey Details 8 002 11/29/2013 This REGULATION is not met as evidenced by: 6 CCR 1011?1 STANDARDS FOR HOSPITALS AND HEALTH FACILITIES (PROMULGATED BY THE STATE BOARD OF HEALTH) Chapter II General Licensure Standards Last amended 06/19/13, effective 08/14/13 PART 3. QUALITY MANAGEMENT 3.1 QUALITY MANAGEMENT PROGRAM. Every licensed or certified facility, except personal care boarding homes of nineteen beds or fewer and except, community residential homes for persons with developmental disabilities shall establish a quality management program appropriate to the size and type of facility that evaluates the quality of patient or resident care and safety, and that complies with this part 3. 3.1.1 Within 90 days of the effective date of this regulation for facilities licensed on the effective date of this regulation and within 90 days of the issuance of a license to a new facility, every facility de?ned in section 3.1 shall submit to the Department for its approval a plan for a quality management system that includes the following elements: (4) a description of the method for investigating and analyzing the frequency and causes of individual problems and patterns of problems; (5) a description of the methods for taking corrective action to address the problems, including prevention and minimizing problems or 1. The facility conducted quality management activities related to nursing care provided. Among other actions taken, Patient Patient Observation Rounds Process: The CEO, Director of Nursing, Director of Risk Management, and Director of Education and Process Improvement revised the Hospital's procedures regarding patient observation rounds. The revisions included adding the responsibilities of the nurse manager, Charge nurse, nursing supervisor, and Hospital administration to oversee that appropriate and compliant patient observation rounds (including Quiet Room rounds) are being conducted. The CEO also revised the patient observation rounds policy and procedure by adding a ?zero-tolerance? expectation of compliance to reinforce the importance of patient observation rounds and to put patient care staff on notice that noncompliance will subject staff members to additional training and possibly appropriate corrective action, up to and including termination. Administrator on Call (AOC) Process: The CEO reviewed and revised the Administrator on Call (AOC) process to attest that the plan of correction will be implemented and monitored for compliance AUTHORIZED PROVIDER REPRESENTATIVES SIGNATURE TITLE DATE If continuation sheet 1 of 66 Colorado Department of Public Heaith and Environment Printed" 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: 3UILDINGZ COMPLETED 064024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF iD PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 002 Continued From page 1 002 risks; have the AOC provide non?clinical support (6) a description Of the method for the follow?up to the evening and overnight shifts to of corrective action to determine the reinforce the importance of the patient effectiveness Of such action; Observation rounds process. Hospital (7) a description Of the method for coordinating executives required to fulfill AOC duties all pertinent case, problem, or risk review include the CEO, CFO, Director of Risk information with other applicable quality Management, Director of Education and assurance and/or risk management activities, Process Improvement, Director of Plant such as procedures for granting staff or clinical Operations, Director Of Business privileges; review of patient or resident care; Development, Director Of Intake, and review of staff or employee conduct; the patient Director Of Clinical Services. The revised grievance system; and education and training process provides for the AOCS to conduct programs; a physical walk-through of Intake, Unit 1, (8) documentation Of required quality Unit 2, and the Adolescent Unit to Observe management activities, inciuding cases, Unit Staff conducting patient Observation problems, or risks identi?ed for review; findings rounds on each Unit. The AOCS aiso Of investigations; and any actions taken to communicate with staff about the address problems or risks; and importance of quality patient care and (9) a schedule for plan impiementation potential employee concerns/issues. Ambassador Rounding: 3.1.5 The Department may audit the quaiity The CEO reviewed and revised the management program to determine its patient Observation rounds process by compliance with the approved plan. adding a designated training ambassador (1) If the Department determines that an to assist nursing staff with Observing, Investigation of any incident or patient or reinforcing, and educating staff performing resident outcome is necessary, It may, unless patient Observation rounds. The Director othenrvise prohibited by law, investigate and Of Nursing seiected the training review relevant documents tO determine actions ambassador from among Behavioral taken by the facility. Health Associates (BHAS) that have (2) This section shail be effective June 1, 1988. consistently demonstrated excellent rounding Skills, communication skills, and The Requirement is NOT MET as evidenced by: role modeling skiiIS. The ambassador conducts random visits on the different Based on staff interviews and review of facility units and shifts seven days per week. - documents, the facility failed to conduct quality The ambassador directly Observes management activities related to nursing care employees conducting rounds and provided, such as patient Observation rounding, reviews Video camera tapes. In addition medication administration and patient to giving the employee direct verbai assessment and documentation. The facility feedback, written feedback when faiied to assess the quality Of the discharge appropriate, and providing verbal planning process and to incorporate adverse feedback to the Charge nurse and nurse patient outcomes after discharge into the supervisor as appropriate, the evaluation Of the discharge planning process ambassador also monitors usage Of the and the the facility?wide quality program. The Quiet Room and Observation rounds done If continuation sheet 2 Of 66 Coiorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 1010712013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 facility failed to conduct quaiity management activities related to adverse events in the care and death of Sample Patient Findings: 1. The facility failed to ensure that nursing services conducted effective quality management activities to evaluate the nursing care provided related to patient observation rounds, medication administration and patient assessment and documentation. Reference 8 0009 for ?ndings regarding staff failure to conduct patient observation rounds. Reference 0007 for ?ndings regarding staff failure to adequately identify assess/reassess a patient with a change of condition and to document findings and initiate appropriate interventions and monitoring. Reference 8 0008 for findings regarding nursing staff failure to administer medications according to physician orders and to adequately monitor the response to medications. 2. The facility failed to ensure that the quality of the discharge planning process was assessed and to incorporate adverse patient outcomes after discharge into the evaluation of the discharge planning process and the facility?wide quaiity program to improve patient care and outcomes. Reference 8 0006 for ?ndings regarding discharge planning/facility failure to develop and maintain a process for evaluating the effectiveness of the hospital?wide discharge planning process and to review adverse patient events, including deaths/suicides, after discharge, from a quality improvement point-Of?view. ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTEVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 2 002 on patients in the Quiet Room, and then submits a written report to the Director of Nursing after each visit. The Director of Nursing reviews the ambassador?s reports each weekday. Monitoring/T racking: For a period of 30 days, the CEO directed the Director of Nursing to monitor the training ambassador process through review of the ambassador's reports each weekday and submission of reports to the CEO each weekday and weekiy. Monitoring results will aiso be reviewed by the Performance Improvement Committee at its meeting. After 30 days, if it is determined that there is 100% compliance with rounding, the frequency of reporting to the CEO may be reduced, but will not be discontinued untii it has been determined that the compliant rounding process and cuiture of safety are thoroughiy ingrained. Staff Training: The CEO directed 100% of nursing staff (RNs and BHAS) to undergo training and complete a Return Demonstration on patient observation rounds. Return Demonstrations were validated by the nurse manager, nurse supervisor, or BHA training ambassador. In addition, the training emphasized the Iirnited use of the Quiet Room and the continued use of patient observation rounds when it is deemed appropriate to place a patient in the Quiet Room for a limited period of time. 100% of patient care staff performed a Return Demonstration competency on patient observation rounds. The Return Demonstration outlined key components concerning patient safety and the patient observation rounding processes, including: 1. Proper use of the flashlight when YRN711 lf continuation sheet 3 of 66 d: Colorado Department of Public Health and Environment rm 8 12/15/2014 Health and Emergency Medical Services Division STATEMENT OF PROVIDER IDENTIFICATION VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 1010712013 NAME OF PROMDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 5 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDERS PLAN OF CORRECTION COMPLETION pREax (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR INFORMATION) TAG To THE APPROPRIATE DEFICIENCY) 002 Continued From page 3 002 3. The facility failed to conduct quality rounding on sleeping patients at night and management activities related to adverse events the process for confirming three in the care and death Of Sample Patient respirations and any change in a patient?s position. Reference 8 0008 for findings related to the 2. informing the RN of any change in facility failure to adequately identify and condition such as abnormal breathing investigate medication variances related to the (including snoring), and patient care and death of Sample Patient repositioning so the RN will assess/reassess the patient's condition. 3. Nurses were also re-trained by the Director of Education and Process Improvement to assess/reassess patient breathing, to take vital signs as appropriate including taking pulse oximeter reading, to attempt to rouse a patient when necessary, to notify the physician Of changes in condition, and to document findings and actions. Monitoring/Tracking: Training was provided to 100% of ail nursing staff with evidence of this retraining placed in the master training fiie. The Director of Nursing was responsible for confirming that all staff received the training. New Employee Orientation: The CEO directed the Director Of Education and Process Improvement to revise the New Employee Orientation process as foilows: 1. TO include a suicide prevention video that orients 100% Of new employees on the importance of patient observation rounds. 2. To provide training on the revised patient observation rounds policy describing the Hospital?s ?zero tolerance? expectation and promoting the importance of patient observation rounds as one Of the most critical functions performed by nursing staff. 3. To emphasize the limited use Of the Quiet Room and the continued use of patient Observation rounds when the use of the Quiet Room is deemed appropriate. If continuation sheet 4 Of 66 Printed: 12/15/2014 Colorado Department Of Pubiic Heaith and EnVIronment Heaith Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 064024 1 0107/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8555 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES in PROVIDERS PLAN OF CORRECTION COMPLETEON PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DEFICIENCY) 002 Continued From page 4 002 4. To include a patient observation rounds practice for ali new hires of clinical staff. 5. To have a Return Demonstration competency on patient observation rounding incorporated into the training and overseen by a Registered Nurse. Annual Competencies Process: The CEO directed the Director of Education and Process improvement to include patient observation rounds training in the Hospital?s Annual Competencies process with nursing staff showing competency through Return Demonstration. The Director of Nursing is responsibte for con?rming the competency of all nurse managers and nurse supervisors in patient observation rounding and in overseeing patient observation rounding by other nursing staff members. Annual Competencies Training was provided to 100% of all patient care and nursing staff with evidence of this retraining piaced in the master training ?les. Video Camera Review Process: The CEO directed the Director of Plant Operations to make Video camera review capability accessibie to the entire Hospital leadership team to enable them to conduct periodic reviews of patient observation rounds. The CEO and Director of Plant Operations reviewed the physical location of all Hospital camera monitoring stations to confirm functionality of each camera reviewing station. The Director of Plant Operations added camera monitors to all Units and to the of?ce to provide review accessibility to the CEO, Director of Nursing, and all Nursing Supervisors. Monitoring/T racking: One randomly selected hour of patient Observation YRN711 If continuation sheet 5 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER IDENTIFICATION NUMBER: 064024 Printed: 12/15/2014 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, STATE, CODE 8565 POPLAR WAY LITTLETON 80130 In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER's PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 5 002 rounds is reviewed daily by Nurse Managers/Supervisors, and weekly by the CEO, Director Of Risk Management, and the Director Of Education and Process Improvement. Observations are documented on the Video Camera Review of Staff Observation Rounds Form which was specifically developed by the Director of Nursing for this process. The CEO provides a summary report Of audit results to the monthiy meetings Of the Committee of the Whole and the MEC, and quarterly to the Board Of Directors. Assessment/Reassessment The CEO directed the Director of Nursing to revise the patient observation rounds policy by adding more precise language about nurses? assessment/reassessment Of patients. This clearer language emphasizes that all patients should be reassessed by an RN if they exhibit medical and/or behavioral changes including repositioning, snoring, and unusuai breathing patterns Of sleeping patients. The CEO directed the Director of Nursing to have 100% Of nurses compiete a competency check-Off on assessment/reassessment Of patients. The Director of Nursing/designees provided retraining and competency checks to ali nurses on assessment/reassessment of patients. The Checklists are in the master training ?les. This training covered the assessment and reassessment of patients? general physical and mental condition, signs and of change in condition, expectations for corresponding documentation, and notification of physicians of changes in patients? condition, including but not iimited to: YRN711 Ii continuation sheet 6 of 66 . . Printed: 12/15/2014 Colorado Department of Publlc Health and EiTVIronment Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 6 002 1. Vital signs 2. Oxygen saturation level 3. Emesis (including color, quantity and quality) 4. Any additional change in patient condition 5. Notification of physician and orders received The Director of Nursing also re-educated nurses on issues that can arise when patients are prescribed multiple medications, particularly medications with sedative effects, and on the need to initiate on?going assessments of patients on multiple medications when the patients appear sedated. The Chief Medical Officer presented a revised Clinical Institute Withdrawal (CIWA) Assessment form for assessing patients going through alcohol detox and a new Clinical Opiate Withdrawal Scale (COWS) Assessment form for assessing patients going through opiate detox to the Medical Executive Committee (MEC) for approval. The CIWA and COWS Assessment forms contain criteria for nurses to use in assessing and scoring withdrawal of patients going through detoxi?cation. The MEC approved the forms and emphasized the importance of: 1. Nurses notifying the physician of any Change in patient condition or of high scores on the or COWS assessment. 2. Nurses documenting their assessment and observations, including their withholding of additional medcations and conducting of ctose patient monitoring while waiting for additional physician orders. The Director of Nursing trained 100the revised and the new COWS assessment forms. YRN711 lf continuation sheet 7 of 66 d: Coiorado Department Of Public Health and Environment run 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUELDING: COMPLETED 054024 10/07/2013 HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 5 POPLAR WAY LITTLETON 80130 1D SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 7 002 The Director of Nursing is monitoring completion Of 100% Of CIWA and COWS forms as described further below. The CEO directed the Director of Education and Process Improvement to conduct additional Mock Code Blue Driils to reinforce nurse competency for patient assessment/reassessment. The Mock Code Blue Drills are conducted using various scenarios tO provide nursing staff a variety of potential patient circumstances where nurses practice assessment and critical-thinking processes. Ten Mock Code Blue Drills have been completed: two mock drills were conducted in July (7.31.13?Unit 2 and the Adolescent Unit), three mock drills in August (8.26.13?Unit 1, 1 and Intake), three mock drills in September (9.5.13?Adolescent medical response, 9.16.13?Gymnasium and Unit 2), and two mock in October (10.16.13?Adolescent Unit and 10.26.13?Unit 1 and Adolescent Unit). Mock drills are tO continue at least twice a month. Findings con?rm that nursing staff benefit by practicing critical thinking skills on various patient scenarios. The Director of Education and Process improvement reports mock drill outcomes at the Committee of the Whole and MEC meetings, and quarterly to the Board of Directors. Each weekday the Director of Nursing is reviewing nurses? assessment/reassessment documentation, including 100% of any CIWA or COWS forms, for patients admitted on and receiving pain medications. The review is to confirm completeness of assessment/reassessment documentation and appropriate actions taken in accordance with policy based on a YRN711 If continuation sheet 8 of 66 Coiorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER NUMBER: 064024 MULTIPLE CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE. ZIP CODE 8565 POPLAR WAY LITTLETON 80130 iD PREFIX TAG SUMMARY STATEMENT OF (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE SHOULD BE TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE 002 Continued From page 8 002 patient's response to medications, change in condition, and/or high score on a or COWS assessment. The Director of Nursing provides a summary report of audit results to the meetings of the Committee of the Whole and the MEC, and the quarterly meetings of the Board of Directors. Medication Administration The Director of Nursing reviewed and confirmed the accuracy and completeness of the Hospital?s medication administration policies. The Director of Nursing re-educated nursing staff on the process for reporting a medication variance or potential error, and clari?ed what is a variance and what should be reported as follows: 1. Ali medication orders that are not written on the MAR as the physician prescribed are considered to be a variance. 2. Additionally, ail medications that are administered incorrectly, or not as the physician prescribed, are considered to be a medication variance. 3. Any staff member identifying a medication variance or potential error should compiete an incident Report and return it to his/her supervisor. 4. The supervisor then forwards the incident Report to the Director of Nursing. 5. following the Director of Nursing?s review, the Director of Risk Management and the Director of Education and Process Improvement also conduct a review. 6. Ail medication variances are reported to the meetings of the Committee of the Whole and the MEC, and to the quarterly meetings of the Board of Directors. 