HospitalInspections.org

Based on review of Arizona Department of Health Services (ADHS) licensing file, hospital policies and procedures, hospital documents, observations, and staff interviews, it was determined the Governing Body and Hospital failed to meet the standards for licensing established by the state licensing agency as demonstrated by:

1.Failure to ensure the facility did not repeatedly admit patients in excess of the licensed capacity which poses a potential risk of impacting the quality of care provided.

2.Failure to review and update hospital policies and procedures every three years. This poses a potential risk of hospital practices being out of compliance with current laws and regulations and the facility not providing care based on best practices.

3.Failure to notify the state licensing agency of a removal of observation/stabilization services which has the potential risk of inadequate oversight of the hospital by the state licensing agency.

4.Failure to ensure a request for approval to increase the facility's licensed capacity was submitted to the state licensing agency which has the potential risk of inadequate oversight of the facility by the state licensing agency.


Findings include:

1. The policy titled "Exceeding Capacity & Ambulance Diversion" requires: "...Destiny Springs Healthcare will ensure that there is a method to identify and document each occurrence of exceeding licensed capacity as our ability to deliver ideal care is inherently linked to capacity management...Destiny Springs Health care will not admit a patient if at capacity without the following actions...An emergency must exist for the patient and the patient must be seen and evaluated by a medical staff member to determine if the admission is emergent...If the medical staff member determines that patient is emergent in nature and needs admission the reason and findings must be documented by the medical staff provider...The CEO and Medical Director are notified that a patient is being admitted and capacity is exceeded...If after hours, the Administrator on Call is notified...The incident is documented, evaluated and actionable items are addressed. The report will be submitted to Quality upon completion. Each incident will be reviewed at the monthly Compliance meeting with a report going to the quarterly board meeting to determine if further action or a root cause analysis is needed...Within 2 hours of exceeding capacity the CEO or AOC will notify Arizona Department of Health Services, Division of Licensing, Bureau of Medical Facilities Licensing at 602-364-3030 during normal business hours and request to speak with the surveyor of the day or a team leader...Destiny Springs Healthcare will ensure that several systematic measure are in place to manage capacity. these include Daily Huddles, discharge planning discussion with providers daily, bed ahead concept as well other (Sic) initiatives to ensure patient throughput and flow is managed in optimal state with patient safety as the primary focus...Destiny Springs Healthcare ensure that all discharges are managed effectively and safely...."

The policy titled "Quality Assessment & Performance Improvement Program" requires: "...The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement...data will be aggregated at least quarterly for performance improvement...The use of root cause analysis will be used as needed...When a need for PI is identified the hospital will develop and implement on action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date...."

The ADHS licensing file notes contained the following information.

The facility's ADHS License issued 04/10/2019 revealed that the facility was licensed for 20 Geriatric, 20 Pediatric, and 50 Adult beds with 9 Observation/Stabilization.

03/31/2020
"...I ' m writing to inform you that we have exceeded the 20 patient capacity on our adolescent unit at this time with a total of 21 adolescent patients...."

04/29/2020
"...I ' m writing to inform you that we have exceeded the 20 patient capacity on our adolescent unit at this time with a total of 21 adolescent patients...."

06/08/2020
" ...I ' m writing to inform you that we have exceeded the 20 adolescent patient capacity at this time. Our current adolescent count is 29 adolescents...."

06/11/2020
"...I ' m writing to inform you that Destiny Springs Healthcare remains over our 20 adolescent patient capacity at this time. Our current adolescent count is 28....

06/15/2020
...I ' m writing to inform you that Destiny Springs Healthcare remains over our 20 adolescent patient capacity at this time. Our current adolescent count is 31...."

06/22/2020
"...I ' m writing to inform you that Destiny Springs Healthcare remains over our 20 adolescent patient capacity at this time. Our current adolescent count is 32...."

The facility's amended ADHS License issued 08/18/2020 revealed that the facility was licensed for 20 Pediatric and 70 General Psychiatric with 9 Observation/Stabilization.

09/04/2020
"...I ' m writing to inform you that we have exceeded the 20 adolescent patient capacity at this time. Our current adolescent count is 30 adolescents...."

09/08/2020
"...After evaluating hospital-wide capacity, we were able to allocate an entire 20 bed unit to adolescent patients in order to support these adolescents getting access to the care they need to stabilize their psychiatric crisis...At this time, the adolescent capacity at DSH is 40...."

09/18/2020
"...We remain over our adolescent capacity at this time, with 40 total adolescent beds being utilized. Staffing levels are being assessed per policy, and the units are staffed to acuity. We hope to return to our normal 20 bed adolescent capacity over the next 2 weeks, however, this is dependent upon the surge in the community...."

10/05/2020
"...At this time our adolescent census remains at 40...."

The facility's ADHS License issued 11/04/2020 revealed that the facility was licensed for 20 Pediatric and 70 General Psychiatric with 9 Observation/Stabilization.

11/16/2020
"... Destiny Springs Healthcare is over adolescent capacity at this time due to surge in the community of adolescent patients requiring inpatient psychiatric care. At this time our adolescent census is at 40. Staffing levels are being assessed per policy, and the units are staffed to acuity...."

11/30/2020
"... Destiny Springs Healthcare is over adolescent capacity at this time due to surge in the community of adolescent patients requiring inpatient psychiatric care. At this time we remain over our licensed capacity for adolescent patients. Staffing levels are being assessed per policy, and the units are staffed to acuity. We hope to return to our normal 20 bed adolescent capacity soon, however, this is dependent upon the surge in the community...."

12/14/2020
"...Destiny Springs remains over adolescent capacity at this time due to the community surge of adolescent patients needing psychiatric care...."

01/07/2021
"...Destiny Springs remains over adolescent capacity at this time due to the community surge of adolescent patients needing psychiatric care...."

The facility's amended ADHS License issued 04/23/2021 revealed that the facility was licensed for 50 Pediatric and 40 General Psychiatric with 9 Observation/Stabilization.

06/01/2021
"...Destiny Springs Healthcare is exceeding licensed capacity at this time with 92 total patients...."

06/21/2021
"...I ' m writing to inform you that Destiny Springs Healthcare is currently operating over adult licensed capacity, with 44 adult patients...."

The facility's amended ADHS License issued 08/02/2021 revealed that the facility was licensed for 52 Pediatric and 40 General Psychiatric with 9 Observation/Stabilization.

The facility's ADHS License issued 11/01/2021 revealed that the facility was licensed for 52 Pediatric and 40 General Psychiatric with 9 Observation/Stabilization.

The facility notified the Department 16 times from 03/31/2020 through 06/21/2021 of exceeding licensed capacity before applying for and being issued an amended license on 08/02/2021.

On 04/27/2022, the following documentation was requested related to admissions exceeding capacity.

1. for each patient admitted to the facility over the licensed capacity documentation that an emergency existed including documentation of the reason and findings after evaluation by a medical staff member.
2. documentation of notification of the CEO and Medical Director that capacity was exceeded
3. documentation of a root cause analysis related to the facility's pattern of admissions exceeding licensed capacity.
4. documentation of any corrective action plans related to the facility's pattern of admissions exceeding licensed capacity

The following documentation was provided on 04/27/2022. It did not include documentation as requested above.

January over census days
1/10/22: 93
1/19/22: 93
1/25/22: 94
1/26/22: 93
1/30/22: 95

February over census days
2/1/22: 94
2/2/22: 93
2/4/22: 94
2/8/22: 93
2/9/22: 96
2/10/22: 94
2/11/22: 95
2/14/22: 93
2/15/22: 95
2/17/22: 96
2/18/22: 96
2/20/22: 93
2/21/22: 93
2/22/22: 93
2/25/22: 94

March over census days
3/1/22: 93
3/8/22: 93
3/11/22: 93
3/15/22: 93
3/16/22: 93
3/22/22: 94
3/23/22: 93
3/29/22: 93

April over census days
4/6/22: 93
4/8/22: 93
4/10/22: 93
4/11/22: 93
4/12/22: 93

Email documentation from the CEO to facility staff dated 02/18/2022 revealed: "...Hi - we need to re-discuss overflow beds. The overflow beds are only used when we are adding an adult or adolescent but not going over the total census of 92. For example - we have an extra kiddo and use the Monarch xtra (Sic) bed for the kiddo. BUT we have to hold an adult bed so our census equals 92. We need to place any patient over 92 in the hall. Otherwise we are over our licensed capacity and in violation of our license. If licensing pulls our census for today it says we are at 96 inpatient. The census is not correct today either as we have a 54 y/o adult in Monarch xtra (Sic) bed and we are over our licensed capacity inpatient...."

The CEO and CNO confirmed on 04/25/2022 that the facility did not have documentation of activities related to correction of the facility's pattern of admitting patients exceeding licensed capacity.

Employee #14 confirmed on 05/05/2022 via email response: "...At April ' s QAPI committee meeting, the committee discussed concerns for a pattern for exceeding capacity in the last 90 days that needed to be addressed. The committee looked at information from our Average Daily Census from Jan, Feb and March to determine the pattern instead of looking at each individual instance. Each individual instance of over capacity is currently discussed at our daily Flash meeting...."

Facility census lists were reviewed and noted to have patient's in excess of the licensed capacity on the following dates. Currently the facility is licensed for 92 beds (52 Pediatric beds and 40 General Psychiatric beds).

01/24/2022
Census count: 94
(this over capacity count was not included in the quality report for over census days listed above)

01/25/2022
Census count: 93

01/30/2022
Census count: 95
Plus 3 additional patients listed as "patients in the hall"

02/08/2022 at 0050
Census count: 93

02/08/2022 at 0634
Census count: 96

02/09/2022
Census count: 96

02/10/2022
Census count: 95

02/28/2022
Census count: 92 at 0013
Plus 4 additional patients listed as "patients in the hall." All 4 patients had been in the hall for 1 day.
(this over capacity count was not included in the quality report for over census days listed above)

02/28/2022 at 2149
Census count: 93
Plus 3 additional patients listed as "patients in the hall."
(this over capacity count was not included in the quality report for over census days listed above)

03/01/2022
Census count: 93
Plus 6 additional patients listed as "patients in the hall." 3 of the 6 patients had been in the hall for 1 day.

03/02/2022
Census count: 93
Plus 3 additional patients listed as "patients in the hall." 1 of the 3 patients had been in the hall for 1 day.
(this over capacity count was not included in the quality report for over census days listed above)

03/14/2022
Census count: 92
Plus 5 additional patients listed as "patients in the hall" one of which was a pediatric patient.

03/15/2022
Census count: 91
Plus 6 additional patients listed as "patients in the hall" one of which was a pediatric patient.

03/16/2022
Census count: 93
Plus 1 additional patient listed as "patients in the hall' who had been in the hall for 1 day.

03/17/2022
Census count: 92
Plus 5 additional patients listed as "patient in the hall." 3 of the 5 patients had been in the hall for 1 day.

03/21/2022
Census count: 94
Plus 3 additional patients listed as "patients in the hall."

03/22/2022
Census count: 94
Plus 5 additional patients listed as "patients in the hall." 3 of the 5 patients had been in the hall for 1 day and 2 of the 5 patients were pediatrics.

04/08/2022
Census count: 93
Plus 4 additional patients listed as "patients in the hall." All 4 patients had been in the hall for 1 day.

04/10/2022 at 0617
Census count: 93

04/10/2022 at 2229
Census count: 93
Plus one additional patient listed as "patient in the hall"

04/11/2022
Census count: 93
Plus 3 additional patients listed as "patients in the hall" one of which had been in the hall for 1 day

04/12/2022
Census count: 93
Plus 7 additional patients listed as "patients in the hall" all of which had been in the hall for 1 day

04/15/2022
Census count: 92
Plus 4 additional patients listed as "patients in the hall" 3 of which had been in the hall for 1 day including 1 pediatric patient that had been in the hall for one day
(this over capacity count was not included in the quality report for over census days listed above)

04/23/2022
Census count: 94
(this over capacity count was not included in the quality report for over census days listed above)

04/24/2022
Census count: 93
(this over capacity count was not included in the quality report for over census days listed above)

04/25/2022
Census count: 94
Plus 4 patients listed as "patients in the hall" 2 of which had been in the hall for 1 day.
(this over capacity count was not included in the quality report for over census days listed above)

The facility exceeded their licensed capacity on 41 days from 01/07/2022 through 04/25/2022

A review of the census for 03/29/2022 timed 06:20 census count of 93 plus 4 "patients in the hall". Further review of the census sheet revealed Patient #36 was assigned to the Phoenix unit in Room 1506-A and Patient #37 was assigned to the Cicada unit in Room 2605-B. A review of Patient #36 ' s Census 15 Minute Check dated 03/29/2022 revealed the assigned room number 1506-A was crossed out and 2605-B had been written in its place. Further review of the form revealed documentation that Patient #36 was located in the patient ' s room sleeping from midnight unit the 03:45 check. From 03:45 check until the 0730 check it is documented Patient #36 was in the Group Room lying down and asleep. A review of the Census 15 Minute Check dated 03/29/2022 for Patient #37 revealed documentation that Patient #37 was in bed asleep in Room 2605-B on the Cicada unit from midnight until 0530. Further review of the form revealed Patient #37 was discharged at 0900 from the Cicada unit. A review of the census for 03/29/2022 timed 14:22 revealed Patient #36 was assigned to the Cicada unit room 2605-B.
On 04/28/2022, the CEO confirmed during an interview that when a patient on the adolescent unit turns 18 the patient is transferred to an adult unit. The CEO confirmed Patient #36 turned 18 on 03/29/2022. After reviewing the Census 15 Minute Check dated 03/29/2022 for Patient #36, the CEO would not confirm that Patient #36 had been moved from the Phoenix unit after the 0330 check and placed in the Group Room on the Cicada unit by the 0345 check. On 05/01/2022, the CEO confirmed via an email to the Department surveyors that Patient #36 had been moved from the Phoenix unit to the Cicada unit during the night as the patient had turned 18. The CEO further confirmed that Patient #36 was placed in the Group Room on the Cicada unit and a mattress had been placed on the floor in the Group Room for Patient #36.

Observation on 04/24/2022 revealed that the facility was overcapacity with 93 inpatients with an additional 4 patients being processed in the admissions department.

