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Based on review of hospital policies/procedures, medical records, and interviews, the Department determined that the administrator failed to require restraints were ordered, applied, managed, and documented for 1 of 1 restrained patients (Patient #6), as demonstrated by:

1. incomplete physician's order form;
2. "PRN" (as needed) orders;
3. Care Plan not updated to include restraint management;
4. no documented staff restraint education; and
5. no documented medical staff restraint education.

Findings include:

The hospital policy/procedure titled Nursing Services Use of Restraints requires: "...Restraints shall only be used for the safety and well being of the patient and only after other alternatives have been tried unsuccessfully...Restraints shall only be used to treat the patient's medical symptoms and never for...staff convenience...If a patient was recently released from restraint and exhibits behavior that can only be handled by the reapplication of a restraint, a new order would be required. Staff cannot discontinue an order and then re-start it under the same order because that would constitute a PRN (as needed) order. Each episode of restraint use must be initiated in accordance with the order of a MD/DO or other LIP (Licensed Independent Practitioner)...reorders are issued only after a review of the patient's condition by...physician...."

The Physician Order Sheet requires the physician/LIP identify and document: date, time, indication for restraint, type of restraint, that less restrictive measures were unsuccessful, (i:e: diversion, parent/guardian in attendance), physical therapist or occupational Therapist evaluation was considered for least restrictive measures, parent/guardian signed consent (yes/no), and physician/LIP signature.

Patient #6 was admitted on 05/16/11, with diagnosed respiratory failure, tracheostomy/ventilator dependence, and multiple co-morbidities, according to the medical record. The patient was restrained 05/24/11 to 06/15/11, intermittently. He was discharged 07/11/11.

1. The Physician Restraint Order form requires: order date and time, type of restraint and reason, less restrictive measures attempted, and parental/guardian consent.

Seventeen (17) physician's restraint orders revealed the following:

No order time: 11 of 17 restraint orders.
No parental consent: 13 of 17.
No indication of less restrictive measures attempted: 4 of 17.
No indication of restraint need: 3 of 17.
No nursing documentation of noting the orders: 16 of 17.

2. "PRN" restraints orders: 3 of 17.

3. The patient's Care Plan did not include Restraint management, interventions, or goals.

4. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) both confirmed that the hospital provided staff restraint education on orientation, however did not maintain verifiable documentation, during interviews conducted on 03/15/12 at 1100.

There was no documentation of Restraint education/inservice, or policy/procedure review, to verify the staff were knowledgeable and competent to manage patient restraints.

5. Eight (8) of 8 physicians/LIPs had no documentation of Restraint education/inservice, or policy/procedure review, to verify providers had a working knowledge of Patient Restraint requirements including order content: Physicians/LIPs #1 through 8.

The Medical Records/Medical Staff Services Director confirmed that she was unaware of any inservices, education, Medical Staff Bylaws, Rules and Regulations, hospital policies, or other requirements, verifying that the Medical Staff/LIPs were knowledge regarding Patient Restraints, during an interview conducted on 03/14/12 at 0900.

The Medical Director, physician #8, indicated that Restraint orders are "good for 24 hours," during an interview conducted on 03/15/12 at 0845. She reviewed Patient #6's medical record but could not independently identify any order errors or omissions related to the attending physician's restraint orders.

The Medical Director, physician #8, confirmed that the Medical Staff are not provided education, inservices, policy notification, regarding Patient Restraints, during an interview conducted on 03/15/12 at 0845.

Based on review of hospital policies/procedures, observation, and interview, it was determined the hospital failed to maintain a safe and sanitary environment.

Findings include:

The hospital Policy/Procedure # 7.5.1.1, titled "Environmental Services Hospital Maintenance" requires: "...The hospital...shall be maintained...clean and sanitary condition...well being...Environmental Services Department...responsible...regular inspection...necessary to maintain...operating condition...."

During a walk-around tour of the facility conducted 03/15/12, at 1100 hours, the following was observed: rust on the examination table (located in the exam room).

The following was observed in room # 5: dirty curtain between beds, dust on wood window blinds and sill, entrance door damaged with gouges and chipped paint, dusty ceiling vent in restroom, debride in bathroom light fixture, pony tail holder over oxygen regulator, dark hair in bed 1 and bed 2; two holes in bottom sheet of bed 2; and stickers on the light switch plate.

The following was observed in room #6: dust on wood window blinds and window sill.

The Administrator, the Director of Nursing (DON), and the Assistant DON, confirmed the above findings 03/15/12.

Based on hospital documents and interview, it was determined the administrator failed to provide documentation of the hospital's current fire inspection report.

Findings include:

The Vice President (VP) of Administrative Support Services confirmed during an interview conducted 03/15/12 at 0930 hours, the inspection was completed by Phoenix Fire Department in January 2012, however, the VP was unable to provide the surveyor with documentation of the inspection. The last inspection report was dated 01/11/11.

An opportunity was provided to submit the fire inspection. None was provided.

Based on review of hospital policies/procedures, observation, and interview, it was determined the administrator failed to require the hospital's equipment was properly maintained according to hospital policy.

Findings include:

The hospital Policy/Procedure # 7.5.1.1, titled "Environmental Services Hospital Maintenance" requires: "...The hospital...shall be maintained...good repair...to ensure...well being...Personnel...provide preventative maintenance...required maintenance program...Environmental Services Department...responsible...regular inspection...necessary to maintain...operating condition...."

The Vice President (VP) of Administrative Support Services confirmed during an interview conducted 03/15/12 at 0930 hours, that he is currently responsible for the facility's support services. The VP confirmed during the interview the location of the repair/ maintenance logs could not be located.

During a walk-around tour of the facility conducted 03/15/12, at 1100 hours, the following was observed in room #5; VCR on stand without a preventative maintenance (PM) sticker; two suction regulators without PM stickers; bed #1 with PM sticker dated 04/08; paint flaking and chipping from wall above beds; foot board on bed 2 broken; and a curved, unsecured metal rod hanging from the suction adapter.

Tour of room #6 revealed a plastic electric switch plate cover chipped, overhead light above bed 1 both sides were loose exposing the bulbs; and a curved, unsecured metal rod hanging from the suction adapter.

The Administrator, the Director of Nursing (DON), and the Assistant DON, confirmed the above findings on 03/15/12.