7. The Director of Nursing works with YRN711 If continuation sheet 9 of 66 . . Printed: 12/15/2014 Colorado Depaitment of Health and EnVIronment Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING, COMPLETED 054024 10/07/2013 HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH MUST BE PRECEEDEO BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 9 002 the Speci?c nurse involved with the variance(s), and identi?es and anaiyzes what happened and any trends (as applicable) with the pharmacist in order to attempt tO prevent reoccurrences. The clarification of what constitutes a reportable medication variance was addressed in the Committee of the Whole meeting. During the MEC meeting on 9/24/2013, all physicians were encouraged to check on their patients? controlled substance prescriptions through review of an online medication verification database. The CEO con?rmed that the pharmacist regularly uses this website to check for polypharmacy issues and is responsible for discussing polypharmacy concerns with the prescribing physician. The Director of Nursing developed a new policy on ?Medication Patches,? which was approved by the MEC. The new policy Ciearly articulates: 1. That Fentanyl patches are not allowed at this Hospital. Those patients presenting with a Fentanyl patch have the patch removed, and the treating physician will prescribe an aiternate medication if needed. 2. The correct process for administering, monitoring, accounting for, and destroying other medication patches, inciuding conducting daily Skin assessments; initiating, timing, and dating the patch; and documenting the skin assessment and presence or absence of a patch. 3. That daily skin assessments may be increased if a patient has a change in condition that warrants an additiona! assessment. 4. The requirement for nurses to contact a physician if a patient exhibits an unusual or unexpected response to a YRN711 If continuation Sheet 10 of 66 . . Printed: 12/15/2014 Colorado Department of PubIIc Health and EnVIronment Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 1010712013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3555 POPLAR WAY LITTLETON 80130 iD SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION pREFax (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 10 002 medication patch, or if a patient appears to have lost a medication patch, and to Obtain new orders about the patch. The Director of Nursing trained 100% of RNS on the new Medication Patches policy, which inciudes the correct process for administering, monitoring, accounting for, and destroying the patches; conducting skin assessment; validating the location of the patch on the patient, and the time, date and the nurse?s initials on the patch; contacting the physician in the event of a problem with a patch; and documenting the assessment, any issues, and any communication with a physician in the medical record. The Director of Nursing also trained 100% of RNS on documenting the date, time and location of the patch and removal of the patch in the MAR. Training also reviewed the process for administering oral medications. Monitoring/T racking: The pharmacist monitors medication patch administration and communicates with the Director of Nursing to confirm proper administration of medication patches. The Director of Nursing audits 100% of documentation on patients with any medication patches, including reviewing the MAR in addition to other locations in the medicai record, to con?rm compliance with the new medication patch policy. All medication variances are reported at the Committee Of the Whole and MEC meetings, and quarterly to the Board of Directors. All trends are referred to and addressed through the Nursing and Pharmacy Departments and subcommittees formed as indicated depending on the identi?ed issues. The Director of Nursing is monitoring the Nursing assessmentS/reassessments, including 100% Of any CIWA or COWS YRN711 If continuation sheet 11 of 66 . . Printed: 12/15/2014 Colorado Department of PublIC Health and EnVIronment Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER MULTIPLE DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 064024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 80130 :0 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DEFICIENCY) 002 Continued From page 11 002 forms used for patients undergoing detoxi?cation, for documentation accuracy and completeness, with results/trends/variances reported at the Committee of the Whole and meetings, and quarterly to the Board of Directors. The Director of Nursing is auditing 100% of assessments of patients admitted on pain medication to con?rm documentation accuracy and completeness. Results are reported in the Committee of the Whole and the MEC meetings, and quarterly to the Board of Directors. 2. The Director of Education and Process Improvement reviewed and con?rmed that, when it is aware of them, the facility reviews and evaluates post?discharge deaths through the QAPI process and Peer Reviews within 30 days after notification of the death. Physicians perform the medical review in the Peer Reviews. Other appropriate clinical personnel, including at least one physician, conduct a multidisciplinary Root Cause Analysis (RCA) of deaths within 72 hours after discharge or a multidisciplinary intensive review of other post-discharge deaths. When an autopsy is invoived and the Hospital is provided with a copy, the Chief Medical Officer reviews the autopsy report and determines whether additionai anaiysis by the multidisciplinary group is warranted. During the Medical Executive Committee (MEC) meeting on 10/01/2013, the physicians on the MEC determined that, going forward, one physician must be present during all reviews of post-discharge deaths. YRN711 If continuation Sheet 12 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division STATEMENT OF DEFECIENCIES AND PLAN OF CORRECTION PROVIDER NUMBER: 064024 Printed: 12/15/2014 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES lD PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE 002 Continued From page 12 002 The Director of Education and Process improvement confirmed that reviews of the reported deaths of patients #11, #12, #13, #14, #16 #21 were done by a multidisciplinary group. The Director of Education and Process improvement then revisited the reviews with the Director of Nursing, Director of Risk Management, Director of Clinical Services, Nurse Managers, and Chief Medical Officer. The Utilization Manager reviewed and confirmed the process for evaluating the effectiveness of the facility-wide discharge pianning activities and also reviewed recent improvements that were made as a result of previous RCAs or intensive analyses. Recent improvements include (but are not limited to) taking factors into consideration as part of discharge planning, increasing documentation on Master Treatment Plans, and physicians about all potential patient assessments. The Director of Ciinical Services re?educated the therapists to inciude stressors in the Master Treatment Plans (MTPs) on November 30, 2012. The Director of Clinical Services reviewed the MTPs Of the cited patients to con?rm that therapists had included stressors in the MTPs. The Director of Citnical Services also confirmed that therapists regularly schedule post-discharge appointments (as indicated) as part of discharge planning so that appropriate follow-up care is in place before a patient is discharged. Monitoring: The Director of Risk YRN711 If continuation sheet 13 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER IDENTIFICATION NUMBER: 064024 Printed: 12/15/2014 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 13 002 Management reviews all post?discharge deaths and confirms that peer review and a multidisciplinary analysis is initiated, and that the group conducting the multidisciplinary analysis includes a physician. Outcomes are reported to the Committee of the Whole (COW). The facility reviewed and improved its discharge planning process, with attention to review and evaluation of adverse patient outcomes that occur after discharge and of which the facility is aware. The Director of Nursing, Performance improvement Manager, and Director of Clinical Services wili meet quarterly to review and analyse post-discharge outcomes and death after discharge data for trends to incorporate into the evaluation of the discharge planning process and facility?wide quality program. The Director Of Risk Management will meet quarterly with Medical Staff Executive Committee to review the quarters death's after discharge for coroner updates,and analyze additional input from physicians and clinicai for loop closure and identi?cation of trends regarding the effectiveness of the discharge planning process. Performance Improvement and Risk Management will implement a Behavior and Identification Scale "Basis 32" in April 2014. Patients will have the Opportunity to ?ll out the scaie at intake and once again at discharge for additional guidance in the discharge process. The program also provides a 45 day post?discharge foiiow-up that provides YRN711 if continuation sheet 14 of 66 Colorado Department of Public Health and Environment Printed: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDWG COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 3 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 002 Continued From page 14 002 post?discharge data for analysis. The Director of Nursing, Manager of Performance Improvement, Clinical Services Director and Director of Risk Management will review the post-discharge data and use the data to improve the effectiveness of the discharge planning process. 8 003 Survey Details 8 003 11/29/2013 This REGULATION is not met as evidenced by: 6 CCR 1011?1 STANDARDS FOR HOSPITALS The MEC discussed patient discharges AND HEALTH FACILITIES (PROMULGATED resulting from the request for release BY THE STATE BOARD OF HEALTH) either by a patient or the patient?s legal Chapter II General Licensure Standards Last guardian and clari?ed the hospital?s amended 06/ 1 9/13, effective 08/14/13 process. It was clari?ed that, if a patient is PART 6. PATIENT RIGHTS found to be at risk Of harming self or 6.100 PATIENT RIGHTS others, a hold will be obtained. If the 6.104 PATIENT RIGHTS POLICY patient does not meet criteria for a hold, (1) The health care entity Shaii develop and the patient will be released. implement a policy regarding patient rights. The policy Shall ensure that each patient or, where The Director of Education and Process appropriate, patient designated representative Improvement re?educated the Nursing has the right to: Staff and the Therapists on the process participate in all decisions involving the for responding to a patient?s request for patients care or treatment; release. (0) refuse any drug, test, procedure, The Director of intake re?educated the treatment and to be informed of risks and Intake Staff on the requirements for benefits Of this action; placing holds and maintaining the hold log, including the requirement to The Requirement IS NOT MET as evidenced by: document on the hold log patients that are placed on hold during the hospital stay. Based on interview and document review the failed to respond to a request by a The Director of Intake amended the patient, and the Patients legai guardian, to be ?Conditions of Admission and Services" discharged from the The patient was a form to Clarify the discharge process for minor, admitted as a voluntary patient, and was patients on voiuntary or involuntary status. not placed on a mental health hold while hospitalized. if continuation sheet 15 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 003 Continued From page 15 003 This failure resulted in a situation in which the basic right of being able to refuse further treatment was not honored by the facility. Findings: 1. The facility did not respond to the legal guardian?s and minor patient's request to be discharged from the facility while the patient was under a voluntary admission. a) On 09/18/13 at 8:45 am, review of the medical record for Sampte Patient #6 was conducted. The record revealed the patient was a minor, admitted voluntarily on 10/06/12, as a waik?in patient. The patient was accompanied by his/her iegal guardian. Diagnoses upon admission were documented as depressive disorder, impulse control disorder, and migraine headaches. The document titled, "Comprehensive Assessment Tool," timed and dated 10/06/12 at 1:30 stated the patient denied suicidal ideation and homicidal ideation upon admission, with no history of aggression. The document revealed the patient had suicidal ldeation "in the last month" but the patient's guardian was not concerned for the patient?s safety and the guardian signed the patient in "voluntarily." A physician progress note, dated 10/08/12, at 8:15 am, completed by Staff Physician revealed documentation that the patient was "no longer depressed or suicidai" and the physician "suspected" the patient ?wants to 0/0 [discharged]." The physician further documented the patient's guardian called the facility on 10/07/12 concerned that s/he made the "wrong decision" to bring the patient to the facility for inpatient services. No further statement was documented by the physician on this date regarding a plan or timeframe in which Monitoring: The Director of Education and Process improvement monitors 100% of requests for release to con?rm compiiance with the release process. The Director of Education and Process Improvement reports outcomes to the Committee of the Whole (COW) meeting and quarteriy to the Board of Directors (BOD). If continuation Sheet 16 of 66 Colorado Department of Public Health and Environment PrInted: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 1 0/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 3 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 003 Continued From page 16 003 the patient would be discharged. A document titled, "Clinical Services/ Case Management Note," dated 10/08/12 at 10:30 am, stated the parents (legal guardian) of the patient are "now concerned" and want the patient "out." However, there was no evidence to show the facility coordinated or initiated steps to discharge the patient who remained on a voluntary admission. A progress note documented by Staff Counselor revealed Staff Counselor #1 documented s/he called the patient's guardian on 10/08/12 at 2:11 p.rn., and the patient's family was "upset because the patient was just going to come in for an assessment" and further documented that a family meeting was scheduled for 10/09/12 at 1:00 pm. Staff Counseior #1 did not document that the patient would be discharged on 10/09/12. A document titled, "Nursing Progress Note," dated 10/08/12 at 3:00 pm, revealed the patient asked "many times" if this was the day s/he wouid be discharged. Review of a document titled, "Discharge Summary," documented by Staff Physician stated the patient was brought in by his/her guardian with "thoughts about suicide with no plan." The Discharge Summary also revealed that when Staff Physician #1 saw the patient on 10/08/12, the patient stated s/he "needed to go home" and the patient?s guardian had called the facility and stated it was a "mistake" to bring the patient to the facility. Staff Physician #1 documented the patient was discharged the next day, 10/09/12, as there was no reason to hold the patient against his/her will and both the patient and his/her guardian wanted the patient to be discharged. YRN711 If continuation sheet 17 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medicai Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDWG. COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 30130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING TAG TO THE APPROPRIATE DEFICIENCY) 003 Continued From page 17 The document titled, "Conditions Of Admission and Services," dated 10/06/12, stated under request for discharge that if a patient wished to "leave the hospital" the patient would need to give verbal or written notice to hospital staff and that the physician would release the patient if deemed no longer a "risk to self or others" unless the physician ordered a face?to?face evaluation to be completed by the physician within 24 hours. The document did not differentiate between patients on a mentai health hold on not on a hold. b) On 09/18/13 at 12:38 pm, the facility policy titled, "Involuntary Admission," revised 07/12, was reviewed. The policy contained guidance for staff regarding the involuntary hospitalization of patients. The policy stated during the admission process, the intake Specialist would determine if the patient was a danger to self (suicidal) or others (homicidal) or graveiy disabled and if this criteria was met, the would initiate a Legal Hold. The medical record for Sample Patient #6 was reviewed for the presence of a mental health hold, or any documentation that the patient shouid be heid as "involuntary." No such documentation was found in the patient's record. 0) On 09/18/13 at 3:46 an interview was conducted with Staff intake Specialist #1 and the facility's Director Of Nursing (DON). The Staff Intake Specialist stated S/he was responsible for keeping the facility log of patients placed on a mental health hoid (M 1 Hold). The Staff Intake Specialist stated Sample Patient #6 was not on the facility's mental health hold log. The DON reviewed the patient?s medical record and stated 's/he couid find no evidence to hold the patient once the patient and the patient's guardian requested to be 003 YRN711 lf continuation sheet 18 of 66 Colorado Department of Public Heaith and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 I ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE 003 Continued From page 18 discharged. The DON stated the facility's process for this situation should have been for nursing staff, or whoever received the call from the patient's guardian, to inform the guardian of the AMA process and to inform the patient?s physician that the patient and guardian wished to discharge. d) On 09/19/13 at 1:45 pm, an interview was conducted with Staff Adolescent Counselor #1 who described the facility's process when a voluntary patient, not on a mental health hoid, requested to be discharged from the facility. The Counselor stated when s/he learned Of this request, s/he would inform the patient?s physician, who would reassess the patient within 24 hours and request a "second Opinion" from another physician if necessary. S/he stated if an adolescent patient or the parent of a patient, not on a mental health hold, wished to be discharged, "Against Medical Advice" papenivork would have to be completed by the patient/parent and the physician would then have 24 hours to respond to the request. There was no documentation to evidence the iegal guardian?s request for discharge, on 10/07/12, had been responded to and acted upon within 24 hours. e) On 09/19/13 at 2:34 pm, an interview was conducted with the facility's Corporate Clinical Director who stated the staff person who took the call from the patient's guardian with the request to discharge on 10/07/12, shouid have contacted the patient's physician immediately and the process to discharge the patient should have been carried out as soon as possible. The Director, who was present when the Staff Counselor was interviewed, stated the Counselor seemed to be unclear how to respond to a discharge request for a patient not on a mental health hold. 003 If continuation sheet 19 of 66 Colorado Department of Public Health and Environment Pr'med: 12/15/2014 Heaith Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 1010712013 HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8555 3 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 003 Continued From page 19 003 The facility document titled, "Conditions of Admission and Services," was reviewed with the Director who con?rmed the document did not offer patients clear information regarding voluntary status or being on a mental health hold and a patient's request for discharge. The Director reviewed the medical record for Sample Patient #6 and stated no documentation was found supporting the patient being held in the facility after 10/07/12. The Director confirmed not discharging Sample Patient #6 at the time of the guardian's ?rst request on 10/07/12, was a violation of the patient's rights. 