Observation on 04/24/2022 revealed a census board in the intake/admissions administrative area. The board revealed that there were three patients housed in room 2502.

Observation on 04/25/2022 revealed that a "cot" had been placed in room 2502 in addition to the 2 licensed beds in the room.

Employee #3 confirmed on 04/25/2022, that the facility had placed a cot in room 2502 to house an additional patient in excess of the facility's licensed capacity.

The CEO and DON confirmed on 04/25/2022 that the facility was operating over capacity with 93 patients.

Employee #4 confirmed on 04/24/2022, that the facility currently had 93 patients admitted and that there were 4 patients being processed for admission 2 of which were transferred from local hospitals and the other 2 were walk in patients.

Employee #18 confirmed on 04/27/2022 that the facility does not notify referral sources including local EDs that the facility does not have a bed for the patient prior to accepting the patient for admission if overcapacity. She stated that the facility accepts all admissions as they cannot turn patients away.

Employee #3 confirmed that once patients present to admissions they are not allowed to leave unless it is AMA (against medical advice). Additionally, patients do not receive active treatment unless it is a diabetic patient that may require an insulin administration, otherwise patients are not administered medications to treat their psychiatric disorder until assigned to a bed.

Employee #14 provided documentation on 05/10/2022 that revealed that the average daily patient census for February 2022 was 93.54 and for March 2022 was 93.87 and confirmed that the facility is operating over licensed capacity.

Employee #14 confirmed on 05/12/2022 that the facility census lists are an accurate accounting of patients within the hospital.

2. The facility's policies and procedures revealed that (23) of (38) policies and procedures provided had not been reviewed or revised within the required three (3) years as follows.

General Standards of Conduct, effective 10/01/2018, no revision date listed
Abuse and Neglect, Identification and Reporting, effective and revision date 10/01/2018
Abuse and Neglect of a Patient by Staff Member, effective and revision date 10/01/2018
Orientation/Inservice, effective and revision date 10/01/2018
Background Investigation & Fingerprint clearance Requirements, effective 07/01/2018, revision date 02/21/2019
Reporting and Non-Retaliation, effective 10/01/2018, no revision date listed
Code Blue, effective and revision date 10/01/2018
Observation Services, effective and revision date 02/18/2019
Medication Administration, effective and revision date 10/01/2018
Nutrition Assessment, effective and revision date 10/01/2018
Interdisciplinary Treatment Plan Team Meetings, effective and revision date 10/01/2018
Interdisciplinary Treatment Planning (ITP) Documentation, effective and revision date 10/01/2018
Exceeding Capacity & Ambulance Diversion, effective 03/28/2019, no revision date listed
Housekeeping/Laundry Infection Control, effective and revision date 10/01/2018
Daily Room Cleaning, effective and revision date 10/01/2018
Restroom Cleaning, effective and revision date 10/01/2018
Discharge Room Cleaning, effective and revision date 10/01/2018
Hazardous Material Management, effective and revision date 10/01/2018
Exposure Control Plan, effective 10/01/2018, revision date 03/25/2019
Incident Reporting Policy, effective 10/01/2018, no revision date listed
Emergency Transfers, effective and revision date 10/01/2018
Planned Transfers and/or Transports, effective and revision date 10/01/2018
Intake Admission Process, effective 10/01/2018, revision date 12/03/2018

Most of the outdated policies has not been reviewed and/or revised since their effective date in October 2018 prior to the facility's initial licensure on April 10, 2019.

Employee #14 confirmed that the facility has not updated policies every three years as required.

3.The ADHS licensing file was reviewed and found that the facility's first license was issued on 04/17/2019. The Department approved the facility to provide (9) observation/stabilization chairs on 04/10/2019.

The ADHS licensing file was reviewed and found that the Department issued a license on 08/18/2020 that approved the facility to provide (9) observation/stabilization chairs.

The ADHS licensing file was reviewed and found that the Department issued a license on 11/04/2020 that approved the facility to provide (9) observation/stabilization chairs.

The ADHS licensing file was reviewed and found that the Department issued a license on 04/23/2021 that approved the facility to provide (9) observation/stabilization chairs.

The ADHS licensing file was reviewed and found that the Department issued a license on 08/02/2021 that approved the facility to provide (9) observation/stabilization chairs.

The ADHS licensing file was reviewed and found that the Department issued a license on 11/01/2021 that approved the facility to provide (9) observation/stabilization chairs.

The facility policy titled "Written Plan of Service and Staff Composition" effective date: 10/01/2018, revision date: 03/06/2022 revealed: "...Observation Center (not currently operational)...."

Observation on 04/24/2022 revealed that the facility had (11) "observation" chairs in the admission/intake area. The chairs in the area did not have the required space between the observation chairs or separate adult patients from adolescent patients.

Employee #4 confirmed on 04/24/2022 that the chairs were not used for observation/stabilization. Employee #4 confirmed that (6) chairs are used for adult intake/admissions and that (5) chairs are used for adolescent intake/admission.

Employee #1 confirmed on 04/25/2022 that the facility does not provide observation/stabilization services and has never provided those services.

4. The policy titled "Exceeding Capacity & Ambulance Diversion" requires: "...Destiny Springs Healthcare will ensure that there is a method to identify and document each occurrence of exceeding licensed capacity as our ability to deliver ideal care is inherently linked to capacity management...Destiny Springs Health care will not admit a patient if at capacity without the following actions...An emergency must exist for the patient and the patient must be seen and evaluated by a medical staff member to determine if the admission is emergent...If the medical staff member determines that patient is emergent in nature and needs admission the reason and findings must be documented by the medical staff provider...The CEO and Medical Director are notified that a patient is being admitted and capacity is exceeded...If after hours, the Administrator on Call is notified...The incident is documented, evaluated and actionable items are addressed. The report will be submitted to Quality upon completion. Each incident will be reviewed at the monthly Compliance meeting with a report going to the quarterly board meeting to determine if further action or a root cause analysis is needed...Within 2 hours of exceeding capacity the CEO or AOC will notify Arizona Department of Health Services, Division of Licensing, Bureau of Medical Facilities Licensing at 602-364-3030 during normal business hours and request to speak with the surveyor of the day or a team leader...Destiny Springs Healthcare will ensure that several systematic measure are in place to manage capacity. these include Daily Huddles, discharge planning discussion with providers daily, bed ahead concept as well other (Sic) initiatives to ensure patient throughput and flow is managed in optimal state with patient safety as the primary focus...Destiny Springs Healthcare ensure that all discharges are managed effectively and safely...."

The policy titled "Quality Assessment & Performance Improvement Program" requires: "...The hospital shall collect and aggregate all data to monitor the effectiveness and safety of services, the quality of care, and identify opportunities for improvement...data will be aggregated at least quarterly for performance improvement...The use of root cause analysis will be used as needed...When a need for PI is identified the hospital will develop and implement on action plan. The action plan will be updated and outcomes determined. If the action plan is found not to be successful then it should be modified and reevaluated at a later date...."

The facility's ADHS License issued 04/10/2019 revealed that the facility was licensed for 20 Geriatric, 20 Pediatric, and 50 Adult beds with 9 Observation/Stabilization.

The facility's ADHS License issued 11/04/2020 revealed that the facility was licensed for 20 Pediatric and 70 General Psychiatric with 9 Observation/Stabilization.

The facility's amended ADHS License issued 08/02/2021 revealed that the facility was licensed for 52 Pediatric and 40 General Psychiatric with 9 Observation/Stabilization.

The facility's ADHS License issued 11/01/2021 revealed that the facility was licensed for 52 Pediatric and 40 General Psychiatric with 9 Observation/Stabilization.

The facility notified the Department 16 times from 03/31/2020 through 06/21/2021 of exceeding licensed capacity before applying for and being issued an amended license on 08/02/2021.

Employee #14 provided documentation of the facility's over capacity days as follows.

January over census days
1/10/22: 93
1/19/22: 93
1/25/22: 94
1/26/22: 93
1/30/22: 95

February over census days
2/1/22: 94
2/2/22: 93
2/4/22: 94
2/8/22: 93
2/9/22: 96
2/10/22: 94
2/11/22: 95
2/14/22: 93
2/15/22: 95
2/17/22: 96
2/18/22: 96

2/20/22: 93
2/21/22: 93
2/22/22: 93
2/25/22: 94

March over census days
3/1/22: 93
3/8/22: 93
3/11/22: 93
3/15/22: 93
3/16/22: 93
3/22/22: 94
3/23/22: 93
3/29/22: 93

April over census days
4/6/22: 93
4/8/22: 93
4/10/22: 93
4/11/22: 93
4/12/22: 93

The facility exceeded their licensed capacity on 41 days from 01/07/2022 through 04/25/2022.

Observation on 04/24/2022 revealed that the facility was overcapacity with 93 inpatients with an additional 4 patients being processed in the admissions department.

Observation on 04/24/2022 revealed a census board in the intake/admissions administrative area. The board revealed that there were three patients housed in room 2502.

Observation on 04/25/2022 revealed that a "cot" had been placed in room 2502 in addition to the 2 licensed beds in the room.

Employee #3 confirmed on 04/25/2022, that the facility had placed a cot in room 2502 to house an additional patient in excess of the facility's licensed capacity.

Employee #1 and 2 confirmed on 04/25/2022 that the facility was operating over capacity with 93 patients.

Employee #4 confirmed on 04/24/2022, that the facility currently had 93 patients admitted and that there were 4 patients being processed for admission 2 of which were transferred from local hospitals and the other 2 were walk in patients.

Employee #14 confirmed on 05/05/2022 via email response: "...At April ' s QAPI committee meeting, the committee discussed concerns for a pattern for exceeding capacity in the last 90 days that needed to be addressed. The committee looked at information from our Average Daily Census from Jan, Feb and March to determine the pattern instead of looking at each individual instance. Each individual instance of over capacity is currently discussed at our daily Flash meeting...."

Employee #14 provided documentation on 05/10/2022 that revealed that the average daily patient census for February 2022 was 93.54 and for March 2022 was 93.87 and confirmed that the facility was operating over licensed capacity. Additionally, Employee #14 confirmed that the facility had addressed the adolescent overcapacity by requesting a modification of the license to increase adolescent beds but that there was no request to increase capacity further after that.

Based on review of the hospital's policies and procedures, personnel files and staff interviews, it was determined the hospital failed to ensure staff had current Level One Fingerprint Clearance, Cardiopulmonary Resuscitation Certification (CPR), Crisis Prevention Institute Certification (CPI), annual competencies and in-services before working with patients. This deficient practice poses a potential risk to the health and safety of patients when patients are placed in contact with non-qualified nursing personnel.

Findings include:

A request was made for annual required competencies and in-service trainings for personnel. The facility did not have a policy.

A request was made for a policy regarding new hire/onboarding requirements. The facility did not have a policy. A copy of an onboarding checklist was provided which included CPR card.

Policy titled "Background Investigation & Fingerprint Clearance Requirements" revealed: " ...Background checks shall include, but not limited to former employment, education, professional credentials and licensure, I+OIG, GSA, and criminal records ...If the results of a criminal record search reveal the existence of misdemeanor or felony convictions that were not discloses by the applicant during the interview process, a Human Resource Representative will contact the candidate and request an explanation ...All employees must receive a Level One Fingerprint Clearance card; or within seven days of employment ...shall apply for a fingerprint clearance card. No individual will be permitted to have contact with patients until clearance card has been received ...."

Behavioral Health Technician job description revealed: " ... CPR certification, Basic Life Support, CPI required prior to patient interaction...."

Twenty-six (26) personnel files were reviewed. The following was revealed during the review:

Level One Fingerprint Clearance:

1 Behavioral Health Technician (BHT) (Employee #65) with thirteen (13) criminal convictions was allowed to work from 02/28/2022 until termination on 03/17/2022 without applying for a fingerprint clearance. The employee was terminated for multiple violations of policies and procedures including inappropriate interactions with adolescent patients.

1 BHT (Employee #51) was allowed to work for ten (10) days with patients before the employee received a Level One Fingerprint Clearance.

1 BHT (Employee #7) was currently working as of 05/10/2022 with an expired as of 04/13/2022 Level One Fingerprint Clearance Card.

1 Registered Nurse (Employee #26) had no Level One Fingerprint Clearance Card on file during the employee's entire term of employment. The employee is no longer employed at the facility.

Cardiopulmonary Resuscitation Certification (CPR)

One (1) employee with an expired CPR card. The card had expired on 02/28/2022. Three (3) employees had no CPR card on file.

CPI training:

Five (5) employees had no documentation regarding current Crisis Prevention Institute (CPI) certification present in their respective personnel files.

Abuse training:
Five (5) employees had no current abuse training documentation in their respective personnel files.

Annual Competencies/In-services:

Two (2) employees had no documentation indicating completion of annual required job competencies present in their respective personnel files.

Employee #1 confirmed on 04/25/2022 that fingerprint clearances were required for all employees. Employee #1 confirmed on 05/01/2022 the personnel files were incomplete and required documentation was missing from the personnel files. Employee #1 further acknowledged that personnel were not current with the required CPI and abuse trainings.

Employee #67 confirmed on 04/28/2022 that CPR certification cards were not present in the 3 employees files and that CPR certification had expired on the fourth employee and there was no record of a new CPR certification.

Based on review of clinical records, policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined the Governing Body failed to be accountable for the conduct of hospital operations and ensure the hospital functioned in a manner for the provision of quality care in a safe environment, This Condition level deficiency is the result of the Condition level and Standard deficiencies found under the Conditions of Patient Rights,Quality Assurance and Performance Improvement (QAPI), Nursing Services, and Special Medical Record Requirements for Psychiatric Hospitals as evidenced by:

A-0049 Medical Staff -Accountability:

Medical staff failed to recognize and respond to a significant change in a patient which resulted in the patient being transferred to another hospital with acute kidney failure, lithium toxicity and severe dehydration.

A-0057 Chief Executive Officer:

The CEO failed to manage the daily functions of the hospital to provide quality care and meet the needs of patients.

A-0115 Condition of Participation: Patient Rights:

Governing Body failed to ensure that each patient's rights were protected and promoted during their hospital admission.

A-0118 Grievances:

The hospital failed to properly identify and investigate a patient grievance.

A-0119 Grievance Review:

The hospital failed to provide the patient with acknowledgment that the patient grievance was received and being investigated.