005 Survey Detaiis 005 11/29/2013 This REGULATION is not met as evidenced by: 6 CCR 101% Standards for HOSPitais and The CEO reviewed and confirmed that the Health Facilities . facility had an acting Human Resource Chapter 18, Hospitals Director in piaoe throughout the period of Promulgated by the State Board Of Health time reviewed by the surveyors; A new Last amended 06/19/13, effective 08/14/13 permanent Human Resource Director Part 7. PERSONNEL. started at the facility on 10/30/13. The facility shall have a personnel department in conformance with the standards established in The facility conducted quality Chapter IV. Part 7, Personnel Department. management activities related to nursing Chapter 4, General Hospitals care provided. Promulgated by the State Board of Health Last amended 06/19/13, effective 08/14/13 1' Ameng other actions taken, Patient Part 7. PERSONNEL Observation Rounding was immediately 7.100 identi?ed as an issue and actions, 7.101 ORGANIZATION AND STAFFING including re?education, were initiated on (1) Each department or service of the hospital 07/27/13 Please see the detailed shall be under the direction of a person quali?ed response to 0009 for actions taken by training, experience, and ability to direct the regarding patient observation rounds. department or service. 2. Please see the detailed response to (2) There shall be sufficient personnel quali?ed 0008 for actions regarding medication by education and experience in each administration by nursing staff, department or service to properly Operate the documentation of patient responses to department or service. medication, and identification of adverse (3) Facility staff shall be licensed or registered in YRN711 if continuation sheet 20 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 1 0/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 accordance with applicable state laws and regulations and shall provide services within their scope of practice and, as appropriate, in accordance with credentialing. (4) All persons assigned to the direct care of or service to patients shall be prepared through formal education, as applicable, and on?the?job training in the principles, the policies, the procedures, and the techniques involved so that the welfare of patients wiil be safeguarded. The Requirement is NOT MET as evidenced by: Based on staff interviews and review of medical records and facility documents, the facility/former CEO/former DON failed to ensure that the nursing staff had adequate on?the?job training and demonstrated skills to conduct adequate patient observation rounds, to safely administer and monitor medication responses for patients and to accurately identify patient changes in condition, initiate appropriate action and provide thorough documentation. Findings 1. Failure to ensure that nursing staff had adequate training and experience to conduct effective patient observation rounds. Reference 0009 for ?ndings related to nursing staff faiiure to conduct effective patient observation rounds. 2. Failure to ensure that nursing staff safety administered medications and monitored/documented medication responses. Reference 8 0008 for findings related to nursing staff failures to correctly/safely administer medications, document responses and identify adverse medication events/medication errors. 3. Failure to ensure that nursing staff had ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 005 Continued From page 20 005 medication events/errors. 3. Please see the detailed response to 0007 for actions taken regarding nursing assessment/reassessment, identification of changes in patients? condition, documentation, appropriate actions and interventions, and monitoring. YRN711 If continuation sheet 21 of 66 Colorado Department of Public Heaith and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE DATE SURVEY BUILDING: COMPLETED 1 13/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH CORRECTSVE ACTION SHOULD BE TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) DATE 005 Continued From page 21 adequate training and experience to identify patient changes in condition, initiate appropriate monitoring and other interventions and to document patient care activities/assessments provided. Reference 8 0007 for findings relate to nursing staff failure to identify a change in condition for Sample Patient #1 and to take appropriate action and provide complete documentation of patient findings/care activities. 8 006 Survey Details This REGULATION is not met as evidenced by: 6 CCR 1011-1, Standards for Hospitals and Health Facilities Chapter 18, Hospitals Promuigated by the State Board of Health Last amended 06/19/13, effective 08/ 1 4/ 13 Part 11. GENERAL CARE SERVICES. The facility shail provide patient care services in conformance with the standards established in Chapter IV, Part 11, General Patient Care Services, Sections 11.101 and 11.102. In addition to the aforementioned requirements, the facility shall comply with the following: Chapter 4, General Hospitals Promulgated by the State Board of Health Last amended 06/19/13, effective 08/14/13 Part 11. GENERAL PATIENT CARE SERVICES 11.100 11.101 ORGANIZATION AND STAFFING (1) The facility shall provide inpatient and outpatient care services. Services shall be provided in accordance with recognized standards of practice, facility policy and procedure, medical orders, and the established pian of care. 11.102 PROGRAMMATIC FUNCTIONS (6) Discharge Planning 005 006 1 1/29/2013 The Director of Education and Process Improvement reviewed and con?rmed that, when it is aware of them, the facility reviews and evaluates post-discharge deaths through the QAPI process and Peer Reviews within 30 days after notification of the death. Physicians perform the medical review in the Peer Reviews. Other appropriate ciinical personnel, including at least one physician, conduct a multidisciplinary Root Cause Analysis (RCA) of deaths within 72 hours after discharge or a muitidisciplinary intensive review of other post?discharge deaths. When an autopsy is involved and the Hospital is provided with a copy, the Chief Medical Of?cer reviews the autopsy report and determines whether additional anaiysis by the multidisciplinary group is warranted. During the Medical Executive Committee (MEC) meeting on 10/01/2013, the physicians on the MEC determined that, going toward, one physician must be present during all reviews of If continuation sheet 22 of 66 Colorado Department of Public Health and Environment Health and Emergency Medicai Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE 006 Continued From page 22 006 The facility shall develop a discharge plan for each inpatient. Discharge planning shall be initiated early in the care, service or treatment process. The facility Shall develop and implement policies and procedures regarding discharge planning. At minimum, the policy and procedure shall address: the discharge planning process. (ii) the qualifications of the staff responsible for implementing discharge planning. initiation of discharge planning in a timely manner to allow for the arrangement of post-hospital care, as needed. (iv) evaluation Of the discharge planning process periodicaiiy for effectiveness. The Requirement is NOT MET as evidenced by: Based on staff interviews and review of medical records and other facility documents, the hospital failed to develop a mechanism or process for on?going re-assessment of the effectiveness of its discharge planning activities. The facility also failed to conduct clinically oriented reviews of potentiai discharge failures, including post?discharge suicides/deaths, as a part of discharge planning process evaluation. Findings: 1. The facility failed to have a process for on?going evaluation of the effectiveness Of discharge planning activities. a) On 09/27/13 at 10:10 am, the Director of Clinical Services was interviewed about the discharge planning activities of the facility. The director stated that s/he was the supervisor Of the social workers and discharge planners for the hospital. When asked if there was a process for evaluating the discharge planning process, s/he acknowledged that they did not have a process in place for that. S/he stated post?discharge deaths. The Director of Education and Process Improvement confirmed that reviews Of the reported deaths of patients #11, #12, #13, #14, #16 #21 were done by a multidisciplinary group. The Director of Education and Process Improvement then revisited the reviews with the Director of Nursing, Director of Risk Management, Director Of Clinical Services, Nurse Managers, and Chief Medical Officer. The Utilization Manager reviewed and confirmed the process for evaluating the effectiveness of the facility-wide discharge planning activities and also reviewed recent improvements that were made as a result of previous RCAS or intensive analyses. Recent improvements include (but are not limited to) taking factors into consideration as part of discharge planning, increasing documentation on Master Treatment Plans, and calling physicians about all potential patient assessments. The Director of Clinical Services had re?educated the therapists to include stressors in the Master Treatment Plans (MTPs) on November 30, 2012. The Director of Clinical Services reviewed the MTPS of the Cited patients to confirm that therapists had included stressors in the MTPs. The Director of Clinical Services also confirmed that therapists regularly schedule post-discharge appointments (as indicated) as part of discharge planning so that appropriate follow-up care is in place before a patient is discharged. YRN711 If continuation sheet 23 of 66 Colorado Department of Public Health and Environment Heaith Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 1 0/07/201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY 80130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCE) TO THE APPROPRIATE DEFICIENCY) 006 Continued From page 23 006 that the evaluation was during the hospitalization for each individual patient, not the discharge process for all patients. S/he stated s/he was unaware that there was a requirement for on?going evaiuation of discharge planning activities for the hospitai. 2. The facility failed to conduct Clinical case reviews of potential discharge failures, including post?discharge suicides/deaths, as a part of discharge planning process evaluation, to address gaps in discharge planning. a) On 09/17/13, 3 list of incidents/occurrences for the facility for the past 12 months was reviewed. The iist contained 7 deaths after discharge. 5 were listed as "After Discharge Death, Suicide," and 1 was listed as "After Discharge Death, Medical," and 1 was listed as "After Discharge Death Other." 6 of those former patients were added to the sample list for review. Sample Patients #11, #13, #14, and #21 were listed as "After Discharge Death, Suicide." Sampie #12 was listed as "After Discharge Death, Medical," and Sampie #16 was listed as ?After Discharge Death, Other." b) Review on 09/23/13 of the medical record of Sample Patient #11("After Discharge Death, Suicide") reveaied that the patient was admitted on 09/12/12 with a diagnosis of Bipolar Disorder with paranoia and history of mania, depression and The patient was discharged on 09/28/12 on day 17 of hospitalization. The hospital was later notified by a county coroner that the patient had committed suicide on 10/22/12, 24 days after discharge. The patient had a history of not following through with medication, signi?cant paranoia and impaired judgment and no established relationship for outpatient therapy support. Review of the case review report, dated The Director of Nursing, Performance Improvement Manager, and Director of Clinical Services will meet quarterly to review and analyse post?discharge outcomes and death after discharge data for trends to incorporate into the evaluation of the discharge planning process and facility-wide quality program. The Director of Risk Management will meet quarterly with Medical Staff Executive Committee to review the quarters death's after discharge for coroner updates,and analyze additional input from physicians and Clinical for loop closure and identi?cation Of trends regarding the effectiveness of the discharge planning process. Performance Improvement and Risk Management will implement a Behavior and Identi?cation Scale "Basis 32" in April 2014. Patients will have the opportunity to ?ll out the scale at intake and once again at discharge for additional guidance in the discharge process. The program also provides a 45 day post?discharge follow-up that provides post-discharge data for analysis. The Director of Nursing, Manager of Performance Improvement, Clinical Services Director and Director of Risk Management will review the post-discharge data and use the data to improve the effectiveness of the discharge planning process. Monitoring: The Director of Risk Management reviews all post~discharge deaths and confirms that peer review and a multidiscipiinary analysis is initiated, and that the group conducting the YRN711 lf continuation sheet 24 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, CODE 8565 POPLAR WAY LITTLETON 80130 In SUMMARY STATEMENT OF TD PROVIDERS PLAN OF CORRECTION COMPLETEON PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 006 Continued From page 24 006 1 1107/12, revealed that a was present for the case review. The only significant clinical findings identified during the review were that the treatment plan did not address life changing stressors, such as the patient's dif?cult financial Situation and recent job loss. There was no evidence of a subsequent review or receipt of a coroner's report/autopsy. On 10/07/13, the facility provide a copy of a death certi?cate that was signed by the coroner on 10/29/12, which stated the cause of death was a suicide due to by ligature hanging. 0) Review on 09/23/13 of the medical record of Sample Patient #12 ("After Discharge Death, Medical") revealed that the patient was admitted on 01/22/13 with a diagnosis of Mood Disorder. The patient was discharged on 01/30/13, day 9 of hospitalization. The hospitai was iater notified by a county coroner that the patient had been found dead on 01/31/13, 1 day after discharge. Since the facility review of the death was conducted before the autopsy/coroner's report were available, the was not sure of the cause and manner of death. Review of the subsequent case review report, dated 02/05/13, revealed that no physician was present during the review. The only significant clinicai factors identi?ed were that the patients treatment pian was not completed and the 7?day update was not done to review whether the patient had met his/her goals. The review was conducted 5 days after the death. At the time of the review on 02/05/13, the facility did not have the cause of death until the autopsy/coroner's report was received by the facility on 07/11/13. Review on 10/07/13 of the Autopsy/Coroner's Report provided to the survey that day revealed that the patient died of naturai causes. The ?nal Cause of Death was Heart Failure due to Hypertension and Arteriosclerotic Cardiovascular Disease, which appeared multidisciplinary analysis includes a physician. Outcomes are reported to the Committee of the Whole (COW). YRN711 If continuation sheet 25 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCEES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 006 Continued From page 25 006 unrelated to his/her condition and hospitalization. d) Review on 09/23/13 of the medical record Of Sample Patient #13 ("After Discharge Death, Suicide") revealed that the patient was admitted on 02/01/13 with a diagnosis of Major Depression, Opiate Abuse and Chronic Pain. The patient was discharged on 0206/13, day 6 of hospitalization. The hospital was later notified by a county coroner that the patient had committed suicide on 02/13/13, 1 week after discharge. Review of the case review report, dated 03/01/13, revealed that no was present during the review. The only significant Clinical factors identi?ed were that pain control and level of depression throughout the hospitalization were not adequately monitored or addressed in the care plan and discharge plan arrangements. The patient contacted a hospitai provider 02/ 12/13, one day before the suicide, stating that the referral pians for pain management appointment had not been successful. The patient was given the name of another pain management program to contact. The case review was conducted approximately 3 weeks after the suicide. A facility document stated that the coroner had requested the medicai record of the patient and had provided the information that the patient had died by suicide from a gunshot wound to the head. e) Review on 09/23/13 of the medical record of Sample Patient #14 ("After Discharge Death, Suicide") reveaied that the patient was actually oniy seen on 03/05/13 for less than an hour in the Intake Department. The patient was seen for an evaluation for day program, after having just been released and referred from another acute care hospital unit earlier that day after a 14 day inpatient hospitalization. The patient had diagnoses Of Anxiety with Xanax YRN711 If continuation sheet 26 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF PROVIDER IDENTIFICATION CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED 064024 10/07/2013 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 30130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 006 Continued From page 26 Abuse and Chronic Pain with daily Migraine Headaches. The patient was "referred to pain management specialists," but the record did not contain the name, number or an appointment date for the referral. The assessment stated the patient was extremely anxious and required a pain management Specialist as well as intensive Outpatient Treatment (IOP). It did not appear that the patient was enrolled in the IOP program at the hospital as planned. The hospital was noti?ed that the patient had committed suicide 03/20/12, approximately 2 weeks after being evaluated. On 09/24/13 at 9:23 am, the Risk Manager confirmed that no review was conducted on the care provided to the patient, since the patient was not admitted. There was no attempt to Obtain a coroner's report/autopsy. f) Review on 09/23/13 of the medical record for Sample Patient #16 "After Discharge Death Other" revealed that the patient was admitted on 07/21/13 with a diagnosis of Mood Disorder and Personality Disorder. The patient was discharged on 07/30/13, day 10. The patient had a very strong family history of Bipolar Disorder with multiple suicides in the extended family and difficult relationships with parents and Siblings. The family expressed concerns about the patient's safety and his/her honesty in reporting and paranoia. The patient was discharged home to family with outpatient therapy arranged. The hospital was later notified by a county coroner that the patient had died on 08/23/13, 23 days after discharge, cause of death still not determined/released by the coroner at the time of the survey. Per interview with the Risk Manager on 09/24/13 at 9:23 am, at the time of the survey, no case review had been conducted after approximately a month after the death of the patient. 006 if continuation Sheet 27 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING. COMPLETED 054024 10/07/2013 NAME or PROVIDER OR SUPPLIER STREET ADDRESS, CITY, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8555 POPLAR WAY LITTLETON 80130 5D SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX CORRECTIVE SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 006 Continued From page 27 The Risk Manager stated that the parent corporation for the facility required that a risk?oriented review had to be completed within 30 days after noti?cation of a death and that the coroner reports lautopsies were usually not available for 2?3 months after a death. S/he stated they did the reviews sometimes without knowing the cause of death and whether it was a suicide, from medical causes, or an accident. S/he stated that s/he revisits the review after the coroner's report/autopsy are received and sometimes gets a physician in for a later review. The Risk Manager was unable to provide evidence of a subsequent review or of a physician review. Autopsy/coroner's report received on 10/21/13 after the survey showed that the patient died by hanging/suicide, there were also "cutting" type injuries, the victim left a "suicide?type note at the scene,? and there was a "Clinicai history of depression and suicidal ideation." 9) Review on 09/24/13 of the medical record for Sample Patient #21 reveaied that the patient was admitted on 04/27/13 with a diagnosis of Bipolar Disorder with history of Alcohoi Abuse, Suicidai Ideation, Personality Disorder and Homelessness. During the hospitalization the patient verbalized concern about being discharge too soon and not being able to afford the medication prescribed (Ability). The provider suggested that the patient speak to the outpatient therapy referral about getting medication samples, but that was not resoived prior to discharge. The patient also had a significant episode of insomnia requiring medication on the night prior to discharge. The patient was discharged on 05/13/13, day 17 of hospitalization. The hospitai was later noti?ed by a county coroner that the patient had committed suicide on 05/13/13, the day of discharge. Review of the case review report dated, 006 If continuation sheet 28 of 65 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER IDENTIFICATION NUMBER: 064024 VIULTIPLE CONSTRUCTION BUILDING: DATE RVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, CODE 8565 POPLAR WAY LITTLETON 80130 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICTENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG To THE APPROPRIATE COMPLETION DATE 006 Continued From page 28 05/28/13 revealed that no was present during the review. The only significant clinical factor identi?ed was that the patient refused to participate in a family meeting prior to discharge. A facility document stated that the facility had been contacted by a local county coroner on 5/14/13, the day after the patient '5 discharge to requested medical records with information that the patient appeared to have committed suicide by a medication overdose. The case review was conducted approximately 2 weeks after the suicide, and the action plan referred to the Discharge Planning policy/procedure which addressed the provision of community resources, including food and shelter, medical care and follow?up to homeless patients as a part of the discharge planning process. but there was no evidence of a subsequent review or an attempt to obtain/review the coroner's report/autopsy. That was confirmed by the Risk manager on 10/07/13 h) During an interview on 09/24/13 at 9:23 am, the Risk Manager stated that the parent corporation for the facility required that a risk?oriented review had to be compteted within 30 days after notification of a death and that the coroner reports lautopsies were usually not available for 2?3 months after a death. S/he stated they did the reviews sometimes without knowing the cause of death and whether it was a suicide, from medical causes, or an accident. S/he stated that s/he revisits the review after the coroner's report/autopsy are received and sometimes gets a physician in for a later review. The Risk Manager was unable to provide evidence of a subsequent review or of a physician review. Of the 6 deaths reviewed (Sample Patients #11, #12, #13, #14, #16, the Risk Manager was 006 If continuation sheet 29 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 iD SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) iD PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE 006 Continued From page 29 only able to provide a review for 4 of the patients #12, #13, S/he provided background notes s/he had done in anticipation of conducting a review of the death of Sample Patient #14. Review of the case reviews conducted by the Risk Manager revealed that they were all conducted from a risk assessment point-of View, rather than from a multidisciplinary clinical case review point of View. Of the the 4 reviews, oniy 1 had a participant in the review. of the reviews included?nursing managers from other units, but no nursing staff who had worked with/knew the patient. Review of each case review report revealed a pattern of the treatment teams not addressing significant issues, such as job loss. financial stressors, pain controi, and lack of family support in the care plan or taking those things into consideration follow-up care and housing situations were arranged. 007 Survey Details This REGULATION is not met as evidenced by: 6 CCR 1011?1, Standards for Hospitais and Health Facilities Chapter 18, Hospitals Promulgated by the State Board of Health Last amended 06/19/13, effective 08/14/13 Part 12. NURSING DEPARTMENT. The facility shall provide nursing services in conformance with the standards established in Chapter IV, Part 12, Nursing Services. Chapter 4, General Hospitals Promulgated by the State Board of Health Last amended 06/19/13, effective 08/14/13 Part 12. NURSING 12.100 12.101 ORGANIZATION AND STAFFING (1) There shall be a nursing department. The nursing department shall be organized formally to provide complete, effective care to each 006 007 In addition to the actions described under 8 0008 and 0009, the facility took the following actions with respect to nursing staff assessments and reassessments of patients? conditions: The CEO directed the Director of Nursing to revise the patient observation rounds poiicy by adding more precise language about nurses? assessment/reassessment of patients. This ciearer language emphasizes that all patients should be reassessed by an RN if they exhibit medical and/or behavioral changes including repositioning, snoring, and unusuai breathing patterns of sleeping patients. 11/29/2013 YRN711 If continuation sheet 30 of 66 . . Printed: 12/15/2014 Coiorado Department of Pubiic Health and EnVIronment Health and Emergency Medicai Services Division STATEMENT OF PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING, COMPLETED 054024 10/07/2013 NAME OF FROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3555 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN or CORRECTION COMPLETHJN PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE 007 Continued From page 30 007 patient. (2) The nursing service department shall be under the direction of a registered nurse qualified by education and experience to direct effective nursing care. 6) The director of nursing Shall be responsible for ensuring that all nursing staff have the qualifications, skills and experience necessary to deliver the care assigned in accordance with professional standards of practice and facility policy and procedure. 12.102 PROGRAMMATIC FUNCTIONS (1) There Shall be written nursing procedures that establish the standards of performance for safe, effective nursing care of patients. These procedures shall be reviewed periodically and revised as necessary. (2) Nursing staff shall conduct initial and ongoing assessments and screenings of the patient physical, cognitive, behavioral, emotional and status in sufficient scope and detail to meet the needs of the patient, according to facility policy and professional standards of practice. The Requirement is NOT MET as evidenced by: Based on review of medical records and facility documents and staff interviews, the director of nursing services failed to ensure that nursing staff adequately assessed and documented patient changes in conditions care and compiled with related poiicies and procedures. Findings: 1. The nursing staff failed to adequately reassess and document the ?ndings for Sampie Patient #1 when there was evidence of a change of condition. The facility Reassessment Policy read: The CEO directed the Director of Nursing to have 100% of nurses complete a competency check-off on assessment/reassessment of patients. The Director of Nursing/designees provided retraining and competency checks to all nurses on assessment/reassessment of patients. The checklists are in the master training fiies. This training covered the assessment and reassessment of patients? general physical and mental condition, Signs and of Change in condition, expectations for corresponding documentation, and notification of physicians of changes in patients? condition, including but not limited to: 1. Vital signs 2. Oxygen saturation levei 3. Emesis (including coior, quantity and quality) 4. Any additional change in patient condition 5. Notification of physician and orders received The Director of Nursing also re?educated nurses on issues that can arise when patients are prescribed multiple medications, particuiarly medications with sedative effects, and on the need to initiate on?going assessments of patients on multiple medications when the patients appear sedated. The Chief Medical Officer presented a revised Ciinical Institute Withdrawal Assessment form for assessing patients going through alcohol detox and a new Clinicai Opiate Withdrawal Scale If continuation sheet 31 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 DATE SURVEY COMPLETED 10/07/201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 007 Continued From page 31 007 2. Each Patient is reassessed daily (every 24 hours) and/or as the patient's condition warrant, by an RN. Any condition change noted must be reported to the RN. 3. Reassessment is done to determine the patient?s response to treatment or when a change occurs each shift." a) Review on 09/18/13 of the medical record for Sample Patient #1 revealed that the patient was a young adult admitted on 7/18/13 with history of diagnoses of Episodic Mood Disorder, Multiple Substance Abuses including Opiates, Cocaine and Benzodiazepines, Victim of Sexual Abuse and insomnia. The patient was treated with Valium and Vistaril for anxiety, fentanyl patches for pain, and the medications, Lexapro and Neurontin The patient was found on 7/27/13 at approximately 9:30 am. not breathing, no pulse, cyanotic and in full rigor mortis in his/her room. (Rigor mortis occurs when the limbs of the corpse becomes stiff and dif?cult to move or manipulate. In humans, it commences after about three to four hours, reaches maximum stiffness after 12 hours, and gradually dissipates untii approximately 48 to 60 hours after death). However, the record showed that 15 minute Checks were documented and showed the patient slept all night from approximately midnight with loud snoring. Priorto the patient's being found dead, nurses were documenting that the patient was very sedated and severai doses of Valium were withheld because of over?sedation, but no nurse initiated additional vital signs to reassess the patient's condition. During the night prior to the patient being found dead, the record showed that the patient was "snoring" very ioudly after having gone to bed in a condition characterized as very sedated. There was no evidence that the patient was assessed by nursing staff during the night with attempts to arouse the patient or (COWS) Assessment form for assessing patients going through opiate detox to the Medical Executive Committee (MEC) for approval. The CIWA and COWS Assessment forms contain criteria for nurses to use in assessing and scoring withdrawal of patients going through detoxi?cation. The MEC approved the forms and emphasized the importance of: 1. Nurses notifying the physician of any change in patient condition or of high scores on the CIWA or COWS assessment. 2. Nurses documenting their assessment and observations, including their withholding of additional medications and conducting of close patient monitoring while waiting for additional physician orders. The Director of Nursing trained 100the revised CIWA and the new COWS assessment forms. The Director of Nursing is monitoring completion of 100% of and COWS forms as described further below. The CEO directed the Director Of Education and Process Improvement to conduct additionai Mock Code Blue Drills to reinforce nurse competency for patient assessment/reassessment. The Mock Code Blue Drills are conducted using various scenarios to provide nursing staff a variety of potential patient Circumstances where nurses practice assessment and critical?thinking processes. Ten Mock Code Blue Drills have been completed: two mock drills were conducted in July (7.31.13?Unit 2 and the Adolescent Unit), three mock drills in August (8.26.13?Unit 1, 8.29.13?Unit 1 and Intake), three mock drills in YRN711 if continuation sheet 32 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 007 Continued From page 32 007 Check vital signs (including oxygenation status). In addition, earlier in the evening prior to the patient?s death, the patient had at ieast two episodes of emesis and required medication for that. There was no documentation of a physical assessment when the emesis events happened, and there was no documentation of the nature, amount and contents of emesis in the record. Further review of the medical record revealed that the patient was receiving Melatonin for sleep, Valium and Vistaril for anxiety, Neurontin and Lexapro for anxiety and depression and Fentanyl transdermal patches for pain. On the two days prior to the patient being discovered deceased on the morning of 07/27/13, the patient received the following medications that had a central nervous system depressing effect: 07/25/13: 3 mg Meiatonin 100 fentanyl transdermal patches 40 mg Lexapro Valium 50 mg Neurontin 1800 mg Vistaril 75 mg 07/26/13: 100 fentanyl transdermal patches 40 mg Lexapro Vaiium 10 mg Neurontin 1800 mg Vistaril 75 mg b) Review of the "Mosby's 2012 Nursing Drug Reference, 25th Edition," revealed the medications all had central nervous system (CNS) depression effects which can cause drowsiness and vital Sign Changes and respiratory depression. There were interactions among some of the medications that potentiated the actions of the various CNS depressants as September (9.5.13?Adolescent medicai response, 9.16.13?Gymnasium and Unit 2), and two mock driils in October (10.16.13?Adolescent Unit and 10.26.13??Unit 1 and Adolescent Unit). Mock are to continue at least twice a month. Findings con?rm that nursing staff benefit by practicing critical thinking skills on various patient scenarios. The Director of Education and Process Improvement reports mock drili outcomes at the Committee of the Whole and MEC meetings, and quarterly to the Board of Directors. Quiet Room Use: The Director of Nursing developed a new Quiet Room form that lists the criteria for use of the Quiet Room, emphasizes the limited use of the Quiet Room, and inciudes a reminder to continue patient observation rounds in accordance with procedure during the short duration a patient is in the Quiet Room. The CEO directed that nursing staff use the new Quiet Room form as a checklist and teaching tool, including during new employee orientation and annual competencies. The Director of Nursing provided training on the new Quiet Room form to 100% of all nursing staff with evidence of this retraining placed in the master training ?les. Each weekday the Director of Nursing is reviewing nurses? assessment/reassessment documentation, including 100% of any CIWA or COWS forms, for patients admitted on and receiving pain If continuation sheet 33 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medicai Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 101071201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES 1D PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE 007 Continued From page 33 007 well as extending the half-life of the Valium. In addition, the half?iife (time required for half of the amount of the medication to be secreted from the body) for Valium was 20?50 hours per dose. Note that the patient had 5 - 10 mg doses on 07/25/13, which was the day the patient began to show significant sedation. By the morning of 07/26/13, the patient was so sedated that S/he only received a 4:05 am. PRN dose of Valium. The morning and evening and PRN doses of Valium were heid due to the patient's level of sedation, but the patient continued to receive the other CNS depressing medications Lexapro, Fentanyl, Neurontin and Vistaril throughout that day. The patient was found to be deceased at about 9:30 am. on 07/27/13. 0) Review of, "Taylor's Clinical Skills Nursing," copyright 2008, pages 745 751 stated standards of nursing care regarding respiratory assessment and measuring blood oxygenation with the use of a pulse oximeter. The standard states Many medications affect the function of the respiratory system. Many medications depress the respiratory system. The nurse should monitor patients taking certain medications, such as opioids, for rate and depth of respirations." The standards state that "a range of 95% to 100% is considered normal," when assessing blood oxygenation with a pulse oximeter. Review of the patient's vital signs revealed that the patient had pulse oximeter reading on admission on 07/18/13 of 99% oxygen saturation. On 07/20/13 and 07/23/13, the patient's oxygen saturation had declined to 94%, which as below the normal range. On 07/26/13, the day prior to the patient's death, the patient's oxygen saturation level was 93% at 8:30 am. and declined to 90%, far below the normal range, by 7:45 p.m. Despite the patient's medications. The review is to con?rm completeness of assessment/reassessment documentation and appropriate actions taken in accordance with poiicy based on a patient?s response to medications, change in condition, and/or high score on a CIWA . or COWS assessment. The Director of Nursing provides a summary report of audit results to the meetings of the Committee of the Whole and the MEC, and the quarterly meetings of the Board of Directors. YRN711 If continuation sheet 34 of 66 Colorado Department of Pubiic Health and Environment Pnnted: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 801 30 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION (EACH DEFECIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR 1.80 IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DEFICIENCY) 007 Continued From page 34 007 decreased oxygen saturation and extreme sedation, no reassessments of the patient were conducted after the 7:45 pm. pulse oximeter reading, even though the patient was on multiple medications, including an opioid, that had respiratory and central nervous system depressing effects. d) On 09/25/13 at 9:20 am, BHA was interviewed by telephone about observation rounds conducted for Sample Patient #1 on the night shift (11 pm. to 7:30 am.) on the night of 07/26-27/13. The BHA stated that the patient was snoring loudly, once asleep at approximateiy 12:00 am. S/he stated that s/he was concerned about the loud snoring, which s/he stated was able to be heard "even at the nurses' station." The BHA stated that s/he went to the charge nurse (RN and medication nurse (RN who were both at the nurses' station and noti?ed them of his/her concern about the ioud snoring. S/he stated that s/he did not see either of the nurses respond to his/her information and go to check on the patient at that time. S/he stated that the charge nurse (RN took over part of his/her rounds at approximately 1 am, including the rounds for Sample Patient S/he stated s/he resumed rounds on Sample patient #1 at approximately 6 am, and recalled that at 6 the patient was no longer snoring loudly. The BHA stated that s/he continued to make rounds until the end of the shift and did ?nal hand?off rounds with the on?coming shift BHA as the shift was ending at 7:30 pm. e) On 09/26/13 at 1:20 pm, RN who was no longer an empioyee of the facility, was interviewed by telephone, about observation rounds conducted for Sample Patient #1 on the night shift (1 1 pm. to 7:30 am.) on the night of 07/26?27/13. S/he con?rmed that Sample Patient #1 was snoring loudly during the night YRN711 If continuation sheet 35 of 66 Colorado Department of Public Heaith and Environment Heaith Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 007 Continued Frorn page 35 and that the noise could be heard even at the nurses station. S/he had no memory of the BHA asking him/her to check on the patient. S/he stated that s/he did make rounds on the patient for part of the night. S/he stated that this was his/her ?rst night working on that unit, so s/he was not familiar with the sleeping habits of Sample Patient including whether the snoring was typical or unusual for that patient. S/he recalled that the patient had appeared very drowsy at about 11:45 pm. when s/he came up to the medication window requesting Valium. S/he stated she refused to give the patient the Valium because Of his/her level of sedation, but did not take vital signs or call the provider. S/he confirmed that s/he did not go in to the patient's room to do an assessment or to initiate vital signs for the patient. S/he stated s/he was a newly graduated nurse and that it was his/her ?rst nursing job. f) On 09/26/13 at 11:55 a. during an interview with the president of the medical staff, the care and medical record of Sample Patient #1 was discussed. The medicai director stated that s/he and another provider had conducted an independent review of the case, since they had not cared for the patient. During the interview, the expectations for nurses to initiate additionai vital signs or other assessments of this patient, related to over-sedation, loud snoring at night and the documentation Of the patients episodes of vomiting was discussed. S/he agreed that nurses Should have initiated reassessment of the patient, provided accurate documentation and even contacted the doctor about concerns related to these issues. 9) On 09/19/13 at 11:05 the Nurse Educator was interviewed and the expectations for documentation of patient and reassessment of the patient when there was 007 YRN711 If continuation Sheet 36 of 66 Colorado Department of Public Health and Environment Prmted: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER IDENTIFICATION VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: 3UILDING: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER I STREET ADDRESS, CITY, STATE, zaP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 3 WAY 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 007 Continued From page 36 007 evidence Of a possible change of condition was discussed, S/he stated that nurses should have reassessed the patient related to increased sedation and very noisy snoring during sleep. In addition, s/he stated that the nurses did not adequately document the episodes Of emesis, including times, whether witnessed, nature of the emesis and quantity, as s/he would expect as a standard of nursing care and documentation. 