A-0123 Grievance Notice of Decision:

The hospital failed to identify, investigate and determine a resolution to a patient grievance.

A-0129 Exercise of Rights:

The hospital failed to allow a patient leave Against Medical Advice coercing the patient to stay, the hospital would not allow a parent to take a minor patient to the Emergency Department for medical care, the hospital did not treat patients with dignity, respect and consideration by not providing a proper room and bed for patients, the hospital did not include the patient and patient's representative in the planning of care.

A-0144 Care in a Safe Setting:

The hospital failed to ensure: Behavioral Health Technicians (BHT) were monitoring patients as assigned, BHTs were monitoring patients and not using their personal cell phones while working, BHTs were properly performing monitoring duties, adult patients were not admitted to adolescent units, adolescent patients were not in same patient care area as adults, and the seclusions rooms were kept locked and secured.

A-0145 Free from all forms of abuse or harassment:

The hospital failed to ensure female patients were not subjected to sexual abuse.

A-0263 Condition of Participation: Quality Assurance and Performance Improvement (QAPI):

The Governing Body failed to monitor the QAPI program activities.

A-273 Data Collection and Analysis:

The QAPI program failed to evaluate the occurrences of exceeding capacity and the impact on quality of care, the QAPI program failed to identify and evaluate an incident involving a patient change in condition requiring an emergency transfer to the ED.

A-0285 Patient Safety, Medical Errors, and Adverse Events:

The QAPI program failed to ensure quarterly reports regarding lithium usage was compiled and reported to the P&T committee.

A-0309 Executive Responsibilities:

The Governing Body failed to monitor the QAPI program activities regarding patient complaints and grievances.

A-0385 Condition of Participation; Nursing Services:

The hospital failed to ensure patients received quality nursing care to meet the needs of the patients.

A-0392 Staffing and Delivery of Care:

The registered nurse failed to identify a change in condition of a patient and failed to document nursing care and interventions provided to the patient.

A-0395 RN supervision of nursing care:

BHTS were not being supervised to ensure job duties were being performed appropriately and correctly.

A-0396 Nursing care plan

Patient treatment and care plans were not implemented and reviewed per policy.

A-0397 Nursing Assignments

Nursing staff are not knowledgeable regarding the acuity plan or how to implement the acuity plan.

A-1620 Condition of Participation: Special Medical Record Requirements:

The hospital failed to ensure treatment plans were implemented and developed to meet the needs of the patient.

A-1640 Individualized and Comprehensive Treatment Plans

The treatment plans were not initiated, developed, implemented and reviewed as per policy.

A-1642 Short-term and Long-term range goals:

Treatment plans had missing short and long term goals and missing target dates.

The cumulative effect of these systemic deficiencies resulted in the hospital's inability to ensure the provision of quality health care in a safe environment, and therefore resulting in the failure to meet the requirements of the Condition of Participation for Governing Body.

Based on review of policies and procedures, hospital medical staff bylaws, medical staff rules and regulations, incident report, U.S. Food and Drug Administration Guidelines on Lithium, medical record review and staff interview,it was determined the governing authority failed to ensure that medical staff recognized and responded to a significant change and decline in Patient #44's medical condition. The deficient practice poses a risk to the health and safety of patients when medical staff do not identify and treat a potential life-threatening change in a patient's condition.

Findings include:

Policy titled "Medical Record Documentation, Record of Care, Treatment and Services (Outpatient/Inpatient) revealed: " ...medical records are adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition ...."

Policy titled "Medication Safety: Lithium Monitoring" revealed: " ...Lithium is a HIGH-RISK/HIGH-ALERT (HRHA) medication due to toxicity occurring at levels close to therapeutic levels ...Unless patient is transferring from an acute medical/surgical hospital and a report of the current lithium level accompanies them, all patients receiving lithium will be ordered a lithium level with their admission lab draws...Signs of toxicity- blurred vision, muscle weakness, drowsiness, coarse tremor, dysarthria, ataxia, confusion, convulsions, nausea with vomiting, ECG changes ...."

Policy titled "Patient Rights and Responsibilities" revealed: " ...Patients have the following rights: ...The right to have all care, procedures, and treatment to be provided, the risks, side effects, and benefits of all medications and treatment procedures that are available ...."

Policy titled "Physician Orders" revealed: " ...all care, treatment, and services provided by the hospital are written directly or indirectly by a physician or licensed independent practitioner (LIP) ...All care, treatment, and services are provided in the hospital is supported by a physician's order ...."

Hospital document titled "Destiny Springs Healthcare Medical Staff Bylaws" revealed: " ...Each staff member, regardless of assigned staff category, and each practitioner exercising temporary privileges under these Bylaws, shall: Provide patients with continuous care at the level of quality and efficiency generally recognized as appropriated; ...."

Hospital document titled "Destiny Springs Healthcare Medical Staff Rules & Regulations" revealed: " ...Each patient will be under the care of an attending physician. The attending physician will be responsible for the care of each patient for whom they have established an attending relationship ...Emergency care of a patient at the Hospital shall be under the direction of the attending Practitioner ...Nursing staff shall be responsible for notifying the appropriate Practitioner, giving emergency care, and referring the patient to the nearest acute care Hospital capable of providing the care needed if the transfer is ordered by a Practitioner ...An appropriate record shall be kept for every patient receiving emergency care, and this documentation will be incorporated into the patient's medical record. The record shall include: Adequate patient identification; pertinent history of the injury or illness, including details of emergency care given to the patient; description of significant clinical, laboratory, and radiologic findings; diagnoses; treatment given; condition of the patient on discharge or transfer ...."

Hospital document titled "Patient Handbook" revealed: " ...Physicians: You will have a Psychiatrist assigned to you who will conduct your evaluation at admission and meet with you during your stay. You will also be evaluated by a member of our medical staff who will take care of any medical needs. Other Physicians may be asked to join the team to address other concerns that you may have ...As a partner in your care, if you experience any change in your condition that is worrisome or that you feel could be a problem, please alert the nurse at any time during your visit. At Destiny Springs Healthcare we have a dedicated team, around the clock to quickly response and assess any concern. We encourage family members and visitors to feel free to report any issues as well ...."

Incident Report dated 02/09/2022 20:30 revealed: " ...2030 Patient had large emesis, bright red blood with small amount of blue powerade. Denies nausea or abdominal pain before and after emesis. Dr Gill called with update on patient. Order received to send patient to emergency room with c/o hemoptisis (sic) and dehydration. 911 EMS activated w/2 minute ETA. Nursing supervisor involved and took patient to Intake for discharge to ER ...." Further review of the incident report revealed a question "did provider see patient _X_ yes __no with no further documentation as to the provider, the date or time when patient was seen.

Patient #44's provider ordered lithium 900 mg oral at bedtime on 01/31/2022 at 2100.

Patient #44's "Lithium Monitoring Form" dated 01/31/2022 revealed: "...(Employee #72) doctor ordered CBC w/ diff, CMP and lithium for 2/3...still no level back yet - got labs back...(Employee #72) canceled lab - since home med...2/17/2022: new lithium lab initiated for 2/21/2022...."

Employee #15 confirmed on 04/26/2022 that a baseline lithium lab was canceled by the provider because the patient was taking lithium at home prior to admission to the hospital. Employee #15 confirmed that Patient #44 should have had a baseline lithium lab drawn upon admission to the hospital as required by facility policy.

Patient #44 Progress Note Internal Medicine dated 02/07/2022 revealed: " ...Patient concerned about his weight, wants a pill to help him lose weight. Also congested, mild cough, diarrhea X 5-6 days ...Assessment/Plan: ...Overweight- discussed lifestyle changes including dietary changes and exercise- dietary consult ...Congestion-runny nose-Mucinex 600 mg BID ...Diarrhea- Imodium q 6 hrs prn ...Cough-very mild-monitor not highly suspicious for COVID-19 ...."

Patient #44 Provider Progress Note dated 02/09/2022 revealed: " ...Pt reports he has had malaise, and had blood in his emesis. He states his urine is dark colored ...."

Patient #44 Dietary Consult dated 02/09/2022 revealed: " ...Patient states he usually eats well, but has been feeling sick for a few days and not able to keep his food down ...Patient encouraged to speak with doctor about nausea ...."

Patient #44 Progress Note Internal Medicine dated 02/09/2022 16:05 p.m. revealed: " ...Pt seen for ? threw up ? some blood streaks c/o dark urine ...fever no, chest pain no, vomiting yes, chills yes, HEENT mild tonsillar enlargement, Assessment/Plan: 1. ? Dark Urine- Dehydration will check UA, lytes; 2. Vomiting- ? some mild streaks check cbc, cmp; 3. Sore throat/chills r/o covid ? chills, taste issues; 4. Diarrhea- resolved ...."

Further review of the medical record failed to reveal any further internal medicine or other medical provider documentation regarding Patient #44 after 02/09/2022 at 16:05 pm. Further review revealed no provider documentation regarding the rationale for transferring the patient to the Emergency Room at another facility after 16:05 pm on 02/09/2022.

Patient #44 Discharge Summary dated 02/10/2022 at 12:09 p.m. revealed: " ...Discharge to acute medical facility due to acute medical problems ...Final exam: Discharged to PCH ...MSE unknown at time of discharge ...."

Email dated 02/12/2022 between Employee #14 and Provider #3 revealed: "Actually I saw this patient on wed the 9th sometime that evening, and later that night I also recommended transfer to ER. Initially there was a question of patient not feeling well and vomiting what I was told a small streak of blood. He came into to see me with a couple cups of fruit snacks that he was eating. I ordered stat labs including urine, also a rapid COVID-19 test which I was informed was positive, Plan was to encourage hydration and review stat labs, however, when patient threw up and with definite blood in vomitus pt was transferred to the ER. Patient was not in any respiratory distress nor were there any urgent phone calls made to on call physician, he was in the medical book for a routine follow up ...."

Review of the IM (internal medicine) log book for 2/9/2022 revealed patient #44 was listed in the IM log book with the reason for MD appt as "threw up very small amount of blood, also c/o brown urine."

Review of Patient #44's medical records dated 02/10/2022 at 1052 from Phoenix Children's Hospital revealed: "...(Patient #44)...presented from an inpatient psychiatry facility with acute hypoxic respiratory failure in the setting of COVID...and concern for bacterial PNA (pneumonia) who was also found to have AKI (acute kidney injury)...leading to lithium toxicity...Problem list: Acute kidney failure...Hematuria...Pneumonia...Finding of abnormal level of lithium in blood...Proteinuria...nephritic syndrome...NEPHRO: Pt was noted to have positive Strep ASO as well as acute kidney injury with with elevated creatinine...Lithium level was noted to be elevated to 2.35...On arrival to the ED pt began having bright red emesis...Toxicology consulted. Lithium levels were closely monitored and slowly declined over the course of the hospitalization...."

US Food and Drug Administration, Medication Guide, Lithium Package Insert, 10/2018 revealed: " ...Lithium toxicity: the toxic concentration for lithium >1.5mEq/L are close to the therapeutic range (0.8 to 1.2 mEq/L) ...Cardiac manifestations involve electrocardiographic changes such as prolonged QT interval, ST and T-wave changes and myocarditis. Renal manifestations include urine concentrating defect, nephrogenic diabetes insipidus, and renal failure, Respiratory manifestations include dyspnea, aspiration pneumonia, and respiratory failure. Gastrointestinal manifestations include nausea, vomiting, diarrhea and bloating ...The risk of lithium toxicity is increased by: recent onset of concurrent febrile illness ...Impaired renal function, volume depletion or dehydration, significant cardiovascular disease, changes in electrolyte concentrations (especially sodium and potassium). Avoid becoming overheated or dehydrated ... Most common side effects of Lithium for children 7-17 years of age include: excessive urination, excessive thirst, nausea, vomiting, decreased appetite ...."

Employee #15 confirmed during an interview conducted on 04/26/2022 that the medical staff should have considered lithium toxicity when the patient began to experience nausea, vomiting and dark urine.

Employee #3 confirmed during an interview on 05/10/2022 that Patient #44 was seen by the internal medicine provider after being logged into the IM log book for routine exam. Employee #3 stated that COVID was present in the unit and the medical staff considered the symptoms Patient #44 was exhibiting were COVID related. Employee #3 confirmed that there was no medical provider documentation in the medical record indicating the rationale for transferring the patient to the Emergency Department.

Based on review of policies and procedures, document review, medical record review, and interview, it was determined that the governing body failed to ensure that the Chief Executive Officer (CEO) was responsible for hospital operations. This deficient practice poses a risk to the health and safety of patients by the failure to comply with the requirements for the following Medicare Conditions of Participation:

Governing Body
Patient Rights
Quality Assurance and Performance Improvement
Nursing Services
Special Medical Records requirements

Findings include:

1. The CEO failed to ensure that a request for approval to increase the facility's licensed capacity was submitted to the state licensing agency.
(Cross reference Tag #A-0022 #1)

2. The CEO failed to ensure that the state licensing agency was notified of the removal of Observation/Stabilization Services from the hospitals scope of services.
(Cross reference Tag #A-0022 #2)

3. The CEO failed to ensure that hospital policies and procedures were reviewed every three (3) years and updated as needed.
(Cross reference Tag #A-0022 #3)

4. The CEO failed to ensure that the licensed capacity of the hospital was not exceeded.
(Cross reference Tag #A-0022 #4)

5. The CEO failed to ensure that staff had current Level One Fingerprint Clearances, Cardiopulmonary Resuscitation (CPR) certification, Crisis Prevention Institute (CPI) certification, annual competencies and in-services before working with patients.
(Cross reference Tag #A-0023)

6. The CEO failed to ensure that the hospital properly defined a grievance; and recognized and investigated Patient #5's grievance per hospital policy and procedure.
(Cross reference Tag #A-0118)

7. The CEO failed to ensure that the hospital identified and acknowledged Patient #5's grievance and responded to the patient in writing within 7 days the receipt of the grievance and within 7 days after the resolution of the grievance.
(Cross reference Tag #A-0119)

8. The CEO failed to ensure that the hospital provided a written notice to Patient #5 of the facility's decision regarding the grievance including staff contact information, the investigation process and results, and the completion date of the investigation.
(Cross reference Tag #A-0123)

9. The CEO failed to ensure that patients were able to exercise their rights as demonstrated by the following:
a. Patients were not allowed to leave Against Medical Advice (AMA).
(Cross reference Tag#A-0129)

The CEO failed to ensure the hospital did not coerce a patient to rescind an AMA request under threat of petition for involuntary admission.

b. Patients were not allowed to be taken to another facility when the hospital was unable to provide a higher level of care that the patient required.
(Cross reference Tag #A-0129)

The CEO failed to ensure that the hospital allowed a minor patient be taken by the patient's parent to an Emergency Department (ED) for medical evaluation and treatment when the patient had a significant change in their medical condition. The RN informed the patient's mother that it would be considered an AMA discharge and the child was receiving medical care at the facility. The patient subsequently was transferred via ALS ambulance to an ED approximately 4 hours later and diagnosed with dehydration, acute kidney failure and lithium toxicity.

c. Patients were not treated with dignity, respect, and consideration.
(Cross reference Tag #A-0129)

The CEO failed to ensure that the hospital treated patients with dignity, respect and consideration by providing patients with a proper room and bed, and not having the patients sleep on cots and mattresses in common areas due to the facility exceeding capacity.

d. Patients and patients' representatives were not included decisions regarding patient care.
(Cross reference Tag #A-0129)

The CEO failed to ensure that patients and patients' representatives were included in development and implementation of the patients plan of care.

10. The CEO failed to ensure that patient care was provided in a safe setting as demonstrated by the following:

a. BHT assigned to LOS of Patient #1 was found to be not monitoring the patient.
(Cross reference Tag #A-0144, A-0145 and A-0395)

b. BHTs were using their personal cell phones excessively while performing job duties and not monitoring patients.
(Cross reference Tag #A-0144 and A-0395)

c. BHTs were using rolling chairs to propel themselves down the hallway while performing patient monitoring.
(Cross reference Tag #A-0144 and A-0395)

d. Adult psychiatric patients were admitted to an adolescent psychiatric unit when adolescent patients were present on the unit.
(Cross reference Tag #A-0144)

e. Adolescent patients were placed in the same patient care area as adult patients.
(Cross reference Tag #A-0144)

f. Seclusion rooms were not kept secured and locked.
(Cross reference Tag #A-0144)

11. The CEO failed to ensure that patients were not subjected to sexual abuse.
(Cross reference Tag #A-0145)

12. The CEO failed to ensure that the quality management program monitored the effectiveness of the safety of services and quality of care related to patients admitted when the hospital was at capacity.
(Cross reference Tag #A-0273 #1)

13. The CEO failed to ensure that the quality management program identified concerns specific to the delivery of hospital services related to patient care in regards to a patient's transfer to an Emergency Department following a change in condition.
(Cross reference Tag #A-0273 #2)

14. The CEO failed to ensure that a quarterly report for the evaluation of lithium use was completed and submitted to the P&T committee.
(Cross reference Tag #A-0286)

15. The CEO failed to ensure that the hospital provided evaluation and oversight related to the patient complaint/grievance process.
(Cross reference Tag #A-0309)

16. The CEO failed to ensure the registered nurse recognized a change in the medical condition of a patient. perform an assessment and provide proper nursing care to the patient.
(Cross reference Tag #A-0392)

17. The CEO failed to ensure that the registered nurse supervised the patient care provided by BHTs.
(Cross reference Tag #A-0395)

18. The CEO failed to ensure that nursing personnel documented properly on Census 15 Minute Checks, changes in patients' conditions and treatment plans.
(Cross reference Tag #A-0396)

19. The CEO failed to ensure that the nursing staff were knowledgeable about the acuity plan and how to implement it.
(Cross reference Tag #A-0397)

20. The CEO failed to ensure that Interdisciplinary Treatment Plans were developed and reviewed, signed and updated as required.
(Cross reference Tag #A-1640)

21. The CEO failed to ensure that ITPs had short-term and long-term goals with target dates.
(Cross reference Tag #A-1642)

The CEO confirmed during an interview on 04/25/2022 that s/he is responsible and accountable for the overall daily function and management of the hospital.

Based on review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by the hospital's failure to:

Findings include:

The Condition level deficiency is the result of the standard deficiencies found under the Conditions of Patient Right in the following tags:

A-0118 failure to properly define, identify and investigate Patient #5's grievance.

A-0119 failure to identify and acknowledge Patient #5's grievance and respond with a written receipt of the grievance and written notice of resolution in the required timeframes.

A-0123 failure to provide written notice of the facility's decision regarding the grievance, including hospital staff contact information, results of the investigation and date the investigation was completed.

A-0129 Failure to allow patients to exercise their rights by:
a. Coercing Patient #5 to rescind leave Against Medical Advice (AMA) request under threat of petition for involuntary admission
b. Not allowing a minor patient to be taken by the patient's parent to the Emergency Department (ED) for medical evaluation and treatment when the patient had a significant change in their medical condition.
c. Not treating patients with dignity, respect, and consideration by having the patients sleep on cots and mattresses in common areas when the facility was exceeding capacity.
d. Not including patients and patients' representatives in the development and implementation of patients' plans of care.

A-0144 Failure to provide care in a safe setting:
a. A Behavioral Health Technician (BHT) assigned to Line of Sight observation (LOS) was found to be not monitoring the patient as ordered.
b. BHTs using their personal cell phones excessively while performing job duties and not monitoring patients,
c. BHTs using rolling chairs to propel themselves down the unit hallway while performing patient monitoring.
d. Adult psychiatric patients were admitted to an adolescent psychiatric unit when adolescent patients were present on the unit.
e. Adolescent patients were placed in the same patient care area as adult patients.
f. Seclusion rooms were not kept locked and secure.

A-145 Failure to ensure female patients were not subjected to sexual abuse.

The cumulative effect of these systemic problems resulted in the hospital being ineffective with promoting and protecting the rights of each patient and failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on review of hospital policies and procedures, hospital documents, hospital complaint/grievance logs, Quality Assurance and Performance Improvement Committee Meeting Minutes, and staff interview, it was determined the Hospital failed to properly define, identify and investigate Patient #5's grievance. This deficient practice poses the risk of patient/family grievances not being addressed and potential problems identified and corrected.

Findings include:

Policy titled "Patient Complaints and Grievances" revealed: " ...Complaint: Any written or verbal expression of dissatisfaction by the patient, patient family patient guardian or other patient caretaker regarding care of services providing by Destiny Springs Healthcare which can be resolved at the point at which it occurs ...Grievance: Any formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family's satisfaction at the point of service. In a grievance situation, the patient (or patient's representative) is specifically requesting that his or her complaint undergo a formal review process ...If the resolution to the complaint is acceptable to the patient (or patient representative), the complaint will be considered closed and no further action will be necessary ...For all formal grievances that do not involve allegations of discrimination or abuse a. the patient advocate is to respond to the patient in writing, and in person if able, within ten (10) days. A copy of the patient's grievance and the written resolution will be kept on file, submitted for review with the Quality Improvement Committee. In instances where final resolution of the issue will take longer than ten (10) days, the patient advocate will communicate this to the complainant, and provide a timeframe by which the issue will be resolved. Once the final resolution is reached the patient advocate will respond again, in writing to the complainant. The extended resolution time frame should not exceed thirty (30) days from the original date of the complaint ...Root cause analysis and/or a systems analysis will be conducted on grievances as appropriate ...."

Hospital document titled "Patient Grievance Form" revealed: " ...Upon submitting this form to any staff member, the staff member will notify the Patient Advocate or hospital administrator and the advocate or administrator will meet with you within twenty-four (24) hour ...."

Hospital document titled "Patient Handbook" revealed: " ...Complaints: Our goal is to make your stay as supportive and recovery oriented as possible. If you become concerned or have an issue, we ask you try to address the issue as soon as possible to ensure a prompt resolution. If this is not possible, you may want to fill out a Complaint/Grievance Form. The Patient Advocate will work with you to address your concerns and to develop a plan to pursue resolution ...Patient Rights ...A patient has the following rights ...To file a complaint or grievance and receive a prompt resolution ...."

Review of Patient Grievance Form dated 01/28/2022 signed by Patient #5 revealed: " ...On 26 January,2022, I under threat of court order, agreed to go to destiny Springs, under the impression that I was voluntary and I could check myself out, AMA if necessary ...When I met Dr. Kramer upon check in, I was advised to fill out the AMA. This was 100% done under his direction ...Later that evening I was approached by the music activities therapist, Ethan?, who advised me the Social Worker had a message for me: Option 1) Rescind the AMA and I will be released Monday; Option 2) Do not rescind and I am guaranteed a court ordered petition ...Later that evening the Social Worker, Peta, met w/me ...Peta explained that the Dr. is not the one who makes discharge decisions. I explained the AMA was only submitted after I met w/ him ...Peta reiterated what Ethan had earlier relayed. She then handed me a pen and instructed me what to write on the AMA, verbadum (sic), to rescind it. This action was only done under threat and was not authentic ...On 28 January 2022, I once again met w/ Dr. Kramer, who stated he was surprised to have seen I rescinded my AMA document. He was (and stated this to me) planning to sign my discharge until he saw me this morning. I asked Dr Kramer, if he felt I was able to be discharged, then why did he not simply discharge me himself, rather than advise me to file an AMA. He stated, "That's just how this facility works." Between what I was advised at the hospital, the misconduct of Peta (social worker), Dr Kramer's advice to file AMA, which was rescinded under threat and duress, I believe my rights as a patient have been violated. I do not consent to remain in this facility and any and every hor (sic) spent here is not consentual (sic) ...I do not agree that the decisions made to keep me until 02/02/2022 by administration should supercede (sic) that of a licensed medical professional. My right to treatment has been violated ...."

Review of hospital document titled "Complaint Follow Up" dated 01/31/2022 revealed: " ...Details of complaint: Communication with Social Worker/Case Manager regarding AMA and petition ...Resolution: ...January 28, 2022, patient submitted an AMA. Social Worker met with patient and explained AMA process, concerns regarding AMA due to significance/reason for patient's inpatient stay. Patient believed that once the provider verbally provided support for AMA the process concluded. Social Worker explained that discharges, including AMA's are decided as a team. Patient rescinded her AMA after received verbal guidance from Social Worker. Patient's [husband] had Surprise police department dispatched to the hospital alleging the hospital was keeping the patient against [her] will. Social Worker explained process to police department ...January 30, 2022 ...Interim Patient Advocate followed-up with clinical team members, including Chief Executive Office, regarding patient's inpatient stay and complaint. CEO noted that provider shared information regarding his support with patient's AMA prematurely and did so without consulting other members of the treatment team. There was enough concern related to patient's inpatient criteria that team members did not feel it was appropriate for patient to discharge less than 48 hours of [her] admission and the team felt it in the best interest of the patient to monitor her for several additional days which still coincided with minimal stay period of 5 days to ensure safety ...."

Review of the Quality Assurance and Performance Improvement Committee meeting minutes dated April, 2022 revealed for the past quarter the following: Complaints: January 20, February 28, March 20; Grievances: January 0, February 0, March 1.

A review of the hospital complaint/grievance log for January, 2022, revealed Patient #5 grievance was dated 01/28/2022 and listed as a complaint in the log. The persons listed as resolving the "complaint" were the CEO, the interim patient advocate and the social worker named in the patient grievance. The date of response was listed as 01/28/2022 and 01/30/2022. The notes section of the log listed Communication: AMA/petition w/clinical team.

Employee #14 confirmed during an interview on 04/27/2022, that the Patient Grievance Form is used for both complaints and grievances. Employee #14 confirmed the facility considers a patient complaint as either a written or verbal complaint about an issue that can be resolved during the patient's stay. Employee #14 confirmed that s/he was unaware that a written complaint is always considered a grievance. Regarding the Patient Grievance Form that Patient #5 submitted, Employee #14 confirmed the facility considered it a complaint and did not investigate it according to the grievance process.

Based on review of hospital policies and procedures, hospital documents and interview, it was determined the hospital failed to identify and acknowledge Patient #5's grievance as a grievance and did not implement it's grievance policy which included responding to the complainant in writing within 7 days after receiving the complaint, and 7 days after the resolution of the complaint for Patient #5. This deficient practice has the potential to affect any patient who submits a grievance or has a grievance submitted by their representative.

Findings include:

Policy titled "Patient Complaints and Grievances" revealed: " ...Complaint: Any written or verbal expression of dissatisfaction by the patient, patient family patient guardian or other patient caretaker regarding care of services providing by Destiny Springs Healthcare which can be resolved at the point at which it occurs ...Grievance: Any formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family's satisfaction at the point of service. In a grievance situation, the patient (or patient's representative) is specifically requesting that his or her complaint undergo a formal review process ...If the resolution to the complaint is acceptable to the patient (or patient representative), the complaint will be considered closed and no further action will be necessary ...For all formal grievances that do not involve allegations of discrimination or abuse a. the patient advocate is to respond to the patient in writing, and in person if able, within ten (10) days. A copy of the patient's grievance and the written resolution will be kept on file, submitted for review with the Quality Improvement Committee. In instances where final resolution of the issue will take longer than ten (10) days, the patient advocate will communicate this to the complainant, and provide a timeframe by which the issue will be resolved. Once the final resolution is reached the patient advocate will respond again, in writing to the complainant. The extended resolution time frame should not exceed thirty (30) days from the original date of the complaint ...Root cause analysis and/or a systems analysis will be conducted on grievances as appropriate ...."

Hospital document titled "Patient Grievance Form" revealed: " ...Upon submitting this form to any staff member, the staff member will notify the Patient Advocate or hospital administrator and the advocate or administrator will meet with you within twenty-four (24) hour ...."

Patient #5 submitted a written grievance on the hospital provided "Patient Grievance Form" on 01/28/2022.

A review of the hospital complaint and grievance log for January, 2022, revealed Patient #5's written grievance was documented on the log as a complaint. There was no written letter in response to the grievance sent to the patient and no written letter of resolution was provided to the patient.

Employee #14 confirmed on 04/27/2022 that Patient #5's written grievance was interpreted by the facility as a complaint and a grievance investigation did not take place.