8 008 Survey Details 8 008 11/29/2013 This REGULATION is not met as evidenced by: 6 CCR 1011-1, Standards for Hospitals 30d Patient Assessment/Reassessment: Health Facilities Chapter 18, The CEO directed the Director of Nursing by the State Board Of HeaIth to have 100% of nurses complete a Last amended 06/19/13, effective 08/14/13 . competency Check_0ff on Part 13- PHARMACEUTICAL SERVICES assessment/reassessment of patients. The facility shall prOVIde pharmaceutical services in conformance with the standards The Director of Nursing/designees estabIIshed in Chapter IV. Part 13. provided retraining and competency Pharmaceutical SGWICGS. checks to a? nurses on Chapter 4, General assessment/reassessment of patients. Promulgated by the State Board Of Health The Checklists are in the master training Last amended 06/19/13, effeCtIVS 08/14/13 This training covered the Part 13. PHARMACEUTICAL SERVICES assessment and reassessment of 13-102 PROGRAMMATIC FUNCTIONS patients? general physical and mentai (5) AdminIStration. MedicatIonS condition, signs and of change be identi?ed WIth at ieast the name, strength, in expectations for anti dosage. Prior to administration, the name, corresponding documentation, and strength, dosage, frequency and route 0f notification of physicians of Changes in administration on the patient order Shall be patients? condition, including but not Checked. The facility shall develop and limited to: impiement policies and procedures regarding: the review of patient drug profiles. 1_ Vital signs safe administration of drugs and biologicals. 2. Oxygen saturation level Only persons who are authorized by law and the 3_ Emesis (including coior, quantity and facility and are appropriately trained shall quality) administer medications 4. Any additional change in patient (C) monitoring and documenting the effects of If continuation Sheet 37 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/0712013 NAME OF OR SUPPLIER HIGHLANDS BEHAVIORAL STREET ADDRESS, STATE, ZIP CODE 8565 POPLAR WAY 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING TAG CROSSREFERENCED to THE APPROPRIATE DEFICIENCY) 008 Continued From page 37 008 medication, including but not limited to, the condition process for monitoring the first dose of a 5. Notification of physician and orders medication that has been identified as one with received the potential for serious adverse reactions. identi?cation and reporting of adverse reactions, interactions, and medication errors. The Requirement is NOT MET as evidenced by: Based on document review and interviews the facility failed to ensure that staff Registered Nurses administered medications per physician orders. Transdermal Fentanyl patches were administered to Sample Patient #1 at a more frequent time interval than ordered by the patient's physician. Nursing staff also failed adequately assess the patient's change of condition that may have been related to the combinations of medications being administered. The facility also failed to investigate the medication regime and medication administration variances that may have contributed to the death of Sample Patient Findings: 1. Registered nursing staff did not administer Fentanyl per a physician's order. Nursing staff Changed a patient's transdermai Fentanyl patch sooner than the 72 hour time interval ordered by the patient's physician. a) On 09/19/13 at 3:26 review of the medical record for Sample Patient #1 was conducted. The patient was admitted to the facility on 07/18/13. Upon admission the patient had been prescribed Fentanyl for Chronic pain issues. The patient's record revealed a physician order for Fentanyl Patch, 100 micrograms, (every) 72 hours was received on 07/18/13. The record reflected that this medication was ordered to be discontinued on 07/21/13. The medical record revealed the The Chief Medical Officer presented a revised Clinical institute Withdrawal (CIWA) Assessment form for assessing patients going through alcohol detox and a new Clinical Opiate Withdrawai Scale (COWS) Assessment form for assessing patients going through opiate detox to the Medical Executive Committee (MEC) for approval. The CIWA and COWS Assessment forms contain criteria for nurses to use in assessing and scoring withdrawal of patients going through detoxi?cation. The MEC approved the forms and emphasized the importance of: 1. Nurses notifying the physician of any change in patient condition or of high scores on the CIWA or COWS assessment. 2. Nurses documenting their assessment and observations, including their withholding Of additional medications and conducting of close patient monitoring while waiting for additional physician orders. The Director of Nursing trained 100the revised CIWA and the new COWS assessment forms. The Director of Nursing is monitoring completion of 100% of CIWA and COWS forms as described further below. The CEO directed the Director of Education and Process improvement to conduct additional Mock Code Blue Drills to reinforce nurse competency for patient assessment/reassessment. The Mock Code Blue Driils are conducted using various scenarios to provide nursing staff YRN711 If continuation sheet 38 of 66 Colorado Department of Public Heaith and Environment Heaith Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 101071201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID . SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 38 008 medication was discontinued on this date (7/21/13) by a physician order as the patient reported s/he "fiushed" one of the Fentanyl patches. A new physician order for Fentanyi Patch, 100 micrograms, 72 hours, was documented in the patient's record on 07/22/13 at 8:45 pm. The Medication Administration Record for Sample Patient completed by nursing staff, revealed Fentanyl, 100 micrograms, in the form of a transdermal patch, was administered to Sample Patient #1 on 07/19/13 at 10:00 am. to the patient's left chest area. Review of the MAR reflected Fentanyl, 100 micrograms was placed "on" the patient on 07/22/13 at 8:45 pm. The MAR reflected that Fentanyi, 100 micrograms was placed on the patient again on 07/25/13 at 9:00 am. and on 07/26/13 at 9:00 am. The doses documented on 07/25/13 and 07/26/ 13 reflected the Fentanyl patches were administered to the patient 24 hours apart, not 72 hours apart as ordered by the patient's physician. NO documentation could be found in the patient?s medical record indicating that nursing staff had received a new order for Fentanyl from a physician or that nursing staff had contacted a physician to obtain a new/different order for this medication. The same disbursement of Fentanyl patches were confirmed on the Fentanyl 50 Patch Inventory Activity form and the Control ll Narcotics form for the same dates. Further there was no documented evidence that the used patches were retrieved by nursing staff prior to administration of the new patches. 2. Registered Nursing staff did not use standards of nursing documentation when documenting activities around administration of Fentanyl patches, or "missing" Fentanyi patches, 3 Schedule II, Controlled Substance. Registered nursing staff did not document skin assessments of Sample Patient #1 prior to the a variety of potential patient circumstances where nurses practice assessment and critical-thinking processes. Ten Mock Code Blue Drills have been completed: two mock drills were conducted in July (7.31.13?Unit 2 and the Adolescent Unit), three mock drills in August (8.26.13?Unit 1, 8.29.13?Unit 1 and Intake), three mock drills in September (9.5.13?Adolescent medical response, 9.16.13??Gymnasium and Unit 2), and two mock in October (10.16.13?Adoiescent Unit and 10.26.13?Unit 1 and Adolescent Unit). Mock drills are to continue at ieast twice a month. Findings confirm that nursing staff benefit by practicing critical thinking skills on various patient scenarios. The Director of Education and Process improvement reports mock drill outcomes at the Committee of the Whole and MEC meetings, and quarterly to the Board of Directors. The Director of Nursing and the Director of Education and Process improvement re?educated 100% of nursing staff (RNS and BHAS) on patient observation rounds as follows: 1. 100% of nursing staff were trained on the revised patient Observation rounds policy. 2. 100% of nursing staff had the observations competency checklist signed Off by the nurse manager, nurse supervisor, or training ambassador. Competency demonstration included the use of the ?ashlight in order to watch the rise and fall of the patient?s chest for three breaths; repositioning the patient when rise and fall of the Chest is not easiiy discernible, the patient is snoring, or the patient has breathing dif?culty; and YRN711 If continuation sheet 39 of 66 Colorado Department of Public Health and Environment Heaith Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 administration Of Fentanyl patches. a) Review of Mosby's 2012 Nursing Drug Reference, 25th edition, stated under dosage and routes, that Fentanyl transdermal patch should be applied to a "flat surface on upper torso and wear for 72 hr; apply new patch on different site for continued relief. b) Review of, "Taylor's Clinical Skills Nursing," copyright 2008, pages 236-239, stated standards of practice for nurses when applying transdermal patches to patients. The standard states the patient's skin should be assessed prior to placing patches and that skin should be clean, dry, and free of hair. The standard states specific medication patches could have speci?c instructions Of where to place patches and that nursing staff Should refer to the manufacturer's instructions to determine where to place patches. The standard states transdermal patches should not be placed on "irritated or broken skin" and that placement Of patches should be rotated. The standard states nurses should write their initials, date, and time of administration on the label side of the patches. The standard states prior to administration of patches, patients should be assessed for "Old patches", which shouid be removed, folded in half and disposed of per the facility?s policy. The standard states, "Document the administration of the medication immediately after administration, including date, time, dose, route of administration, and site of administration on the MAR or record using the required format." The standard goes on to state, "Ongoing assessment is an important part of nursing care to evaluate patient response to administered medications and early detection of adverse effects. if an adverse effect is suspected, withhold further medication doses and notify the patient 5 primary healthcare provider. Additional intervention is based on type Of reaction and patient assessment." ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 39 008 arousing the patient and checking Vital signs when a physical or mental change has occurred with the patient. Monitoring/Tracking: Each weekday, the Director Of Nursing is reviewing nurses? assessment/reassessment documentation, including 100% Of any CIWA or COWS forms, for patients admitted on and receiving pain medications. The review is to con?rm completeness of assessment/reassessment documentation and appropriate actions taken in accordance with policy based on a patient?s response to medications, change in condition, and/or high score on a CIWA or COWS assessment. The Director of Nursing provides a summary report of audit results to the meetings of the Committee of the Whole and the MEC, and the quarterly meetings of the Board of Directors. Medication Administration: The Director of Nursing reviewed and confirmed the accuracy and completeness Of the Hospital?s medication administration policies. The Director of Nursing re-educated nursing staff on the process for reporting a medication variance or potential error, and clari?ed what is a variance and what Should be reported as follows: 1. All medication orders that are not written on the MAR as the physician prescribed are considered to be a vanance. 2. Additionally, all medications that are administered incorrectly, or not as the physician prescribed, are considered to be If continuation sheet 40 of 66 . . Printed: 2 Colorado Department of Public Health and Envrronment 1 [15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING. COMPLETED 064024 1 0107/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 3 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF OEFICIENCIES ID PROVIDERS PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DEFICIENCY) 008 Continued From page 40 008 c) The FDA put out public health alerts in 2005 and again in 2007 stating "the [adverse event] reports indicate that patients are continuing to incorrectly use the fentanyl patch by replacing the patch more frequently than directed in the fentanyl patch instructions, applying more patches than prescribed, or applying a heat source to the patch, all resulting in dangerously high fentanyl levels in the blood. The fentanyl patch contains fentanyl, a very potent narcotic pain medicine. It is only intended for treating persistent, moderate to severe pain in patients who are opioid-tolerant, meaning those patients who take a regular, daily, around-the?Clock narcotic pain medicine. This is extremely important because patients who are opioid-tolerant are more resistant to the dangerous Side effects of narcotic pain medicines than patients who only occasionally take these medicines. For patients who are not opioid-tolerant, the amount of fentanyl in one fentanyl patch of the lowest strength is large enough to cause dangerous side effects, such as respiratory depression (severe trouble breathing or very slow or Shallow breathing) and death professionals who prescribe and patients who use the fentanyl patch should be aware of the signs of fentanyl overdose including the following: trouble breathing or slow or Shallow breathing; slow heartbeat; severe sieepiness; cold, Clammy Skin; trouble walking or talking; or feeling faint, dizzy, or confused. if these signs occur, patients or their caregivers Should get medical attention right away." d) Review of the full package insert for Duragesic (fentanyl) patches revealed the following information and instructions for use: Duragesic (Fentanyl) contains a high concentration of Fentanyl, a Schedule II controlled substance, which is subject to misuse, abuse, addiction, and criminal diversion. Fatal respiratory depression could a medication variance. 3. Any staff member identifying a medication variance or potential error should complete an Incident Report and return it to his/her supervisor. 4. The supervisor then tonrvards the incident Report to the Director of Nursing. 5. Following the Director of Nursing?s review, the Director of Risk Management and the Director of Education and Process Improvement also conduct a review. 6. All medication variances are reported to the meetings of the Committee of the Whole and the MEC, and to the quarterly meetings of the Board of Directors. 7. The Director of Nursing works with the specific nurse involved with the variance(s), and identi?es and analyzes What happened and any trends (as applicable) with the pharmacist in order to attempt to prevent reoccurrences. The clarification of what constitutes a reportable medication variance was addressed in the Committee of the Whole meeting. The Director of Nursing re-educated all nursing staff on the medication administration process. Training included but was not limited to: 1. Medication variances from the prescribing phase 2. Medication variances from the transcription phase 3. Medication variances from the administration phase 4. Medication variances through the monitoring phase 5. Nurses notifying the physician, informing the physician about YRNT11 If continuation Sheet 410i 66 . . Printed: 12/15/2014 Coiorado Department of PublIC Health and EnVIronment Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER IDENTIFICATION CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS HEALTH SYSTEM 3555 3 POPLAR WAY LITTLETON 80130 In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 008 Continued From page 41 008 occur in patients who are not Opioid-tolerant and in patients that are opioid?tolerant even if DURAGESIC is not misused or abused. Schedule II opioid substances, including Fentanyl, have the highest potential for abuse and risk of fatal overdose due to respiratory depression. Respiratory depression has been reported with use of DURAGESIC in patients who are opioid?tolerant, even when DURAGESIC has been used as recommended and not misused or abused. Persons at increased risk for Opioid abuse include those with a personal or family history of substance abuse (inciuding drug or alcohol abuse or addiction) or mental illness major depression). Patients at increased risk may still be appropriately treated with modi?ed?release opioid formulations; however, these patients will require intensive monitoring for signs of misuse, abuse, or addiction. The patch may be used continuously for 72 hours, and each patch shouid be applied to a different skin site after removal of the previous transdermal patch. Patches should be applied to intact, non?irritated, and non?irradiated Skin on a flat surface such as the chest, back, flank, or upper arm. if the patch falls off before 72 hours, dispose of it by folding in half and flushing down the toilet. A new patch may be applied to a different skin site. Proper disposal of Duragesic is advised in order to prevent adverse reactions, including death, associated with accidentai secondary exposure to Duragesic. Dispose of used patches by folding the adhesive side of the patch to itself, then flush the patch down the toilet immediately upon removal. e) Lab results from a drug screen dated 07/19/13, at the time of admission, showed Sample Patient #1 was positive for penzodiazepines, cocaine, and opiates. In the Discharge Summary for the patient, the physician stated the patient had a history of polypharmacy concerns, and initiating additional patient monitoring The MEC voted to eiiminate Fentanyl patches from the formulary. Any new patient admitted with a Fentanyl patch must have the patch removed, and an alternative pain medication must be prescribed. During the MEC meeting on 9/24/2013, all physicians were encouraged to check on their patients? controlled substance prescriptions through review of an online medication verification database. Physicians can access the database and confirm a patient?s currently prescribed narcotics and dosages, regardless of who the prescribing physician is. Utilization of the medication verification website provides physicians with information about medications prescribed to their patients so the physicians are well-informed of potential polypharmacy concerns and accurate medication dosages before they order additional medications or make changes in their patients' medications. Follow?up email correspondence to the physicians reminded them about using this medication verification website. The CEO con?rmed that the pharmacist regularly uses this website to check for polypharmacy issues and is responsible for discussing polypharmacy concerns with the prescribing physician. The Director of Nursing developed a form and is monitoring to con?rm the pharmacist is checking the website as indicated. The Director Of Nursing deveioped a new policy on ?Medication Patches,? which was YRN711 If continuation sheet 42 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 attention de?cit hyperactivity disorder, major depressive disorder, and a history of substance dependence. f) Review of the medicai? record for Sample Patient #1 revealed documentation by a Registered Nurse on 07/19/13, that Fentanyl patches were placed on the patient?s "left chest area." No further documentation was found in the record indicating where subsequent patches were placed, so no evidence was documented that the patches were "rotated or placed on a different site, per the manufacturer's directions. 