Based on review of policies and procedures, hospital documents and staff interview, it was determined the hospital failed to identify a patient grievance and to require staff to provide Patient #5 with written notice of the facility's decision regarding the grievance, the hospital staff contact person, the steps taken to investigate the grievance, the results of the investigation, and date of completion/ resolution. This deficient practice poses a potential risk to patient health and safety when hospital staff fail to identify a grievance and document how/if /when a grievance was resolved, and communicate this information to patients.

Findings include:

Policy titled "Patient Complaints and Grievances" revealed: " ...Complaint: Any written or verbal expression of dissatisfaction by the patient, patient family patient guardian or other patient caretaker regarding care of services providing by Destiny Springs Healthcare which can be resolved at the point at which it occurs ...Grievance: Any formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family's satisfaction at the point of service. In a grievance situation, the patient (or patient's representative) is specifically requesting that his or her complaint undergo a formal review process ...If the resolution to the complaint is acceptable to the patient (or patient representative), the complaint will be considered closed and no further action will be necessary ...For all formal grievances that do not involve allegations of discrimination or abuse a. the patient advocate is to respond to the patient in writing, and in person if able, within ten (10) days. A copy of the patient's grievance and the written resolution will be kept on file, submitted for review with the Quality Improvement Committee. In instances where final resolution of the issue will take longer than ten (10) days, the patient advocate will communicate this to the complainant, and provide a timeframe by which the issue will be resolved. Once the final resolution is reached the patient advocate will respond again, in writing to the complainant. The extended resolution time frame should not exceed thirty (30) days from the original date of the complaint ...Root cause analysis and/or a systems analysis will be conducted on grievances as appropriate ...."

Hospital document titled "Patient Grievance Form" revealed: " ...Upon submitting this form to any staff member, the staff member will notify the Patient Advocate or hospital administrator and the advocate or administrator will meet with you within twenty-four (24) hour ...."

Hospital document titled "Patient Handbook" revealed: " ...Complaints: Our goal is to make your stay as supportive and recovery oriented as possible. If you become concerned or have nan issue, we ask you try to address the issue as soon as possible to ensure a prompt resolution. If this is not possible, you may want to fill out a Complaint/Grievance Form. The Patient Advocate will work with you to address your concerns and to develop a plan to pursue resolution ...Patient Rights ...A patient has the following rights ...To file a complaint or grievance and receive a prompt resolution ...."

Patient #5 submitted a written grievance on 01/28/2022 on the hospital's "Patient Grievance Form".

Employee #14 confirmed on 04/28/2022 that the grievance Patient #5 submitted on 01/28/2022 was not recognized as a grievance but as a complaint. Employee #14 confirmed that the facility did perform a proper grievance investigation regarding Patient #5's grievance as the facility considered it a complaint. Employee #14 confirmed that the facility did not provide any grievance resolution information to Patient #5.

Based on review of hospital policies and procedures, hospital documents, medical records, observations and staff interviews, it was determined the Hospital failed to ensure patients were able to exercise their rights as demonstrated by:
1. Coercing Patient #5 to rescind leave Against Medical Advice (AMA) request under threat of petition for involuntary admission.
2. Not allowing a minor patient be taken by the patient's parent to an Emergency Department for medical evaluation and treatment when the patient had a significant change in their medical condition.
3. Not treating patients with dignity, respect, and consideration by having patients sleep in common areas.
4. Not including the patient or patient's representative in planning the care of the patient.

These deficient practices pose a risk to the health and safety and well-being of patients when their rights are not promoted and protected.

Findings include:

1. Policy titled "Discharge Planning" revealed: " ...Discharges Against Medical Advice ...at the time of admission, patients/guardians are informed of their rights to request discharge at any time and the legal and ethical limitations that are association with discharges against medical advice (AMA) ...AMA discharges still require discharge planning, to the extent that it can be conducted within the legal timeframe of up to 72 hours. (24 hours excluding weekends and holidays) ...Patients who are discharged AMA shall still receive a medication list at discharge and discharge instructions, to the extent these instructions can be completed ...Patients who are discharged AMA may receive discharge prescriptions if such prescriptions would support the individual's continued likelihood of recovery, at the physician's discretion ...Patients are discharged AMA still require a discharge summary and all applicable documentation ...."

Policy titled "Elopement/AMA" revealed: " ...Procedure for Discharge Against Medical Advice: All voluntary patients who have signed themselves into the hospital for treatment have the right to terminate their stay with or without the consent of the Attending Physician. The only exceptions to the above are: Patients on legal holds, persons under guardianship that authorizes decisions for health care ...1. If the patient requests discharge, the patient will be advised of the AMA procedure. 2. A Registered Nurse will assess the patient's legal, physical, and mental health status including the potential for risk of harm to self or other. 3. The RN will notify the patient's attending Physician. 4. If the attending Physician decides to discharge AMA: a. The RN will take the order to discharge the patient AMA. B. Request that the patient read and sign the Against Medical Advice Discharge form. If the patient refuses staff shall document refusal on the form. C. Complete discharge procedure. D. Clearly document the entire process in the patient's chart. E. Complete Suicide Risk Assessment.5. If the attending/covering physician assesses the patient to be harmful to self or others, obtain an order to implement the Involuntary Commitment process ...."

Policy titled "Intake Admission Process" revealed: " ...IV. Additional Education and forms to complete on Admission: ...b. Prior to admission to the inpatient unit, the RN/Social Worker/therapist will educate the patient/guardian, and/ or caregiver regarding the admission process ...Special care will also be taken to educate the patient/guardian, and/or caregiver(s) regarding restrictions of items that the patient is allowed to have, the facility is a non-smoking facility, and the process should the patient or guardian request that the patient leave against medical advice (AMA). See AMA policy ...."

Policy titled "Patient Rights" revealed: " ...Patient Rights according to federal and state guidelines include the following at a minimum ...The right to receive considerate, respectful care in the least restrictive environment which preserve your dignity ...d. The right to make informed decisions regarding his or her care, including being informed of their health status, being included in care planning and treatment, and being able to request or refuse treatment. This right does not include the provision of treatment or services deemed medically unnecessary or inappropriate ...."

Hospital document titled "Medical Staff rules and Regulations" revealed: "...Discharge: Patients shall be discharged only on a written order of the attending physician...Should a patient express an intent to leave the hospital, the physician will be contacted to make a determination whether to discharge the patient, discharge the patient against medical advice, or commence the petitioning process...."

A review of Patient #5 medical record revealed the patient was voluntarily admitted on 01/26/2022. On 01/27/2022 at 10:20 a.m., Patient #5 signed Leave Agaist Medical Advice (AMA) paperwork after discussing the AMA process with the attending psychiatrist. A Social Worker note dated 01/27/2022 revealed Patient #5 had rescinded the AMA paperwork after being told about the "AMA/petition process".

Patient #5 submitted a grievance on a "Patient Grievance Form" on 01/28/2022 regarding the patient's treatment by staff and staff intimidating and coercing the patient to rescind the previously submitted AMA paperwork. Patient #5 stated on the grievance form that staff had told the patient if the AMA paperwork was not rescinded the facility would petition for a Title 36 court ordered admission for the patient.

Review of hospital document titled "Complaint Follow Up" dated 01/31/2022 revealed: " ...Details of complaint: Communication with Social Worker/Case Manager regarding AMA and petition ...Resolution: ...January 28, 2022, patient submitted an AMA. Social Worker met with patient and explained AMA process, concerns regarding AMA due to significance/reason for patient's inpatient stay. Patient believed that once the provider verbally provided support for AMA the process concluded. Social Worker explained that discharges, including AMA's are decided as a team. Patient rescinded her AMA after received verbal guidance from Social Worker. Patient's [husband] had Surprise police department dispatched to the hospital alleging the hospital was keeping the patient against her will. Social Worker explained process to police department ...January 30, 2022 ...Interim Patient Advocate followed-up with clinical team members, including Chief Executive Office, regarding patient's inpatient stay and complaint. CEO noted that provider shared information regarding his support with patient's AMA prematurely and did so without consulting other members of the treatment team. There was enough concern related to patient's inpatient criteria that team members did not feel it was appropriate for patient to discharge less than 48 hours of her admission and the team felt it in the best interest of the patient to monitor her for several additional days which still coincided with minimal stay period of 5 days to ensure safety ...."

Employee #14 confirmed on 05/09/2022 that Patient #5 rescinded her AMA paperwork on 01/27/2022.Employee #14 stated that if Patient #5 resubmitted the AMA paperwork on 01/28/202 the 24 hour waiting period for an AMA would fall on a weekend, and she would not have been discharged until Monday 01/31/2022. Employee #14 confirmed patients are informed about the facility's AMA process which includes discussing Title 36 petition. Employee #14 confirmed on 05/12/2022 that the facility did not have a minimum stay period.

2. Hospital document titled "Patient Handbook" revealed: " ...Nursing Staff: The nursing staff included Registered Nurses (RN), Licensed Practical Nurses (LPN's) and Behavioral Health Technicians (BHT's). Members of the nursing staff will be assigned to you each shift. They will meet with you and discuss any physical or emotional problems that you may be experiencing. The RN, LPN, or BHT will work as a team to meet your physical and emotional needs during your stay ...As a partner in your care, if you experience any change in your condition that is worrisome or that you feel could be a problem, please alert the nurse at any time during your visit. At Destiny Springs Healthcare we have a dedicated team, around the clock to quickly response and assess any concern. We encourage family members and visitors to feel free to report any issues as well ...."

Patient #44 Nursing Note dated 02/08/2022 2:32 a.m. revealed: " ...Patient resting in bed quietly at the start of 2300 shift. Pt woke up at 0130 and threw up twice the meatball sub he had eaten earlier ...."

Patient #44 Nursing Note dated 02/09/2022 10:38 a.m. revealed: " ...Patient reported this morning that he threw up blood. RN looked and patient had phlem (sic) pit up with a trace amount of bright red blood. Previous shift reported that patient threw up his dinner. Patient is isolated in his room until seen by medical ...."

Patient #44 Provider Progress Note dated 02/09/2022 revealed: " ...Pt reports he has had malaise, and had blood in his emesis. He states his urine is dark colored ...."

Patient #44 Quick Note dated 02/09/2022 4:08 p.m. revealed: " ...Patients mother called at 1550 on 2/9/21 to talk to patient and then to this RN. Patients mom states she is concerned we are not taking her son seriously with being sick. This RN informed parent that the medical provider had just seen him and was currently putting in orders for him. This RN let mom know that so far orders were for routine labs and c/s on his urine. Mom asked when results would be in this RN informed her labs were scheduled as routine not STAT and would be sent our tomorrow morning with the lab collection and would have results the following day. Mom asked if she could take him to a medical facility instead, and was informed it would be an AMA discharge. Mom stated she feels we are doing well with his mental health but nor his medical health and is concerned. This RN assured her we are testing and treating him for his current symptoms ...."

Transition Transfer dated 2/9/2022 20:30 p.m. revealed: " ...patient Condition: patient may be at risk for deterioration from or during transport signed by Employee #32 time 2038 ...reason for transfer: for equipment or services not available at this facility ...Hospital acceptance: Name of destination hospital Banner Thunderbird, accepted by Amanda, RN time 2130, accepting MD: ER physician ...Discharge vitals: Time: 1930 BP 142/95, pulse 117, Respirations 17, Temp 97.5 ...Risks for transfer: COVID +, hemoptysis ...Mode of Transport: ALS ambulance; Service contacted: Fire department (911) by Employee #32 at 2030 ETA 2 minutes; ...Patient consent: mother called 2040 ...."

Employee #3 confirmed on 04/27/2022 that the parent of Patient #44 was not allowed to take the patient to the Emergency Department for evaluation. Employee #3 stated the patient was being evaluated and treated by the hospital's internal medicine provider. Employee #3 confirmed the patient was transferred to the Emergency Department via ALS (advanced life support) ambulance at 2030, which was 5 hours after the patient's mother requested to take the patient to the ED.

3. Arizona Administrative Code, Title 9, Chapter 10, Article 1. General
R9-10-101 Definitions.
52. "Common area" means licensed space in a health care institution that is:
a. Not a resident's bedroom or residential unit.

Policy titled "Admission, Continued Stay, and Exclusionary Criteria" revealed: " ...For admission to the adolescent unit: Patient must be 11-17 years old of age. Patients under age 11 can be considered for admission if approved by the Medical Director or CEO ...For admission to the adult unit: Patient must be 18 years or older ...."

Policy titled "Written Plan of Service and Staff Composition: Leadership" revealed: " ...Inpatient Units: Lotus is a 22-bed adolescent unit ...teens aged 11-17 ...Koi and Cicada are 20-bed adult acute units that provide care to adults 18 years of age and above ...Monarch is a 10-bed specialty unit ...adolescents aged 11-13 ...Phoenix is a 20-bed adolescent unit ...teens aged 11-17 ...."

Observation on the Koi unit on 04/25/2022 revealed a small cot in room 2504. Employee #3 confirmed the cot is considered Bed #3 when the facility is overcapacity. The capacity for Koi is 20 beds. The census for Koi unit for 04/25/2022 was 21 patients.

A review of the Census List for 02/14/2022 22:57 p.m. revealed room 1511 had 3 patients assigned to the room in bed #1, #2 and #3. The facility census was 93, overcapacity by 1 patient.

A review of the Census List for 02/15/2022 06:01 a.m. revealed room 1511 had 3 patients in beds #1, #2, and #3; room 2504 had 3 patients in beds #1, #2, and #3. The facility census was 95, overcapacity by 3 patients.

A review of the Census List for 02/16/2022 23:16 p.m. revealed room 1511 had 3 patients in beds #1, #2, and #3; room 2504 had 3 patients in beds #1, #2 and #3; room 2603 had 3 patients in beds #1, #2 and #3; room 2604 had 3 patients in beds #1, #2, and #3. The facility census was 96, overcapacity by 4 patients.

A review of the Census List for 02/17/2022 22:39 p.m. revealed Monarch (a 10 private bed unit) had a census of 11 with a patient in room 2210-2. Room 2210 is a common area known as a group room.; Room 2504 had 3 patients in beds #1, #2, and #3; room 2603 had 3 patients in beds #1, #2, and #3; room 2604 had 3 patients in beds #1, #2, and #3; room 2605 had 3 patients in beds #1, #2, and #3. The census was 97, overcapacity by 5 patients.

A review of the Census List for 03/29/2022 06:20 a.m. revealed Patient #36 was on the Phoenix unit in room 1506-A.

Patient #36 Census 15 Minute Check dated 03/29/2022 revealed from time 0000 through 0345 patient was in room asleep. At 0345 through 0715 it is documented that the patient was in the group room lying down and asleep. At the bottom of the document is written 1506-A with a line through it and 2605-B written next to it. Room 2605-B is located on the adult Cicada unit. Further review of the form revealed the patient's date of birth was 03/29/2004, indicating the patient had turned 18 at midnight on 03/29/2022.

Observation on 04/25/2022 of the common area group room revealed a door with a window and 2 chairs. There was no bathroom or window in the room.

Employee #11 confirmed on 04/24/2022 that when the facility is overcapacity patients are placed on cots in the largest room on the unit. The cot would be considered bed #3.

Employee #1 confirmed on 04/25/2022 that the facility has 3 cots for overcapacity placement of patients. Employee #1 confirmed that patients are not placed on mattresses in common areas if there are no cots available for overflow. Employee #1 confirmed on 05/01/2022 that Patient #36 was a patient on the Phoenix unit and turned 18 on 03/29/2022. Employee #1 confirmed that Patient #36 was moved from the adolescent Phoenix unit at 0345 a.m. to the Cicada unit and placed a common area group room on a mattress for the remainder of the night as there was no bedroom with a bed or cot available for the patient to sleep.

4. The policy titled "Interdisciplinary Treatment Plan Team Meetings" revealed: "...Per the interdisciplinary Treatment Planning (ITP) Policy, all patients shall have an ITP initiated and reviewed by the team within 72 hours of admission. Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner...Patient/Guardian/Caretaker Involvement...Patients and their guardians and/or caretakers are considered active members of the treatment team....When a patient has a legal guardian, the social worker shall attempt to coordinate communication within 72 hours with the guardian to discuss the ITP and elicit the guardian's signature, representing agreement with the ITP...If the guardian is unable or refuses to come to the hospital for a meeting, the social worker may fax the completed master ITP to the guardian via secure fax and a phone call shall occur with the team to discuss the ITP. If no fax is available, the guardian may provide a verbal agreement or disagreement and this is clearly documented on the ITP...."

The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual ' s clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

The treatment plan for each patient included a signature page for members of the treatment team, the "patient/client", the "parent/guardian". Below the signature lines is another signature line that reads "A copy of this treatment plan was: ____ given to the patient/client/family OR ____ declined by the patient/client/family: Date: ____ Clinician: ___________ Title: ________.

A review of thirteen medical records revealed the following:

Patient #8
Patient #8 was a minor. There was no signature or documentation that the treatment plan was developed with and signed by the guardian. The plan was not provided to the patient/guardian.

Patient #9
Patient #9 was a minor. The signature line for "Patient/Client" was written in "refused". No parent/guardian signed as having participated in the development and agreement of the treatment plan.

Patient #10
Patient #10 was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #11
Patient #11 is a minor. The treatment plan was not provided to the parent/guardian or declined by the parent/guardian.

Patient #12
Patient #12 is a minor. The treatment plan was not signed by the parent/guardian. The treatment plan was not provided to the parent/guardian or declined by the parent/guardian.

Patient #13
Patient #13 was a minor. The treatment plan was not provided to the parent/guardian or declined by the parent/guardian. There was no parent/guardian signature on the treatment plan.

Patient #14
Patient #14 was a minor. The treatment plan was not provided to the parent/guardian or declined by the parent/guardian.

Patient #15
Patient #15 was a minor. The treatment plan was not provided to or declined by the parent/guardian.

Patient #16
Patient #16 was a minor. The treatment plan was not signed by the parent/guardian. The treatment plan was not provided to or declined by the parent/guardian.

Patient #17
Patient #17 was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to or declined by the parent/guardian.

Patient #18
Patient #18 was a minor. The treatment plan was not signed by the parent/guardian. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The parent/guardian was not provided or declined the treatment plan.

Patient #19
Patient #19 was a minor. No parent/ guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to or declined by the parent/guardian.

Patient #20
Patient #20 was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to or declined by the parent/guardian.

Employees #1 and #14 confirmed on 04/28/2022 and again on 05/03/2022 that treatment plans reviewed were incomplete with missing signatures from parents/guardians and no documentation treatment plans were provided to parents/guardians as per policy.

Based on review of hospital policies and procedures, medical records, observations, and staff interviews, it was determined the Hospital failed to provide a safe environment for patients by:
1. BHT assigned to LOS of Patient #1 was found to be not monitoring the patient as ordered.
2. BHTs using their personal cell phones excessively while performing job duties and not monitoring patients.
3. BHTs using rolling chairs to propel themselves down the unit hallway while performing patient monitoring.
4. Adult psychiatric patients were admitted to an adolescent psychiatric unit when adolescent patients were present on the unit.
5.Adolescent patients were placed in the same patient care area as adult patients.
6. Seclusion rooms were not kept locked and secured.

Findings include:

1. The policy titled "Levels of Observation" revealed: "...Line of Sight (LOS): staff have visual observation of the patient at all times...Each patient's location and behavior, regardless of level of observation, is documented on the patient's Census 15 Minute form by the assigned staff...Line of Sight (LOS) Observation...During LOS, staff have visual identification of the patient at all time (Sic)...."

Observation on 04/25/2022 revealed Patient #1 returning to the unit from outside recreational activity. The patient's assigned BHT was not present with the patient.

Patient #1's Census 15 Minute Check dated 04/25/2022 revealed that the patient's assigned BHT was not present on the unit. A second BHT (Employee #42) took over monitoring the 15-minute checks. A copy of the form was reviewed and found that Employee #42 had pre-charted the 15-minute checks for an hour ahead.

Employee #42 confirmed on 04/25/2022, that every 15-minute checks had been documented an hour ahead of the actual time.

Employee #3 confirmed on 04/25/2022 that Patient #1 is on a line of sight (LOS) monitoring. Additionally, the patient's assigned BHT was not present with the patient. Employee #3 confirmed that Employee #42 took over for the assigned BHT and that 15-minute checks had been pre-charted as to Patient #1's whereabouts and activities and did not accurately reflect where the patient was or what he was doing.

2. The facility policy titled "Use of Cell Phones While Conducting Company Business" requires: "...It is the expectation that employees use professional judgment related to the use of cell or land-based telephones for personal matters during times when they are scheduled to be conducting company business. Employees are prohibited from using these phones when the employee should be performing patient care...Meal and break periods are permissible times when an employee may use a cell phone for personal matters in approved locations...."

Observation of video surveillance footage dated 04/11/2022 from 2025 to 2315. The staff member unlocked the patient's room to allow the patient in and then sat in a chair at the doorway at 2028. The staff member pulled a cell phone out of her pocket and began scrolling the phone and texting until 2115. A second staff member relieves her at 2115. The second staff member sits in a chair in the patient's doorway and pulls out her cell phone and uses it until the first staff member returns to take back over at 2123. The first staff member is seen pulling her phone out and using it continuously until 2313.

Observation of video surveillance footage dated 04/11/2022 from 2315 to 2329 revealed three staff members, one sitting in a patient's doorway, another leaning against the door frame, and another standing just outside a patient's room having an animated conversation. The conversation continues for 15 minutes when one staff pulls a cell phone out of her pocket and begins scrolling while walking away and a second staff takes a cell phone out of her pocket and is seen making a call before walking away leaving the third staff member at the patient's room.

Observation of video surveillance footage dated 04/11/2022 at 2332 revealed a staff member who is sitting in the patient's doorway on her cell phone scrolling media and texting. At 2336 a second staff brings a rolling office chair down the hallway for the staff to sit on. The second employee stays at the end of the hall with the first staff member and has an animated conversation at the patient's doorway. She has her cell phone out and is scrolling media and sharing what is on her phone with the other staff member for 15 minutes. During the 15 minutes both staff have their cell phones out for several minutes comparing screens and are seen talking and laughing. At 2349 one staff member is seen partially entering the patient's room to show the second staff member something. The staff member is seen laughing and talking in an animated manner. The staff inside the patient's room comes out of the doorway but remains in the hall and continues to talk and laugh with the other staff member, pulling her phone out of her pocket periodically to share something on the phone with the other staff member. This continues until 2357 when one staff member walks away. The remaining staff is seen sitting in the doorway in a rolling office chair while scrolling her cell phone. The staff member not sitting in the patient's doorway returns at 0027 (04/12/2022). A conversation starts between the two staff members, one takes her cell phone out of her pocket and is seen scrolling media and sharing with the other staff member. The conversation is animated and lasts until 0038 when one staff walks away.

Observation of video surveillance footage dated 04/12/2022 at 0058 a staff member has wheeled herself into the doorway further and lays her head up against the door frame. Very little movement is seen until 0111. The staff member repositions herself at 0112. There is no movement by staff until 0122 when she repositions herself again. Movement is not seen again until 0126 when she repositions again with her head against door frame at 0138. The staff then repositions again at 0140 in such a way as it appears she is trying to sleep. Her head is facing into the door hinge until 0143 when she repositions to the other side of the door frame. No movement is seen until 0147 when a second staff walks down the hall and starts a conversation.

At 0201 staff change out and the second staff is seen wheeling herself further into the patient's room. She is on her cell phone and has earbuds in. At various points you can see her feet up in the door frame and her spinning around in the chair and rolling in and out of the room.

Employee #43 confirmed on 05/10/2022 after viewing footage with the surveyor that staff did not follow facility policy for cell phone use.

3. "Levels of Observation" requires: "...It is the policy of the facility to provide a safe environment and utilize levels of monitoring and observation matched to the patient's individualized needs and based on assessed risk...."

"Census Check" requires: "...An accurate record of the whereabouts of all clients on the units will be maintained during each shift...."

Observation of video surveillance footage dated 04/09/2022 at 2245 revealed a BHT doing a 15-minute census check. Another census check was not conducted until 0114.

Observation of video surveillance footage dated 04/07/2022 at 2214 revealed a BHT in a large rolling office chair conducting census checks. The BHT sat in the office chair and was seen kicking her feet off on the floor and pushing with her hands on the walls to propel the chair down the patient room hallway to conduct 15-minute census checks. The BHT did not get up from the chair during the checks.

The same BHT was also seen conducting checks in the same manner at 2232 and 2254 on 04/07/2022.

Video surveillance footage dated 04/07/2022 through 04/19/2022 revealed significant variations in how staff performed 15-minute census checks. The majority of staff conducted the check in less than 30 seconds for the entire unit. Some staff used flashlights to view patients in rooms, most did not. Some staff briefly stopped at the patient's doorway to look in while others didn't glance in as they walked by. On 04/19/2022 at 0129 a staff member was observed walking down the hallway with a flashlight then pulling a cell phone out of her pocket. She was seen scrolling on her phone when she walked down the length of the hall and back. The staff member spent 20 seconds walking the length of the hall while on her phone and did not look in some of the rooms while doing her rounds.

Employee #43 confirmed on 05/10/2022 that staff are not allowed to use rolling chairs as it is a safety issue, and that staff did not conduct safety checks appropriately and within the 15-minute time frame.

4. Policy titled "Admission, Continued Stay, and Exclusionary Criteria" revealed: " ...For admission to the adolescent unit: Patient must be 11-17 years old of age. Patients under age 11 can be considered for admission if approved by the Medical Director or CEO ...For admission to the adult unit: Patient must be 18 years or older ...."

Policy titled "Written Plan of Service and Staff Composition: Leadership" revealed: " ...Inpatient Units: Lotus is a 22-bed adolescent unit ...teens aged 11-17 ...Koi and Cicada are 20-bed adult acute units that provide care to adults 18 years of age and above ...Monarch is a 10-bed specialty unit ...adolescents aged 11-13 ...Phoenix is a 20-bed adolescent unit ...teens aged 11-17 ...."

A review of the Census List for 02/17/2022 at 22:39 p.m. revealed Monarch unit had ten (10) patients ages 11-13 years old and one (1) male patient age 54 years old, who was in room 2210-2.

A review of the Census List for 02/18/2022 at 6:22 a.m. revealed Monarch unit had ten (10) patients ages 11-13
years old and two (2) male patients ages 22 years old and 54 years old, who were in room 2210-1 and 2210-2.

A review of the Census List for 02/18/2022 at 14:28 p.m. revealed Monarch unit had ten (10) patients ages 11-13 years old and one (1) male patient age 54 years old, who was in room 2210-2.

Employee #4 confirmed on 04/24/2022 Monarch unit was the younger adolescent unit for patients ages 11-13 years old. Employee #4 confirmed that adolescent patients are placed on the adolescent units and adults are placed on the adult units. Employee #4 confirmed that co-ed rooming is not allowed.

Employee #3 and #14 confirmed on 05/10/2022 that the Census List is what the facility uses to give an accurate accounting of where all patients are in the building at the time the Census List report is procured.

5. Policy titled "Admission, Continued Stay, and Exclusionary Criteria" revealed: " ...For admission to the adolescent unit: Patient must be 11-17 years old of age. Patients under age 11 can be considered for admission if approved by the Medical Director or CEO ...For admission to the adult unit: Patient must be 18 years or older ...."

A policy on cohorting adult patients with pediatric patients was requested. The facility did not provide the requested policy.

Observed while on tour on 04/24/2022 was a door with a sign "Adolescent Intake" posted. Further down the hall was another door observed with a sign "Adult Intake".

Observations conducted on 04/25/2022 in the Intake area revealed four (4) of eleven (11) patient recliners occupied. Six (6) recliners were observed directly up against the side a drywalled barrier "a pony wall" approximately three (3) feet tall and approximately ten (10) feet long., this was the "adult" side of Intake. On the other side of the "pony wall" directly up against the side of the wall were three (3) patient recliners with two (2) more additional recliners directly across from the 3 recliners. These 5 chairs constituted the "adolescent" side of Intake. The 6 recliners in the "adult" section were approximately one (1) to two (2) inches apart. The 5 chairs on the "adolescent" side were approximately 1-2 inches apart. The only barrier visible between the adult and adolescent areas was the "pony wall" and the chairs on both sides were abutting the wall. An adult male was observed sitting in a recliner on the "adult" side of intake. The patient had his arm draped over the back of the recliner and his hand was touching the top of the recliner directly behind his chair on the "adolescent" side of Intake. Two female adolescent patients were observed in recliners on the "adolescent" side. One female was in a recliner up against the pony wall and the other female patient was in a recliner directly across from the first female. Also observed where two (2) patient bathrooms directly next to each other. On one of the bathroom doors was a sign " Adult Patients Only" and on the other bathroom door was a sign "Adolescent Patients Only".