9) Review of the initial nursing assessment for Sample Patient dated 07/19/13, revealed a skin assessment was documented by nursing staff. The medical record contained no other documentation of skin assessments by nursing staff, including no assessment of the patient's skin prior to placing fentanyl patches, per the manufacturer and per standards of nursing care. h) Review of the initial nursing assessment dated 7/19/13 for Sample Patient #1 revealed the patient's pain level was 5/10 on the facility's pain scale upon admission. A nursing note dated 07/23/13 at 2:15 pm, stated the patient was "groggy and sluggish was lying down during the day shift" and "complained of pain." A nursing noted dated, 07/25/13 at 3:30 pm, documented a quote by the patient during this shift that, still have pain, anxiety." A nursing note dated 07/25/13 at 5:50 documented the patient complained of "back pain, spasms, took meds," and returned to bed and fell asleep. No documentation was found in the medical record of the patient's level of pain or further description of pain on these dates. No documentation was found in the medical record on these dates of PRN medications being administered to the patient for pain or other attempts to address patient-reported pain. ED SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 008 Continued From page 42 008 approved by the MEC. The new policy cleariy articulates: 1. That Fentanyl patches are not allowed at this Hospital. Those patients presenting with a Fentanyl patch will have the patch removed, and the treating physician will prescribe an alternate medication if needed. 2. The correct process for administering, monitoring, accounting for, and destroying other medication patches, including conducting daily skin assessments; initialing, timing, and dating the patch; and documenting the skin assessment and presence or absence of a patch. 3. That daily Skin assessments may be increased if a patient has a Change in condition that warrants an additional assessment. 4. The requirement for nurses to contact a physician if a patient exhibits an unusual or unexpected response to a medication patch, or if a patient appears to have lost a medication patch, and to obtain new orders about the patch. The Director of Nursing trained 100% of RNs on the new Medication Patches policy, which includes the correct process. for administering, monitoring, accounting for, and destroying the patches; conducting skin assessment; validating the location of the patch on the patient, and the time, date and the nurse?s initials on the patch; contacting the physician in the event of a problem with a patch; and documenting the assessment, any issues, and any communication with a physician in the medical record. The Director of Nursing also trained 100% of RNS on documenting the date, time and location of the patch and removal of the patch in YRN711 lf continuation sheet 43 of 66 Printed: 12 15 20 Colorado Department of Public Health and Envrronment I I 14 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 1010712013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 POPLAR WAY LITTLETON 80130 1D SUMMARY STATEMENT OF DEFICIENCIES I9 PROVIDERS PLAN OF CORRECTEON COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY on LSC TAG To THE APPROPRIATE DEFICIENCY) 008 Continued From page 43 008 i) Review Of, "Taylor's Clinical Skills Nursing," copyright 2008, pages 555 590 stated standards of nursing care regarding pain. The standards state an accurate assessment of pain is necessary to "guide treatment/relief interventions andevaiuate the effectiveness of pain control measures. The standard states the Registered Nurse should document pain assessment and other significant issues such as pain relief and patient responses. Documentation should include a rating of pain as well as a description of pain provided by the patient. j) A Nursing note documented on 07/26/13 at 10:40 pm. stated the patient had emesis x2 and vomited up his/her most recent medications. The note went on to state the patient was "still having difficulties coping and may be withdrawing from excessive amounts of narcotics in system." No further nursing documentation was found to support what "excessive narcotics" meant. The nurse's note further stated the patient would continue to be monitored in a quiet room every 15 minutes and the current treatment plan would stay enforced. No documentation was found in the record that the patient?s physician was contacted, even with a suspicion by nursing staff of excessive narcotics in the system nor that they suspected the patient may be in withdrawals. k) A nursing note dated 07/27/13 at 5:50 am, stated the patient was at the medication window at 11:45 pm, requesting medications s/he had refused earlier at 9:00 pm, and was failing asleep standing at the med window. The note further stated while the patient was at the medication window drinking Boost, s/he was falling asleep. No documentation by nursing staff was found indicating nursing staff contacted the patient's physician regarding the patient's status. the MAR. Training also reviewed the process for administering oral medications. Monitoring/T racking: The pharmacist monitors medication patch administration and communicates with the Director Of Nursing to confirm proper administration of medication patches. The Director of Nursing audits 100% of documentation on patients with any medication patches, including reviewing the MAR in addition to other iocations in the medical record, to con?rm compliance with the new medication patch policy. All medication variances are reported at the Committee of the Whole and MEC meetings, and quarterly to the Board of Directors. All trends are referred to and addressed through the Nursing and Pharmacy Departments and subcommittees formed as indicated depending on the identi?ed issues. The Director of Nursing is monitoring the Nursing assessments/reassessments, including 100% Of any or COWS forms used for patients undergoing detoxi?cation, for documentation accuracy and completeness, with results/trends/variances reported at the Committee of the Whole and MEC meetings, and quarterly to the Board of Directors. The Director of Nursing is auditing 100% of assessments of patients admitted on pain medication to con?rm documentation accuracy and completeness. Results are reported in the Committee of the Whole and the MEC meetings, and quarterly to the Board of Directors. YRN711 If continuation sheet 44 of 66 Colorado Department ofPublic Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER NUMBER: 064024 MULTIPLE CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE 008 Continued From page 44 I) A nursing note dated 07/21/13 at 3:15 pm, stated the patient "lost his/her Fentanyl patches (plural) as s/he flushed them down the toilet. The nurse documented the patient then denied flushing Fentanyl patches (plural). The note stated a skin check of the patient and a room check were completed. The nursing note did not state the absence of Fentanyl patches on the patient. The nursing note, as written, indicates both Fentanyl patches were flushed down the toilet by the patient. m) Review of a physician order dated 07/21/13, stated for nursing staff to apply Fentanyl patches (100 micrograms) and to "date, time, and check each shift for placement." This order was followed by a physician order, from the same physician, to discontinue Fentanyl as the patient was "removing and throwing away" the patches. n) Review of a nursing note dated 07/26/13 at 3:00 pm, quoted the patient as stating, "Do get a patch now? This one felt off. No further documentation from nursing staff was found regarding a fentanyl patch falling off, if the patch was reapplied to the patient, if the patient's physician was noti?ed of this, or if pharmacy was contacted to aid nursing staff with reapplying the patch or obtaining another patch. 0) There was no documentation by nursing staff in the patient's medical record that Fentanyl patches were visualized daily, or at any interval, to ensure patches remained in place, were intact, that patches had not been removed, etc. even with a physician's order on 07/21/13 to do so and with evidence of the patient fiushing patches. p) Review of the facility's medication administration policy stated nothing about the administration of patch medications, labeling of patches, or documentation regarding placement 008 YRN711 if continuation sheet 45 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF NUMBER: 064024 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 008 Continued From page 45 008 of patches on patients. Section titled, "Administration," stated licensed nursing staff must know the "correct medication, usual dosing, route of administration, appropriate time, expected effects, contraindications, early signs of untoward effects and toxicity, and possible interactions with other drugs or food of the medication they are administering." The policy further stated nursing staff would verify the medication matches the physician's order, and that the medication is being administered at the "proper time, in the prescribed dose, and by the correct route." Nothing in the policy addressed how patches were to be administered, skin checks conducted integrity of patient's skin who was receiving medication via patches, or rotation Of patches administration Sites. q) On 09/2011 3 at 12:37 pm, an interview was conducted with the facility's previous Director of Nursing, who was functioning as the Chief Clinical Officer and Interim Chief Executive Of?cer (Interim CEO) to discuss issues regarding Fentanyl patches for Sample Patient The Interim CEO stated s/he iearned after the patient's death, that the patient reported to staff a missing Fentanyl patch sometime between 07/22/13 and 07/25/13. The Interim CEO stated s/he learned that staff found a medication patch in the courtyard and placed it back on the patient. When asked how staff knew this was a fentanyl patch and that it was the patch missing from Sample Patient she stated the patient was the only patient on any kind Of medication patch on this date. S/he confirmed the patches were not being labeled by nursing staff at this time. The Interim CEO confirmed there was no documentation of this incident in the medical record for Sample Patient including no documentation that the patient's physician was informed Of the incident. The interim CEO con?rmed there was no documented communication with pharmacy YRN711 If continuation sheet 46 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/2013 NAME or PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC INFORMATION) ID PLAN OF CORRECTION COMPLETION PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 46 regarding placing the found patch on the patient. The interim CEO stated Registered Nurses did not document the presence of medication patches, including fentanyl patches, each day when patients were assessed. S/he stated when removing fentanyl patches; this was not documented as a waste by nursing staff even though the habit was for nurses to discard used fentanyl patches into a red sharps container. The Interim CEO con?rmed no documentation that on 07/26! 13, when 2 tentanyl patches were placed at 24 hours, the existing 2 patches were documented as removed and discarded. S/he stated the new documentation for RN use regarding fentanyl had not yet gone through the "chain of command for approval," so was not being used by nursing staff. r) On 09/23/13 at 2:11 pm, the nurse manager that had retrieved the patch from the outside exercise court sometime between 07/22/13 and 07/25/13 was interviewed. She stated that the patch was not initiated or dated, but s/he was certain that it was the patient's fentanyl patch, because of the appearance and the fact that no other patient was currently on that type of patch (Note: two patches had been apptied). When asked if s/he consuited with the physician or the pharmacist before re?applying the patch, s/he stated that s/he only re?applied the patch after consultation with either the COO/Interim CEO or the Acting DON. She stated that the patch did not appear to be damaged or adulterated in any way that would have put the patient at risk. 5) On 09/23/13 at 3:58 pm, the Corporate Clinical Director stated that the lack of documentation of the event was unacceptable, the patches should have been initialed and dated. S/he also expressed concern that the patch had been re?applied to the patient. The facility Nurse Educator also stated his/her concerns about the lack of initialing and dating the patches and the lack of documentation of 008 YRN711 if continuation sheet 47 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 the entire loss/retrieval/re?application of the transdermal fentanyl patch episode. They both state that the new fentanyl policy would speci?cally address these issues and would be followed up with staff re-education about the use of all patches. t) Review of the facility's document titled, Medicai Executive Committee Meeting Minutes dated 09/24/13, revealed a discussion had occurred at this meeting regarding the use of fentanyl patches in the facility. The meeting minutes stated a need for a fentanyl protocol and process to be established for the facility as one did not currently exist. Meeting minutes reflected the medical staff voted unanimously to remove fentanyl from the facility formulary and that while admitted, patients who had been receiving fentanyl would be placed on alternative medications. Prior to this vote, administration had complied a fentanyl patch order form which included instructions to nursing staff on how to apply these patches, to write that date and time of administration and the nurses's initials on each new patch, and to dispose of patches by placing them in the red sharps container on the nursing units. NO documentation or discussion was found in the meeting minutes of the Medical Executive Committee or the Committee Of the Whole regarding placement and documentation required of nursing staff for any other patches used in the facility . u) On 09/24/13 at 11:23 am, an interview was conducted with the facility's contracted pharmacist who stated patches other than fentanyl are used in the facility. No policy or guidance produced that indicated how RNS were to apply, label and document all patches used for patients. V) Review on 09/25/13 of the autopsy/coroner's report for Sample Patient #1 revealed that the patient's death was caused by complications of ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG "to THE APPROPRIATE DEFICIENCY) 008 Continued From page 47 008 YRN711 lf continuation Sheet 48 Of 66 Coiorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF AND PLAN OF PROVIDER IDENTIFICATION NUMBER: 064024 VIULTIPLE CONSTRUCTION BUILDING: DATE SU RVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE. ZIP CODE 8565 POPLAR WAY 80130 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) COMPLETION DATE 008 Continued From page 48 acute fentanyl toxicity. 2. The nursing staff failed to adequately reassess and document the ?ndings for Sample Patient #1 when there was evidence of a change of condition that may have been related to the medications the patient was receiving. The facility's Reassessment Policy read: 2. Each Patient is reassessed daiiy (every 24 hours) and/or as the patient's condition warrant, by an RN. Any condition change noted must be reported to the RN. 3. Reassessment is done to determine the patient's response to treatment or when a change occurs each shift." a) Review on 09/18/13 of the medicai record for Sample Patient #1 revealed that the patient was a young adult admitted on 7/18/13 with history of diagnoses of Episodic Mood Disorder, Multiple Substance Abuses including Opiates, Cocaine and Benzodiazepines, Victim of Sexual Abuse and Insomnia. The patient was treated with Valium and Vistaril for anxiety, fentanyl patches for pain, and the medications, Lexapro and Neurontin The patient was found on 7/27/13 at approximateiy 9:30 am. not breathing. no pulse, cyanotic and in fuil rigor mortis in his/her room. (Rigor mortis occurs when the limbs of the corpse becomes stiff and dif?cuit to move or manipulate. in humans, it commences after about three to four hours, reaches maximum stiffness after 12 hours, and gradually dissipates until approximately 48 to 60 hours after death). However, the record showed that 15 minute checks were documented and showed the patient slept all night from approximately midnight with loud snoring. Prior to the patient's being found dead, nurses were documenting that the patient was very 008 YRN711 If continuation sheet 49 of 66 Coiorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 OF DEFICIENCIES IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY COMPLETED 10/07/201 3 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITYI STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR 1.80 INFORMATION) TAG To THE APPROPRIATE DEFICIENCY) 008 Continued From page 49 008 sedated and several doses Of Valium were withheld because of over-sedation, but no nurse initiated additional vital signs to reassess the patient's condition. During the night prior to the patient being found dead, the record showed that the patient was "snoring" very loudly after having gone to bed in a condition characterized as very sedated. There was no evidence that the patient was assessed by nursing staff during the night with attempts to arouse the patient or Check Vital Signs (including oxygenation status). In addition, earlier in the evening prior to the patient's death, the patient had had at least two episodes Of emesis and required medication for that. There was no documentation of a physical assessment when the emesis events happened, and there was no documentation Of the nature, amount and contents of emesis in the record. Further review Of the medical record revealed that the patient was receiving Melatonin for sleep, Valium and Vistaril for anxiety, Neurontin and Lexapro for anxiety and depression and Fentanyl transdermal patches for pain. On the two days prior to the patient being discovered deceased on the morning of 07/27/13, the patient received the following medications that had a central nervous system depressing effect: 07/25/13: 3 mg Melatonin 100 fentanyl transdermal patches 40 mg Lexapro Valium 50 mg Neurontin 1800 mg Vistaril 75 mg 07/26/13: 100 fentanyl transdermal patches 40 mg Lexapro Vaiium 10 mg Neurontin 1800 mg If continuation Sheet 50 Of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 VIULTIPLE CONSTRUCTION BUILDING: DATE SU RVEY COMPLETED 10/07/2013 NAME or PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID PREFIX TAG SUMMARY STATEMENT OF (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC EDENTIFYING INFORMATION) ID PREFIX TAG PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE DEFICIENCY) COMPLETION DATE 008 Continued From page 50 Vistaril 75 mg b) Review of the "Mosby?s 2012 Nursing Drug Reference, 25th Edition," revealed the medications all had central nervous system (CNS) depression effects which can cause drowsiness and vital sign changes and respiratory depression. There were interactions among some of the medications that potentiated the actions of the various CNS depressants as well as extending the half-life of the Valium. in addition, the half?iife (time required for half of the amount of the medication to be secreted from the body) for Valium was 20-50 hours per dose. Note that the patient had 5 10 mg doses on 07/25/13, which was the day the patient began to show significant sedation. By the morning of 07/26/13, the patient was so sedated that s/he only received a 4:05 am. PRN dose of Valium. The morning and evening and PRN doses of Valium were held due to the patient's level of sedation, but the patient continued to receive the other CNS depressing medications Lexapro, Fentanyl, Neurontin and Vistaril throughout that day. The patient was found to be deceased at about 9:30 am. on 07/27/13. 0) Review of, "Taylor's Ciinical Skills Nursing," copyright 2008, pages 745-751 stated standards of nursing care regarding respiratory assessment and measuring blood oxygenation with the use of a pulse oximeter. The standard states "Many medications affect the function of the respiratory system. Many medications depress the respiratory system. The nurse should monitor patients taking certain medications, such as opioids, for rate and depth of respirations," The standards state that "a range of 95% to 100% is considered normal," when assessing blood oxygenation with a pulse oximeter. 