Observation conducted on 04/27/2022 in the Intake area revealed two (2) of the adult recliners were occupied. One adult patient was a female who was curled up in the recliner wrapped in a blanket. The back of the recliner was reclined and touching the back of the recliner directly behind it on the adolescent side of Intake. An adult male patient was sitting in a recliner on the adult side, the recliner was turned toward the "pony wall" divider and the adolescent side of Intake at approximately a 25-degree angle so the patient could observe the patients on the adolescent side of Intake. On the adolescent side of Intake was two female patients sitting in 2 of recliners up against the barrier wall.

A review of the Census 15 Minute Check for Patient #21 revealed the patient was in Intake from 14:15 p.m. on 03/21/2022 until 03:15a.m. on 03/22/2022. Patient #21 is a 13-year-old female.

A review of the Census 15 Minute Checks for Patient #48 revealed Patient #48 was in the Intake area from midnight 03/22/2022 until 12:00 pm (noon) on 03/22/2022. Patient #48 is a 31-year-old male.

A review of the Census List for 04/13/2022 at 06:14 a.m. revealed there were seven (7) patients in the Intake area. Of those 7 patients, five (5) were adult males ranging from age 18 years to 45 years old. The remaining two patients were minors, a 12-year-old female and Patient #11 who is a 15-year-old male.

A review of the Census 15 Minute Checks for Patient #11 revealed the patient was in the Intake area from 19:41 p.m. on 04/12/ 2022 until 10:00a.m on 04/13/2022.

Employee #1 confirmed that the facility had combined the adult and adolescent Intake areas into one area. Employee #1 stated the 2 units were combined to streamline the intake process. Employee #1 stated adolescent patients are not in the Intake area at night, they are only allowed in Intake during the day shift. Employee #1 stated the Intake area is not considered a patient care area because patients are not considered admitted to the facility until the provider has written admitting orders.

Employee #4 confirmed patients are held in Intake overnight until a patient bed is available on one of the units. Employee #4 stated patients in the Intake area are evaluated by an RN, a social worker and a provider. Once the provider writes orders, the patient is "officially" admitted. Employee #4 stated that while patients are being held in Intake they are not being treated for their psychiatric issues but will receive necessary medication such as insulin.

Employee #3 confirmed that once a patient enters Intake they cannot leave the facility, even if they come in voluntarily. Employee #3 stated that the patient would need to be evaluated and it would need to be determined the patient was safe to leave if they decided against treatment. Employee #3 confirmed that Census 15 Minute Checks are completed on all patients in Intake even though they are not admitted.

Employee #68 confirmed that the adolescent patients are not in Intake overnight because there are adult patients present in the Intake area at night.

Employee #19 confirmed that adolescent patients are held in the Intake area overnight and will be transferred to an adolescent unit the next day after there have been discharges.

Employee #69 confirmed that adolescents are not admitted to Intake at night unless the patient comes in as a walk-in. Employee #69 confirmed that not allowing adolescents in Intake at night was because it was a safety concern.

Employee #70 confirmed staffing was partially the reason for not bringing adolescents in at night. Employee #70 stated usually there are 2 registered nurses (RNs) and 2 behavioral health technicians (BHTs) for the day shift and 1 RN and 1 BHT for the night shift. Employee #70 stated there is not enough staff at night to properly supervise and monitor the safety of the adolescent patients if they are admitted to the Intake area at night.

The facility is placing adolescent patients in the same Intake area as adult patients to await room placement. The facility staffs the Intake area with 2 RNs and 2 BHTs during the day shift and 1 RN and 1 BHT during the night shift. Staff and administration provided conflicting information regarding the Intake area and if it is a patient care area. Staff and administration provided conflicting information regarding adolescent patients being admitted to Intake during the night shift. Review of hospital documents and medical records reveal evidence that the facility is placing adolescent patients in the same patient care area as adult patients during both the day and night shifts.

6. An incident report dated 03/30/2022 at 1600 revealed that patients had access to the seclusion bathroom to "snort" medications.

An incident report dated 03/30/2022 at 1630 revealed that "a broken red G2 pen was found in seclusion room along with vistaril powder."

Observation on 04/24/2022 revealed that the door to the seclusion room on Cicada unit was unlocked and ajar. Two unsecured wheelchairs were stored inside the seclusion room.

Employee #4 confirmed on 04/24/2022 that the seclusion room was not locked as required and that they are not supposed to be used to store medical equipment.

Observation on 04/25/2022 revealed that the door to the seclusion room on Lotus unit was unlocked and ajar.

Employee #3 confirmed on 04/25/2022 that the seclusion room was not locked as required.

Based on review of policy and procedure, facility documents, observation, and interview, it was determined that the facility failed to ensure that female patients were not subjected to sexual abuse. This deficient practice poses a potential risk to the patient's health and safety, self-esteem, and wellness and recovery process.

Findings include:

The policy titled "Patient Sexual Behavior" revealed: "...Destiny Springs Hospital (DSH) has a no sexual relations between hospital patients during the course of hospitalization policy...Patients are also educated regarding the hospital policy and risks associated with sexual activity in a psychiatric hospital, including limited capacity to consent, pregnancy, and sexually transmitted diseases. DSH will take precautions to protect patients from sexual abuse and restrict sexual relations between patients...Sexual misconduct comprises a broad range of behaviors focused on sex that may or may not be sexual in nature. Any intercourse or other intentional sexual touching or activity without the other person's consent is sexual assault, which is a form of sexual misconduct under this Policy...All staff will...Protect patients who may be vulnerable to being sexually abused by other patients...Any observation of sexual touching and sexual misconduct will be reported to the treatment team who will develop treatment goals and interventions...Patients who are found to be engaging in sexual contact with other patients: will be reminded of the policy....may have limitations or restrictions placed on their activities...may be required to be placed on a line of sight...will be assessed by a clinical staff to determine whether there is any predatory or exploitive behavior involved. A clinical determination may be made as to whether the patient and/or victim should receive counseling or be involved in education programs which address this issue. Modifications to the patient's treatment plan will be made as determined to be necessary by the treatment team...Known Inappropriate of Deviant Sexual Problems as a Treatment Issue...Patients exhibiting specific sexual problems or behaviors such as sexual disorders, dysfunctions, "high-risk" behavior, and/or inappropriate or unlawful behavior may have the problem/behavior addressed on their individualized treatment plan...."

The policy titled "Interdisciplinary Treatment Plan Team Meetings" revealed: "...Per the interdisciplinary Treatment Planning (ITP) Policy, all patients shall have an ITP initiated and reviewed by the team within 72 hours of admission. Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner...."

The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual ' s clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

The policy titled "Patient Rights" requires: "...Patient Rights according to federal and state guidelines include the following at a minimum...The right to received care in a safe setting...The right to be free from all forms of abuse or harassment; including sexual abuse or sexual assault...."

The policy titled "Levels of Observation" revealed: "...Line of Sight (LOS): staff have visual observation of the patient at all times...Each patient's location and behavior, regardless of level of observation, is documented on the patient's Census 15 Minute form by the assigned staff...Line of Sight (LOS) Observation...During LOS, staff have visual identification of the patient at all time (Sic)...."

Patient #1's Biopsychosocial Assessment dated 03/10/2022 revealed: "...Past Psychiatric History...has been assaultive...Has injured others...."

Patient #1's Nursing Note dated 03/22/2022 revealed: "...(Patient #1's) danger to others has been identified as a significant problem requiring treatment...."

Patient #1's Nursing Note dated 03/23/2022 revealed: "...Patient became upset...and while holding pens postured towards the group facilitator attempting to stab him with the pens...."

Patient #1's Case Management Note dated 03/28/2022 revealed: "...DCS CM reports clt is not able to return to group home due to aggressive bx with staff. RTC seems only option at this time. Clt does have legal charges pending...."

Patient #1's Case Management Note dated 04/01/2022 revealed: "...Team discussed where SMB dx (Sexually Maladaptive Behavior diagnosis) may have come form (Sic). Team discussed clt was previously at an SMB group home before coming to Destiny Springs...Team discussed if psychosexual assessment had been completed on clt. DCS CM believes one was completed at (Facility #1) or when clt was in detention. DCS CM will complete research and clarify in the week. DCS CM report clt is under investigation with 3 females and if convicted will be charged as an adult...Next staffing scheduled 4/4/22 at 2pm...."

Patient #1's Case Management Note dated 04/04/2022 revealed: "...Team was under the impression a psychosexual assessment was completed. However, psychosexual assessment has not been located...."

Patient #1's Case Management Note dated 04/08/2022 revealed: "...Team discussed potentially moving clt units as clt has been getting closer friendship with female peer on the unit. ADON for adolescents not in agreement as clt has hx of bx and could happen on any unit potentially moved to...."

Patient #1's Case Management Note dated 04/21/2022 revealed: "...SW informed team clt has two additional pending charges from his last week. Clt allegedly kissed one of the other female peers and father pressed charges on clt. Yesterday clt allegedly touched another female peer's buttocks. Peer's mother pressed charges for touching clt. CCO, ADON and SW informed team clt is not safe at Destiny Springs due to the threats and peers going toward clt to hurt clt. Mercy Care Rep informed team Destiny Springs should be able to provide additional staff for these current concerns placing clt on 1:1 or 2:1. DCS CM reports placement center is not an option due to his bx and aggression hx...."

The Surprise Police Department report dated 03/23/2022 revealed: "...Patient #2...was observed near the nurse's station by staff members with suspicious marking(s) on her neck. When asked by staff about the mark(s) (name of Patient #2) stated 'it was a hickey from (Patient #1).' 'He grabbed me'...(Patient #2) additionally stated (Patient #1) put his fingers inside her vagina and (Patient #3) vagina. (Patient #2 further stated (Patient #1) keeps trying to touch her and is making him angry when she said no. (Patient #2) stated during the same timeframe (Patient #1) masturbated into a cup in the gymnasium and (Patient #3) put the semen in her vagina...(Patient #1) was found an (Sic) another female patients (Sic) bedroom the previous week...At this time (Patient #2, 3, and 1) are at Destiny Springs in the 'general population' (mixture of male and female) of other patients with in (Sic) the facility...At this time Destiny Springs Mental Facility is unable to keep (Patient #1) in an isolated area due to staffing and other limitations...At this time he is still conducting regular activities with the rest of the juveniles in the Lotus unit...."

Incident Report dated 03/22/2022 revealed "...(Patient #2) reported that....(Patient #1, 2, and 3) were in the conference room and (Patient #1) [put his fingers inside (Patient #2 and 3)]...(Patient #2) also reported that (Patient #1) keeps trying to touch her and is making him angry when she says no...."

Incident Report dated 03/22/2022 revealed that Patient #2 had a "hickey" and when questioned by staff reported: "...another patient did it over the weekend and there were other in the room that saw. Patient said 'he just grabbed me'...."

Incident Report dated 03/22/2022 revealed that Patient #3 reported: "...(Patient #1) was not only touching her alone but other girls on the unit too...he was being very inappropriate. (Patient #3) said that male patient was trying to kiss her too. Patient also told staff that each time they go to the gym is when he sees the opportunity to start touching on girls and also outside too when staff take them...."

Incident Report dated 03/23/2022 revealed that Patient #3 reported: "...pt asked to speak privately with writer. During one to one conversation pt stated that male peer (Patient #1) had been physically touching her. Pt reports (Patient #1) would rub her arm and wait until he was unobserved and brush her breast. He would also rub her upper leg and brush vaginal area when unobserved. She also reports pt peer would rub hip and again wait until unobserved to brush buttocks...Says she was afraid to say 'no' to patient or report to staff...."

Another Incident Report was reviewed; however, it was undated and revealed: "...(Patient #2) states that (Patient #1) masturbated in a cup in the gym and (Patient #3) put the semen in her vagina...."

Surprise Police Report dated 03/24/2022 revealed: "...On 03/23/2022 at approximately 0900 hours, (Patient #1) committed assault and disorderly conduct, when he attempted to stab (Employee #43) with two pens while he was a patient at Destiny Springs Healthcare located at 17300 N Dysart Road in Surprise, Arizona...."

Incident Report dated 03/25/2022 revealed: "...Two pens in his hands (Patient #1). Attempted to stab (Employee #43)...."

Incident Report dated 04/17/2022 revealed: "...This writer observed patients kissing on the unit. Nurse saw patient in glass reflection. Male pt (Patient #1) tapped female pt (Patient #35) on shoulders, when female turned around male leaned in to kiss her...Providers notified parent of female pt notified...."

The Census lists for 03/21/2022 and 03/22/2022 revealed that the facility was over licensed capacity on both days having a census of 94 for each day. The facility is only licensed for 92 inpatient beds.

PATIENT #1

Patient #1's initial treatment plan was initiated on 03/11/2022 and completed on 03/12/2022 which included long-term and short-term goals all with the same target date of 03/18/2022.

The medical record did not contain an updated treatment plan until 03/31/2022. The long-term goal was not updated and had the same target date on the initial treatment plan of 03/18/2022. The short-term goals had a target date of 04/07/2022. The medical record did not contain documentation that an update occurred on 03/23/2022 involving unwanted sexual activity by Patient #1 to Patients #2 and #3, which resulted in DCS and law enforcement involvement.

The medical record did not contain an updated treatment plan until 04/19/2022.

The CEO confirmed on 04/28/2022 and again on 05/03/2022, that Patient #1's treatment plans were not reviewed and updated as required by facility policy at a minimum of every seven days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner even with the assault and sexual misconduct incidents occuring on 03/23/2022, which involved law enforcement and DCS, that would require reviews and updates to the patient's treatment plan.

Observation on 04/25/2022 revealed Patient #1 returning to the unit from outside recreational activity. The patient's assigned BHT was not present with the patient.