008 YRN711 If continuation sheet 51 of 66 Colorado Department of Public Health and Environment Pnnted: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 064024 10/07/2013 NAME OF PROVIDER 0R SUPPLIER STREET ADDRESS, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 POPLAR WAY 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 51 008 Review of the patient's vital signs revealed that the patient had pulse oximeter reading on admission on 07/18/13 of 99% oxygen saturation. On 07/20/13 and 07/23/13, the patient?s oxygen saturation had declined to 94%, which as below the normal range. On 07/26/13, the day prior to the patient 5 death, the patient?s oxygen saturation level was 93% at 8:30 am. and declined to 90%, far below the normal range, by 7:45 pm. Despite the patient's decreased oxygen saturation and extreme sedation, no reassessments of the patient were conducted after the 7:45 pm. pulse oximeter reading, even though the patient was on muitiple medications, including an opioid, that had respiratory and central nervous system depressing effects. d) On 09/25/13 at 9:20 am, BHA was interviewed by teiephone about observation rounds conducted for Sample Patient #1 on the night shift (1 1 pm. tO 7:30 am.) on the night of 07/26?27/13. The BHA stated that the patient was snoring loudiy, once asleep at approximateiy 12:00 am. S/he stated that S/he was concerned about the loud snoring, which s/he stated was able to be heard "even at the nurses? station." The BHA stated that s/he went to the charge nurse (RN and medication nurse (RN who were both at the nurses station and noti?ed them of his/her concern 1 about the ioud snoring. S/he stated that s/he did not see either of the nurses respond to his/her information and go to check on the patient at that time. S/he stated that the charge nurse (RN took over part Of his/her rounds at approXimately 1 am, including the rounds for Sample Patient S/he stated S/he resumed rounds on Sample patient #1 at approximately 6 am, and recalled that at 6 am, the patient was no longer snoring loudly. The BHA stated that S/he continued to make rounds untii the end Of the shift and did ?nal hand?off rounds with the YRN711 If continuation sheet 52 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: . 064024 MULTIPLE CONSTRUCTION BUILDING: DATE SURVEY COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY 80?! 30 ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 52 on-coming shift BHA as the shift was ending at 7:30 pm. e) On 09/26/13 at 1:20 pm, RN who was no longer an employee of the was interviewed by telephone, about observation rounds conducted for Sample Patient #1 on the night shift (11 pm. to 7:30 am.) on the night of 07/26?27/13. S/he con?rmed that Sample Patient #1 was snoring loudly during the night and that the noise couid be heard even at the nurses station. S/he had no memory of the BHA asking him/her tocheck on the patient. S/he stated that s/he did make rounds on the patient for part of the night. S/he stated that this was his/her first night working on that unit, so s/he was not familiar with the sleeping habits of Sample Patient including whether the snoring was typical or unusual for that patient. S/he recalled that the patient had appeared very drowsy at about 11:45 pm. when s/he came up to the medication window requesting Valium. S/he stated she refused to give the patient the Valium because of his/her level of sedation, but did not take vitai signs or cat! the provider. S/he confirmed that s/he did not go in to the patient's room to do an assessment or to initiate vital signs for the patient. S/he stated s/he was a newly graduated nurse and that it was his/her ?rst nursing job. f) On 09/26/13 at 11:55 a. during an interview with the president of the medical staff, the care and medical record of sample patient #1 was discussed. The medical director stated that s/he and another provider had conducted an independent review of the case, since they had not cared for the patient. During the interview, the expectations for nurses to initiate additionai vital signs or other assessments of this patient, related to over?sedation, loud snoring at night and the documentation of the patients episodes of vomiting was discussed. 008 YRN711 If continuation sheet 53 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY COMPLETED 10/07/2013 NAME OF OR HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 S/he agreed that nurses should have initiated reassessment of the patient, provided accurate documentation and even contacted the doctor about concerns related to these issues. 9) On 09/19/13 at 11:05 am, the Nurse Educator was interviewed and the expectations for documentation of patient and reassessment of the patient when there was evidence of a possible change of condition was discussed. S/he stated that nurses should have reassessed the patient related to increased sedation and very noisy snoring during sleep. In addition, s/he stated that the nurses did not adequately document the episodes of emesis, including times, whether witnessed, nature of the emesis and quantity, as s/he wouid expect as a standard of nursing care and documentation. 3. The facility failed to appropriately review the death event (Sample Patient and insure corrections were made to avoid further serious medication errors of a iike nature. a) On 09/19/13 at 4:09 an interview was conducted with the facility's former Chief Executive Of?cer (CEO), who also served as the facility's Director of Nursing (DON) and Director of Quality. The CEO was asked to review the medical record-for Sample Patient #1 and to explain the administration of fentanyl patches at a 24 hour interval, on 07/25/13 and 07/26/13, instead of the 72 hour interval ordered by the patient's physician. The CEO could ?nd no documented reason that the medication was administered at a 24 hour interval. When asked if this medication error was identi?ed by the and reported internally as a medication error, s/he stated it was not reported as an "incident? or "event" and felt it did not constitute a medication error. The CEO stated the administration of the fentanyl patches for ID SUMMARY STATEMENT OF DEFICIENCIES iD PROVIDERS PLAN OF CORRECTION COMPLETION (EACH MUST BE PRECEEDED BY EULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 53 008 YRN711 if continuation sheet 54 of 66 Colorado Department of Pubiic Heaith and Environment Health Facilities and Emergency Medicai Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS. CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 lD SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 54 008 Sample Patient #1 had been looked into by the facility and it was his/her Opinion that this was not a medication error but a transcription error on the part of nursing staff. The CEO stated when s/he investigated this issue it was not determined which Registered Nurse had made the transcription error because "no one could remember" who did the transcribing of the medication administration record on the date in question. The CEO confirmed that because s/he believed this issue was not a medication error, it was not documented for discussion in Quaiity Meetings and was not reviewed further by facility staff. The CEO stated s/he had no documentation of this issue being discussed with nursing or other facility staff. e) On 09/19/13 at 4:25 pm, the facility's Corporate Clinical Director, who was present when the former CEO was interviewed regarding the administration of Fentanyl patches, stated the administration/changing of the patches on 07/25/13 and 07/26/13 constituted a medication error as the patches were changed out at 24 hours instead of at 72 hours as the patient's physician ordered. The Director stated this incident should have been documented by the facility as a medication error so that it could be reviewed in Quaiity Meetings and corrections made. t) On 09/20/13 at 4:30 the Corporate Clinical Director provided the facility's current policy titled, "Medication Administration," revised 10/21/09, for review. The policy stated it wasthe responsibility Of the night shift nursing staff to ensure that physician orders were transcribed accurately. 9) On 09/20/13 at 10:28 am, an interview was conducted with Staff Physician #3 who stated s/ne was one Of the facility physicians who reviewed the medical record for Sample Patient 1 If continuation sheet 55 of 66 Colorado Department of Public Health and Environment Printed: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 054024 10/07/201 3 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC EDENTIFYING INFORMATION) TAG CROSS-REFERENCE) TO THE APPROPRIATE DEFICIENCY) 008 Continued From page 55 008 #1 as this patient died in the facility on 07/27/13. Physician #3 reviewed the change of the patches at 24 hours instead of the ordered 72 hour interval and stated S/he would View this as a medication error. Physician #3 stated s/he serves on the facility's Medicai Executive Committee. h) Review of Committee of the Whoie (COW) Meeting Minutes for January 2013 through August 2013 were reviewed. It was documented that the facility?s Risk Manager presented information at these meetings each month regarding facility medication errors. July data regarding medication errors provided by the Risk Manager stated there were 6 medication errors in Juiy with "omissions" as the highest category of errors. Nine medication errors were reported in June 2013 and all 9 errors "reached the patient." The fentanyl patch error was not included in the data presented to the Committee for the month of July. 8 009 Survey Details 8 009 11/29/2013 This REGULATION is not met as evidenced by: 6 CCR 1011-1, Standards for Hospitals and Patient Observation Rounds Process; Health Facilities Chapter 18, Hospitals The CEO, Director of Nursing, Director of Promulgated by the State Board of Health Risk Management, and Director of Last amended 06/19/13, effective 08/14/13 Education and Process Improvement Part 26. PATIENT CARE revised the Hospital's procedures SERVICES. regarding patient observation rounds. The facility shall provide patient care The revisions included adding the services in conformance with the standards responsibilities of the nurse manager, established in Chapter IV, Part 26, charge nurse, nursing supervisor, and Patient Care Services, Sections 26.101, and Hospitai administration to oversee that 26.102. appropriate and compliant patient Chapter 4, General observation rounds (including Quiet Room Promuigated by the State Board of Health rounds) are being conducted. The CEO Last amended 06/19/13, effective 08/14/13 also revised the patient observation Part 26. SERVICES YRN711 If continuation sheet 56 of 66 Colorado Department of Public Heaith and Environment Heaith Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER IDENTIFICATION AND PLAN OF CORRECTION NUMBER: 064024 MULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 1 0/07/2013 NAME OF OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION COMPLETION PREFIX (EACH MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE GATE TAO REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 009 Continued From page 56 009 26.101 ORGANIZATION AND STAFFING (1) General hospitals may provide services; however, facilities that do not provide or substance abuse services shall develop and implement a written plan for the referral of patients to treatment options. The following standards apply only if the facility provides care. care includes, but is not limited to, the provision of the foiiowing as appropriate to the patient: physician and nursing services, services, social services, occupational therapy and recreational therapy. (3) Nursing Services (C) All nursing personnel assigned to care for specific populations, such as pediatric or geriatric patients, shall be trained, have the necessary experience and maintain current competency. Unexpected emergency events that require the use of nurses that lack the necessary training, experience or competency are exceptions; such events shall be documented and, where possible, planned for in the future. Inexpert nursing personnel in such events shall be assigned to the lowest acuity situations possible. (7) There shalt be a sufficient number of quali?ed clinical and supportive staff to assess the needs of patients, implement individualized active treatment care plans, and ensure a safe therapeutic environment for patients and staff. The Requirement is NOT MET as evidenced by: Based on document review, interviews, and observations, the facility failed to ensure the on?going physical safety of patients admitted to the facility. Patient safety observations were not conducted by facility staff per the facility's policy and expectations. rounds policy and procedure by adding a ?zero-toierance? expectation of compliance to reinforce the importance of patient observation rounds and to put patient care staff on notice that noncompliance will subject staff members to additional training and possibly appropriate corrective action, up to and including termination. Training on the revised Patient Observation Rounds Process and monitoring actions are described further below. Administrator on Call (AOC) Process: The CEO reviewed and revised the Administrator on Call (AOC) process to have the AOC provide non-clinical support to the evening and overnight shifts to reinforce the importance of the patient observation rounds process. Hospital executives required to fulfill AOC duties include the CEO, CFO, Director of Risk Management, Director of Education and Process Improvement, Director of Plant Operations, Director of Business Development, Director of Intake, and Director of Clinical Services. The revised process provides for the AOCS to conduct a physical walk?through of Intake, Unit 1, Unit 2, and the Adoiescent Unit to observe Unit Staff conducting patient observation rounds on each Unit. The AOCS also communicate with staff about the importance of quality patient care and potential employee concerns/issues. The revised process calls for the AOCS to do these walk?throughs on the following schedule: 1. To be physically present on the units during a portion of the evening and If continuation sheet 57 of 66 Colorado Department of Public Health and Environment Printed 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER VIULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF NUMBER: 3UILDING: COMPLETED 054024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS HEALTH SYSTEM 3555 5 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECT EVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 57 009 night shifts for two weeks. The faiiure to perform adequate safety CheckS 2. After the two?week period, to begin placed all patients at risk because of threats to random in?house checks beginning their health and welfare going unidenti?ed by 10/25/13 on off-hour Shifts. staff. 3. For the next 60 days, to report to an evening or night shift 1 time per day for Findings: every day the AOC is on call. This inciudeS weekends. 1. Facility staff did not perform patient safety 4. After the 60?day period if nursing observations (15 minute Checks) per the staff are rounding in compliance with facility's policy. Sample Patient #1 who was policy, AOC expectations will return to the found dead and in a condition of rigor mortis following process where the AOC must: (indicating that the patient had a died hours prior to being discovered) despite patient Observation a) Report to an evening or night rounds having been conducted. Despite Shift 1 time per week for the week the subsequent staff training and re?education and AOC is on call (Mon?Fri). implementation of additional video monitoring of b) Report to a day, evening, or night staff performance of rounds, on 9/27/13, video Shift 1 time per weekend for the weekend Observation of patient observation rounds the AOC is on cali (Sat, Sun, Holiday). conducted on the night shift of 09/23/13 to C) Conduct a physical walk-through 09/24/13 on Sample Patient #22, revealed that of Intake, Unit 1, Unit 2, and Adolescent the patient observation rounds were still not Unit. being conducted correctly per policy/procedure. d) Observe Unit Staff conducting rounds on each Unit. a) Review on 09/18/13 of the medical record for e) Communicate with staff about Sample Patient #1 reveaied that the patient was patient care and employee concerns or a young adult admitted with history of issues. diagnoses of Episodic Mood Disorder, Muitiple f) To assure randomness to the Substance Abuses including Opiates, Cocaine monitoring process, the CEO also and Benzodiazepines, Victim of Sexual Abuse randomiy Checks rounding compliance and insomnia. The patient was treated with ?ix/week on a different day from when the high doses of Valium and Vistaril for anxiety, AOC checks. Fentanyi patches for pain, and other medications. The patient was Ambassador Rounding: found at approximately 9:30 am. not breathing, no pulse, cyanotic and in full rigor mortis in The CEO reviewed and revised the his/her room, despite documentation of having patient observation rounds process by been Checked every 15 minutes throughout the adding a designated training ambassador night and morning shifts. The record showed to assist nursing staff with observing, the Checks were documented as completed and reinforcing, and educating staff performing the patient Siept all night from approximately patient Observation rounds. The Director midnight with loud snoring. At ieast a day prior of Nursing selected the training to the patient being found dead, nurses ambassador from among Behavioral documented the patient was very sedated and Health Associates (BHAS) that have YRN711 If continuation Sheet 58 of 66 Colorado Department of Public Health and Environment Prmted' 12/15/2014 Heaith Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIES PROVIDER MULTIPLE DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED 054024 1010712013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3555 3 POPLAR WAY 80130 ID SUMMARY STATEMENT OF DEFICIENCIES lD PROVIDERS PLAN OF CORRECTION COMPLENON PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 58 009 several doses of Valium were withheld because consistently demonstrated excellent of overwsedation, but nO nurse initiated rounding skills, communication skiils, and additional vital Signs to reassess the patient's role modeiing skiils. The ambassador condition. During the night prior to the patient conducts random visits on the different being found dead, the record indicated that the units and Shifts seven days per week. patient was "snoring" very loudly after having The ambassador directly observes gone to bed in a condition documented as very employees conducting rounds and sedated and his/her Valium was withheld due to reviews video camera tapes. In addition the There was no evidence that the to giving the employee direct verbal patient was reassessed by nursing during the feedback, written feedback when night with attempts to arouse the patient or to appropriate, and providing verbal check vitat signs. feedback to the charge nurse and nurse supervisor as appropriate, the b) Review on 10/08/13 of the medicai reference ambassador also monitors usage of the book, "Stedman's Medical Dictionary, 28th Quiet Room and observation rounds done Edition, Lippincott Williams Wilkins, 2006, on patients in the Quiet Room, and then page 1699 revealed the following, in part: submits a written report to the Director of "rigor - rigidity, stiffness Nursing after each Visit. The Director of mortis - Stiffening of the body, 1-7 hours after Nursing reviews the ambassador?s reports death, from hardening of the muscular tissues each weekday. as a consequence Of the coagulation of the myosinogen and paramyosinogen; it disappears Monitoring/T racking: For a period of 30 after 1?6 days or when decomposition begins; days, the CEO directed the Director of cadaveric rigidity, postmortem rigidity." Nursing to monitor the training ambassador process through review Of the ambassador?s reports each weekday c) On 09/24/13 at 11:30 the facility's policy and submission of reports to the CEO titled, "Patient Observation Policy," revised each weekday and weekly. Monitoring 03/23/12 was reviewed. The policy stated all results will also be reviewed by the patients "are supervised, at a minimum, every Performance Improvement Committee at 15 minutes," through rounds/Observations by its meeting. After 30 days, if it is staff tO ensure patient safety. The policy stated determined that there is 100% compiiance Behaviors! Health Associates (BHAS) would with rounding, the frequency Of reporting observe patients every 15 minutes and specific to the CEO may be reduced, but will not information regarding the patient would be be discontinued until it has been documented on the patient observation form. determined that the compliant rounding The policy stated each patient would have an process and culture of safety are individual observation form that would be thoroughly ingrained. compieted and would be become part of the patient's medical record and the patient's Staff Training: identity would be verified, and the location of the patient and patient's behavior would be The CEO directed 100% Of nursing staff documented. The policy went on to state (RNS and BHAS) to undergo training and required documentation of patient activities complete a Return Demonstration on YRN711 If continuation sheet 59 Of 66 Colorado Department Of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCJES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 DATE SURVEY BUILDING: COMPLETED 10l07/20?i 3 NAME OF PROVIDER OR SUPPLIER BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION - PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 59 009 when patients were awake during the day. The policy directed when patients were on bed rest or asleep, the BHAS would look for the rise and tail of the patient?s chest, count at least 3 respirations, and make sure the patient "moved from his/her previous steeping position" and document per the policy and the Observation form. d) Review on 09/17/13 of an internal investigative document related to the death Of Sample Patient related to the Patient Observation Policy, 2 Behavioral Health Associates (BAHs) stated that they had not conducted patient Observation rounds according to policy. in addition, it stated that staff were viewed on camera not conducting patient Observation rounds according tO policy. Staff were not visualizing the patient and were marking that the patient was asleep in the quiet room. e) On 09/18/13 at 12:46 pm, an interview was conducted with the facility?s Risk Manager who stated S/he had reviewed camera tapes Of the room Sample Patient #1 was in on 07/26/13 and 07/27/13. The Risk Manager stated s/he "focused on the to determine if they were conducting patient safety Observations per policy. S/he stated the camera tape review reflected the observations were not being conducted per the facility's policy. S/he stated some Observations were "fly?by's" meaning BHAS "glanced in the door" Of the patient room and did not walk inside the room in order to Observe the rise and fall of the patient's chest and to Observe at least 3 respirations. The Risk Manager stated s/he reviewed the camera tape Of Sample Patient #1 '5 room and did not see the patient change position or move during the night shift and through the morning of 07/27/13. The Risk Manager stated she began reviewing the facility's patient Observation policy with nursing staff and BHAS and obtained Signatures from patient observation rounds. Return Demonstrations were validated by the nurse manager, nurse supervisor, or BHA training ambassador. in addition, the training emphasized the limited use of the Quiet Room and the continued use Of patient Observation rounds when it is deemed appropriate to place a patient in the Quiet Room for a limited period of time. 100% of patient care staff performed a Return Demonstration competency on patient Observation rounds. The Return Demonstration outlined key components concerning patient safety and the patient observation rounding processes, including: 1. Proper use of the flashlight when rounding on steeping patients at night and the process for confirming three respirations and any change in a patient?s position. 2. informing the RN Of any change in condition such as abnormal breathing (including snoring), and patient repositioning so the RN will assess/reassess the patient's condition. 3. Nurses were also re?trained by the Director of Education and Process Improvement to assess/reassess patient breathing, to take vitai signs as appropriate inciuding taking pulse oximeter reading, to attempt to rouse a patient when necessary, to notify the physician of changes in condition, and to document findings and actions. Monitoring/Tracking: Training was provided to 100% of all nursing staff with evidence of this retraining placed in the master training file. The Director Of Nursing was responsible for confirming YRN711 If continuation sheet 60 Of 66 Colorado Department of Public Health and Environment Prmted' 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCJES PROVIDER IDENTIFICATION MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: 3UILDING: COMPLETED 064024 10/07/2013 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 3555 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF In PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 60 009 staff indicating they understood the policy and that all staff received the training. expectations for conducting patient observations. The Risk Manager stated New Employee Orientation: expectations for patient safety observations was also conducted with new staff nurses and BHAS The CEO directed the Director of and was also part of annual competencies. The Education and Process Improvement to Risk Manager stated since the death of Sample revise the New Employee Orientation Patient staff nurses and BHAS were process as follows: informed that if it was found that patient safety observations were not conducted per the 1. To include a suicide prevention facility's policy, corrective action would be taken Video that orients 100% of new employees up to and including termination of employment. on the importance of patient observation rounds. The Risk Manager stated since the death of 2. To provide training on the revised Sample Patient administrative staff patient observation rounds policy increased their morning/daily review of camera describing the Hospitai?s "zero tolerance? tapes from the day/night before. S/he stated expectation and promoting the importance each morning s/he reviewed an hour of tape of patient Observation rounds as one of from each of the 3 facility units and documented the most critical functions performed by the review which included the time staff entered nursing staff. a patient's room and when staff exited the room. 3. To emphasize the limited use of the The Risk Manager stated s/he documented if Quiet Room and the continued use of there were not 4 observations made of each patient observation rounds when the use patient room in a 1?hour time frame. S/he stated of the Quiet Room is deemed appropriate. S/he also documented if staff was in a patients 4. To include a patient observation room for less than 9 seconds as it would take at rounds practice for ail new hires of Clinical least this much time to conduct an observation staff. including Observing 3 respirations. The Risk 5. To have a Return Demonstration Manager stated s/he also reviewed tapes to see competency on patient observation that BHAS were documenting on the patient?s rounding incorporated into the training and observation sheets at the time of observation overseen by a Registered Nurse. instead of later, which was identified as a problem by the facility. The Risk Manager stated Annual Competencies Process: since the death of Sample Patient administrative review of camera. tapes had The CEO directed the Director of increased and 3 staff members were reviewing Education and Process Improvement to tapes including him/herself, the former Chief include patient observation rounds training Executive Of?cer, and the Plant Operations in the Hospital?s Annual Competencies Director. The Risk Manager stated choosing the process with nursing staff showing videos to review was random and that s/he competency through Return received documentation Of tape reviews from Demonstration. The Director of Nursing is the former CEO and the Plant Operations responsible for con?rming the Manager when their reviews were completed. competency of all nurse managers and The Risk Manager stated the facility's patient nurse supervisors in patient observation YRN711 If continuation sheet 61 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES PROVIDER AND PLAN OF CORRECTION NUMBER: 064024 CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 10/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 61 009 observation poiicy and the safety observations document completed for each patient, were not changed Since the patients' death. t) On 09/19/13 at 12:08 pm, an interview was conducted with the facility's former, interim CEO who confirmed orientation for new staff nurses and BHAS had not changed since the death of Sample Patient and that annual competencies regarding patient safety observations had not changed. The interim CEO stated staff had been re-educated Using the same facility policy and documents. The interim CEO stated s/he did conduct some reviews of camera tapes after the death of Sample Patient but as of approximately the first week of September, 2013, S/he no longer had rights to View tapes on facility computers, so S/he was no longer conducting tape reviews. 9) On 09/27/13 at 11:16 an interview was conducted with the Corporate Clinical Director who stated the expectation after the death of Sample Patient #1 was that administrative staff would increase the review of camera tapes in order to monitor nursing staff and BHAs conducting patient safety observations per facility policy and per recent re?training of staff. The Director stated this had not happened and the daily review of a sample of tapes by the facility Risk Manager was not an increase of administrative monitoring of this issue. h) On 09/27/13 at 9:36 am, View of recent camera tapes was conducted with the facility's Risk Manager, the Corporate Clinical Director, and the facility's Staff Educator and Performance Improvement Specialist. At 10:28 am, the Risk Manager compieted review of a random sampie of tapes from the previous 24 hour period and documented the results of the rounding and in overseeing patient observation rounding by other nursing staff members. Annual Competencies Training was provided to 100% of ail patient care and nursing staff with evidence of this retraining placed in the master training files. Quiet Room Use: The Director of Nursing developed a new Quiet Room form that lists the criteria for use of the Quiet Room, emphasizes the limited use of the Quiet Room, and includes a reminder to continue patient observation rounds in accordance with procedure during the short duration a patient is in the Quiet Room. The CEO directed that nursing staff use the new Quiet Room form as a checklist and teaching tool, including during new employee orientation and annual competencies. The Director of Nursing provided training on the new Quiet Room form to 100% of all nursing staff with evidence of this retraining piaced in the master training files. Video Camera Review Process: The CEO directed the Director of Plant Operations to make Video camera review capability accessible to the entire Hospital leadership team to enable them to conduct periodic reviews of patient observation rounds. The CEO and Director of Plant Operations reviewed the physical iocatlon of all YRN711 If continuation sheet 62 of 66 Colorado Department of Public Health and Environment PM ed 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF DEFICIENCIEs MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: COMPLETED 064024 10/07/2013 NAME or PROVDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS HEALTH SYSTEM 8565 POPLAR WAY LITTLETON 80130 10 SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION COMPLETION PREFEX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 009 Continued From page 62 009 review. Review of the tape of the Adult Unit 1 Hospital camera monitoring stations to showed a BHA in patient room #2108 for 17 confirm functionality of each camera seconds on one observation, 9 seconds on the reviewing station. The Director of Plant next observation of this patient, and ?naily only Operations added camera monitors to all 4 seconds in the patient's room at 3:30 am. The Units and to the of?ce to provide Risk Manager stated when s/he reviewed a BHA review to the CEO, Director in a patient room for iess than 9 seconds, s/he of Nursing, and all Nursing Supervisors. thinks the patient was probably awake and spoke with the BHA or had some interaction to Monitoring/Tracking: One randomly let staff know the patient was safe. The Risk selected hour of patient Observation Manager followed up on this 4 second patient rounds is reviewed daiiy by Nurse safety Observation and stated Staff BHA #1 Managers/Supervisors, and weekly by the documented at 3:30 am. that the patient in CEO, Director of Risk Management, and room #2108 was asieep. The Risk Manager the Director of Education and Process stated this patient safety observation was not Improvement. Observations are conducted per facility poiicy. S/he stated the documented on the Video Camera Review expectations of staff, and recent retraining of of Staff Observation Rounds Form which staff, noted the BHAS did not spend enough was specifically developed by the Director time in the patient's room to observe 3 of Nursing for this process. The CEO respirations. provides a summary report of audit results to the meetings of the Committee i) On 09/18/13 a document provided by the of the Whole and the MEC, and quarterly Interim Director of Nursing, outlining the actions to the Board of Directors. taking by nursing after the death of Sample Patient #1 was reviewed. The document and Summary of monitoring activities: accompanying documents detailed meetings held with staff to review expectations for 1. The Director Of Risk Management following the Patient Observation Rounds monitors Incident Reports for ongoing policy/procedure, including having all staff Sign compliance with regulatory requirements an attestation that they would follow the policy. including nursing staff following patient The attestation included the key elements from observation rounds correctly. the policy, including, looking for the rise and fali 2. The ambassador is conducting 40 of the Chest, counting at least three respirations hours of random monitoring of patient and making sure that the patient moved from observation rounds during the week to his/her previous sleep position. There was Check compliance with Hospital policy and evidence that all nursing staff had been regulatory requirements. The re?tralned regarding conducting patient ambassador is submitting both Observation rounds (15 minute checks) competency checklists and summary according to the policy by the time of the survey. reports to the Director of Nursing for review each weekday. j) On 09/27/13 at 2:26 pm, during an interview 3. Managers are conducting daily video with the Faciity's Risk Manager, the surveyor camera reviews for at least 1 hour out of requested to review tapes of a patient "Quiet the previous 24 hours, unit specific, with Room" to observe staff observations of patients priority on Checking rounds on high acuity YRN711 if continuation sheet 63 of 66 Colorado Department of Public Health and Environment 12/15/2014 Health and Emergency Medical Services Division STATEMENT OF PROVIDER IDENTIFICATION CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 064024 10/07/2013 NAME OF PROVIDER OR SUPPLER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 5 POPLAR WAY 80130 ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) 009 Continued From page 83 009 placed in this type of room. The Risk Manager patients; producing a summary report on stated S/he did not necessarily look for staff the completed review form; and observations of these rooms even though each submitting the report to the Director of Quiet Room had a camera inside the room. Nursing for review each weekday. Quiet Rooms were used in the facility for 4. Nurse supervisors are also patients who required closer observation by conducting Video camera reviews Of staff, therefore the camera in the rooms. Tape patient observation rounds during their review revealed that on 09/24/13, in the shift (with a focus on high risk situations, adolescent unit, a child, Sample Patient #22, inciuding Quiet Room usage) and was sleeping in a Quiet Room. Review of tapes completing a summary report to be reflected facility BHA #2 was not conducting submitted to the Director of Nursing for patient safety Observations per the facility's review each weekday. policy. The tape reflected that on 09/24/13 at 5. The nurse manager submits a 02:29:59, BHA #2 was in the patient's room for completed Summary Report to the 1lseconds but did not Shine the ?ashiight Director of Nursing after each shift. The toward the patient in order to ensure Summary Report includes observations Observation of the rise and felt of the patient's from Video camera reviews, direct chest and to observe 3 respirations. At observation of nursing staff, and any 02:43:35, BHA #2 was observed in the patient's retraining or corrective actions taken. room for 6 seconds with the flashlight shining 6. Each weekday, the Director of toward the ceiling not toward the patient. At Nursing submits an Executive Summary 02:58:54 BHA #2 was observed in the patient's Report to the CEO based on the nurse room for 5 seconds, and at 03:18:02, the BHA managers? Summary Reports, personal was observed in the patient's room for 9 observations, and actions taken. seconds. At 03:44:56, the BHA was observed in 7. The Director of Nursing submits a the patient's room for 17 seconds but turned compieted weekly Summary Report to the away from the patient at one point and looked at CEO, which includes camera reviews and the door. At 04:14:37, BHA #2 was observed in feedback from the training ambassador. the patient's room for 6 seconds. The 8. The weekly Summary Reports are observation time between 03:44:56 and also reviewed during the weekly Nurse 04:14:37 was almost 30 minutes, not the Forum meeting. required 15 minute interval. At 04:31:47, BHA #2 9. Weekly reports are compiled and was observed in the patient's room for 5 reported at the meetings of the seconds holding the flashlight up toward the Committee of the Whole and the Medical ceiling. At 04:45:20, the tape Showed a green Executive Committee, at FLASH meetings light Shining into the room for a few seconds and of the administrative leadership team no staff person entering the room. At 05:08:21, each weekday, and at quarterly Board of BHA #2 was observed opening the patient's Directors meetings. door, which had been left open, but did 10. Reports from the revised AOC not step inside the room to observe the patient. process described above are given to the Instead, the BHA stood at the threshold of the CEO each weekday until the end of the door and backed out of the room 3 seconds 60-day monitoring period. The CEO later. At 05:20:37, BHA #2 was observed in the reports results/trends/variances as patient's room for 5 seconds. No further review indicated to the meetings of the YRN711 lf continuation sheet 64 of 66 Colorado Department of Public Heaith and Environment Printed: 12/15/2014 Health Facilities and Emergency Medical Services Division STATEMENT OF PROVIDER CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: BUILDING: COMPLETED 034024 10/07/2013 NAME OF PROVEER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE HIGHLANDS BEHAVIORAL HEALTH SYSTEM 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION COMPLETION (EACH DEFICIENCY MUST BE PRECEEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD SE DATE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 009 Continued From page 64 009 of this tape was conducted by the surveyor and Committee of the Whole and the MEC, the facility?s Risk Manager. The Risk Manager and to the quarterly meetings of the Board confirmed the ?ndings refiecting lack of correct Of Directors. patient safety Observations by BHA #2 for approximately 3 hours while Sample Patient #22 was Sleeping. The Risk Manager con?rmed the necessity of staff using a ?ashlight while Observing in Quiet Rooms, even though there was dim light provided in these rooms. k) On 09/27/13 at 3:10 pm, review of the medical record for Sample Patient #22 was conducted and revealed this was a 9 year old male with a history of seizure disorder who had been moved to the Quiet Room. The Patient Rounds Observation sheets for Sample patient #22 dated 09/24/13 Showed all safety observations were conducted by BHA #2 beginning at midnight through 4:30 am. and from 05:15 am. through 7:15 am. Documentation by BHA #2 reflected the patient was steeping at each observation with the exception of the 3:30 am. and 4:00 am. observations when the patient was documented as "sleeping in bed." The observation Sheet revealed that the Observations conducted at 04:45 am. and 05:00 am. were conducted by other staff whose initial could not be matched with a Signature. I) On 09/27/13, review of the facility's retraining documents for nurses and BHAs regarding patient safety observations was conducted. The documents were titled, "Patient Observation Rounds Expectations Acknowledgement." The documents restated expectations from the facility's patient safety observation poiicy and included the expectation that staff would look for the rise and fall of a sleeping patient?s chest and Observe at least 3 respirations for sleeping patients. Staff BHA #1 initialed and signed this document on 8/20/13 and Staff BHA #2 initialed and signed the acknowledgement on 7/30/13. YRN711 If continuation Sheet 65 of 66 Colorado Department of Public Health and Environment Health Facilities and Emergency Medical Services Division Printed: 12/15/2014 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PROVIDER IDENTIFICATION NUMBER: 064024 VIULTIPLE CONSTRUCTION DATE SURVEY BUILDING: COMPLETED 1 0/07/2013 NAME OF PROVIDER OR SUPPLIER HIGHLANDS BEHAVIORAL HEALTH SYSTEM STREET ADDRESS, CITY, STATE, ZIP CODE 8565 POPLAR WAY LITTLETON 80130 ID SUMMARY STATEMENT OF DEFICIENCIES PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FULL TAG REGULATORY OR LSC IDENTIFYING INFORMATION) ID PLAN OF CORRECTION COMPLETION PREFIX (EACH CORRECTIVE ACTION SHOULD BE DATE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) YRN711 If continuation sheet 66 of 66