Patient #1's Census 15 Minute Check dated 04/25/2022 revealed that the patient's assigned BHT was not present on the unit. A second BHT (Employee #42) took over monitoring the 15-minute checks. A copy of the form was reviewed and found that Employee #42 had pre-charted the 15-minute checks for an hour ahead.

Employee #42 confirmed on 04/25/2022, that every 15-minute checks had been documented an hour ahead of the actual time.

Employee #3 confirmed on 04/25/2022 that Patient #1 is on a line of sight (LOS) monitoring only and not 1:1 or 2:1 as recommended by AHCCCS-Mercy Care. Additionally, the patient's assigned BHT was not present with the patient. Employee #3 confirmed that Employee #42 took over for the assigned BHT and that 15-minute checks had been pre-charted as to Patient #1's whereabouts and activities and did not accurately reflect where the patient was or what he was doing.

Based on a review of the hospital documents, quality program, and interview, it was determined the hospital failed to implement and maintain an effective, ongoing quality assessment and performance improvement program as evidenced by the failure to be in compliance with the standards found in this Condition of Participation.

A-0273
1. the hospital's failure to monitor the effectiveness of the safety of services and quality of care provided related to patients who were admitted to inpatient units when the hospital was at capacity as required by the hospital policy on Overcapacity.

2. the hospital's failure to identify concerns specific to the delivery of hospital services and/or environmental services related to patient care in regard to a patient's transfer to an Emergency Department following a change in condition which poses a risk to patients when concerns regarding patient care and services provided are not identified and corrected.

A-0286 the hospital's failure to ensure a quarterly report for the evaluation of lithium use was completed and submitted to the P&T committee which poses a patient safety risk if the facility is not monitoring rational for use, lab monitoring, dosing changes, and compliance with safety practices.

A-309 the hospital's failure to require evaluation and oversight related to the patient complaint / grievance process.


The cumulative effect of these systemic problems resulted in the hospital's inability to have an effective quality assurance performance improvement program to assess opportunities for improvement.

Based on policy and procedure, hospital documents, medical records, and staff interviews, it was determined the Hospital failed to ensure :

1. the implementation of the method for evaluating the occurrences of exceeding licensed capacity to include actions taken when appropriate as evidenced by the hospital not following the established policy and procedure for the evaluation of overcapacity events.

2.the quality management program evaluated and performed a root cause analysis of a patient's transfer to an Emergency Department which poses a risk to patients when concerns regarding patient care and services provided are not identified and corrected.

Findings include:

1. The facility document titled "Quality Assurance and Performance Improvement Plan" revealed: "...The Governing Board of the hospital will oversee the measurement and use of data based on priorities specific to the hospital's needs...Quality improvement activities emerge from a systematic and organized framework for improvement...The Governing Board and CEO have charged the QAPT committee with carrying out the purpose and scope of quality improvement efforts at Destiny Springs Healthcare...This committee provides ongoing operational leadership of continuous quality improvement activities at DSH. It meets at least ten (10) times a per year...The Governing Board provides leadership for the Quality Improvement process...."

The facility policy titled "Exceeding Capacity & Ambulance Diversion" requires: "...Destiny Springs Healthcare will not admit a patient if at capacity without the following actions...The following steps are taken once it is determined the patient must be admitted...a. The CEO and Medical Director are notified that a patient is being admitted and capacity is exceeded...b. If after hours the Administrator on Call is notified...c. The incident is documented, evaluated and actionable items are addressed. The report will be submitted to Quality upon completion. Each incident will be reviewed at the monthly Compliance meeting with a report going to the quarterly board meeting to determine if further action or a root cause analysis is needed...."

Review of the facility document for overcapacity days revealed that the facility exceeded their licensed capacity on 41 days from 01/07/2022 through 04/25/2022.

Observation on 04/24/2022 revealed that the facility was overcapacity with 93 inpatients with an additional 4 patients being processed in the admissions department.

Observation on 04/24/2022 revealed a census board in the intake/admissions administrative area. The board revealed that there were three patients housed in room 2502.

Observation on 04/25/2022 revealed that a "cot" had been placed in room 2502 in addition to the 2 licensed beds in the room.

The policy revealed the Quality Department will evaluate each occurrence of exceeding licensed capacity, including any actions taken for resolving occurrences of exceeding licensed capacity.

The reports submitted to Quality for emergency overcapacity admissions were requested but not provided.

Employee #14 confirmed on 05/10/2022 that overcapacity admission reports are not completed as outlined in the facility policy.

2. The facility policy titled "Quality Assurance and Performance Improvement Plan" revealed: "...quality data gathered from numerous sources which may include: ...Incident reports and adverse events...Data gathered will be used to monitor the effectiveness and safety of services and quality of care...when negative trends or outcomes are identified, a root cause analysis will be completed as appropriate and will include adequacy of staffing...

Incident report dated 02/09/2022 20:30 p.m. revealed: "...Patient had large emesis, bright red blood with small amount of blue powerade. Denies nausea or abdominal pain before and after emesis. Dr Gill Called with update on patient. Order received to send patient to emergency room with c/o hemptisis (sic) and dehydration. 911 EMS activated with 2 minute ETA, Nursing supervisor involved and took the patient to intake for discharge to ER...."

The incident report did have a follow up or corrective action documented.

A review of the Quality Assurance and Performance Improvement Committee Meeting Minutes from April, 2022, revealed the incident involving the patient's transfer to the ED was not investigated, evaluated or reported to the QAPI Committee.

Employee #14 confirmed on 05/10/2022 that the quality department did not evaluate the incident involving the patient transfer to the ED for quality of care or perform a root cause analysis to determine if the incident could have been avoided or how care could be improved.

Based on review of policy and procedure, facility documents, and interview, it was determined that the facility failed to ensure a quarterly report for the evaluation of lithium use was completed and submitted to the P&T committee which poses a patient safety risk if the facility is not monitoring rational for use, lab monitoring, dosing changes, and compliance with safety practices.

Findings include:

The facility policy titled "Medication Safety: Lithium Monitoring" requires: "...On a quarterly basis, the pharmacist submits an evaluation of the lithium use in the facility through the P&T committee. This review includes the review of a representative sample of lithium use and at a minimum examines the following: a. Overall Usage rates and rationale for use...b. Compliance with laboratory testing requirements...c. Appropriateness of dosage changes based on laboratory testing...d. Compliance with safety practices including HIGH RISK HIGH ALERT labeling and pharmacist review...."

A copy of the quarterly reports for evaluation of the lithium use in the facility submitted to the P&T committee was requested but not provided.

Employee #15 confirmed on 04/28/2022 that quarterly reports for the evaluation of lithium use if the facility were not completed.

Based on review of hospital policies and procedures, hospital documents, and staff interviews, it was determined that the Governing Body failed to provide evaluation and oversight to the Quality Assurance and Performance Improvement (QAPI) program related to the patient complaint/grievance process. This deficient practice poses a significant risk for patient's health and safety, when the hospital's Governing Body and CQI Committees fail to ensure that quality improvement , quality assessment, quality of care and performance improvement projects are evaluated.

The facility policy titled "Quality Assurance and Performance Improvement Plan" revealed: "...quality data gathered from numerous sources which may include: ...grievances...Data gathered will be used to monitor the effectiveness and safety of services and quality of care...when negative trends or outcomes are identified, a root cause analysis will be completed as appropriate...."

The facility policy titled "Patient Complaints and Grievances" revealed: " ...Complaint: Any written or verbal expression of dissatisfaction by the patient, patient family patient guardian or other patient caretaker regarding care of services providing by Destiny Springs Healthcare which can be resolved at the point at which it occurs ...Grievance: Any formal verbal or written expression of dissatisfaction with some aspect of care or service that has not been resolved to the patient/family's satisfaction at the point of service. In a grievance situation, the patient (or patient's representative) is specifically requesting that his or her complaint undergo a formal review process ...If the resolution to the complaint is acceptable to the patient (or patient representative), the complaint will be considered closed and no further action will be necessary ...For all formal grievances that do not involve allegations of discrimination or abuse a. the patient advocate is to respond to the patient in writing, and in person if able, within ten (10) days. A copy of the patient's grievance and the written resolution will be kept on file, submitted for review with the Quality Improvement Committee. In instances where final resolution of the issue will take longer than ten (10) days, the patient advocate will communicate this to the complainant, and provide a timeframe by which the issue will be resolved. Once the final resolution is reached the patient advocate will respond again, in writing to the complainant. The extended resolution time frame should not exceed thirty (30) days from the original date of the complaint ...Root cause analysis and/or a systems analysis will be conducted on grievances as appropriate ...."

Hospital document titled "Patient Grievance Form" revealed: " ...Upon submitting this form to any staff member, the staff member will notify the Patient Advocate or hospital administrator and the advocate or administrator will meet with you within twenty-four (24) hour ...."

Review of the Quality Assurance and Performance Improvement Committee meeting minutes dated April, 2022 revealed for the past quarter the following: Complaints: January 20, February 28, March 20; Grievances: January 0, February 0, March 1.

Employee #14 confirmed during an interview on 04/27/2022, that the Patient Grievance Form is used for both complaints and grievances. Employee #14 confirmed the facility considers a patient complaint as either a written or verbal complaint about an issue that can be resolved during the patient's stay. Employee #14 confirmed that s/he was unaware that a written complaint is always considered a grievance. Employee #14 confirmed that grievances were not being reported correctly.

Based on review of hospital policies and procedures, documents, medical records observations and interviews, it was determined that the Hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following references to standard level deficiencies:

A-0392 The registered nurse failed to assess and recognize a change in medical condition of a patient and document nursing interventions provided.

A-0395 The registered nurse failed to supervise BHTs and the patient care provided.

A-0396 Nursing personnel did not document properly on Census 15 Minute Checks, changes in patients' conditions and treatment plans.

A-0397 The registered nurse is not knowledgable about the acuity plan or know how to implement the acuity plan.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Nursing Services, which poses a potential risk to the health and safety of patients when personnel fail to meet the needs of the patients and ensuring a safe environment for patients.

Based on review of policies and procedures, registered nurse job description, incident report, medical record and staff interviews, it was determined the Hospital failed to ensure that the registered nurse assessed and recognized a significant change in Patient #44's condition and documented nursing interventions. The deficient practice poses a threat to the health and safety of patients when a change in condition is not assessed and documented, thus inhibiting a timeline of medical events for the medical team to be able to provide proper care to patients.

Findings include:

Policy titled "Admission Assessment Guidelines: Provisions of Care, Treatment, and Services" revealed: " ...RN staff are required to complete daily assessment and progress note of each patient and document by the end of his/her shift in the medical record ...."

Policy titled "Change in Patient Condition" revealed: " ...If the RN determines that a patient may be experiencing a change in condition or any form of physical deterioration from their baseline, they will complete the Modified Early Warning Score (MEWS) form ...Changes in condition include, but are not limited to: Alteration in mental status; pallor, diaphoresis; sudden onset of pain; rapid or slowed heart or respiratory rate; systolic BP>180 or< 80; Decreased urinary output; Any other sign or symptom the RN determines with their clinical judgement to be a change in baseline ...This policy is not meant to limit the RN's ability to use their judgement to call a Code Blue at any time ...."

Policy titled "Emergency Transfer, Provision of Care, Treatment, and Services" revealed: " ...An emergency transfer occurs when a patient moves from the inpatient hospital or outpatient program directly to another equivalent inpatient or outpatient program with no interruption in care, These transfers are not planned and occur as a result of a medical emergency ...The primary criteria for an emergency transfer is an immediate threat to a patient's physical health, which is threatened by the following: impact on airway, respirations, or ventilation; impact on circulation; injury, infection, or other condition requiring immediate treatment that the hospital cannot provide ....if the condition is emergent but survival is unlikely to be impacted by a brief delay, the RN will immediately contact the patient's internal medicine consultant for an order for transfer ...the RN will also be responsible for informing the patient (when able), the patient's guardian, and any caretakers listed as emergency contacts, of the circumstances of the transfer and the location where the patient was transferred ...During patient stabilization and anticipating the arrival of emergency medical services (EMS), the unit clerk shall gather a transfer packet which includes: Patient transfer Form, Face sheet, copy of recent medications administration record (MAR), copy of the patient's history and physical and any follow up notes, copy of the patients psychiatric evaluation, copy of the patients most recent labs, radiologic examinations, or other diagnostic testing ...At time of transfer, the patients nurse shall call a nurse to nurse report to the receiving hospital this report shall also include: the reason or patient transfer, patient physical and psychosocial status , brief summary of care, treatment and services provided to the patient ...."

Policy titled "Medical Record Documentation, Record of Care, Treatment and Services (Outpatient/Inpatient)" revealed: " ...medical records are adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition ...Documentation Additions ...Additions to the patient record, made after completion of the patient's care, shall be dated, timed, and signed by the person making the addition along with a "late entry" notation ...."

Policy titled "Nursing Philosophy" revealed: " ...Nursing staff contributes to the continual care of patients from the time of referral to discharge from the hospital ...The nursing staff meets all of the needs of the patient within the realm of their responsibilities as defined within their job description ...."

Policy titled "Nursing Scope of Service" revealed: " ...The Nursing Department maintains a well-trained, competency verified, highly qualified staff who are fully vetted to promote excellence in overall delivery of nursing care and services ...Nursing is the single discipline that provides 24 hour daily patient care and services ...Assessment is a foundational element of nursing care ...RNs will be on duty for patient care delivery 24 hours a day, 7 days a week. RN assessment is ongoing and informs each subsequent step in the nursing process ...Implementation of nursing care will be conducted according to hospital policies and procedures, standards of nursing care, and as appropriate with the orders provided by the medical staff. Documentation of patient care is an essential part of implementation ...."

Hospital document titled "Patient Handbook" revealed: " ...Nursing Staff: The nursing staff included Registered Nurses (RN), Licensed Practical Nurses (LPN's) and Behavioral Health Technicians (BHT's). Members of the nursing staff will be assigned to you each shift. They will meet with you and discuss any physical or emotional problems that you may be experiencing. The RN, LPN, or BHT will work as a team to meet your physical and emotional needs during your stay ...As a partner in your care, if you experience any change in your condition that is worrisome or that you feel could be a problem, please alert the nurse at any time during your visit. At Destiny Springs Healthcare we have a dedicated team, around the clock to quickly response and assess any concern. We encourage family members and visitors to feel free to report any issues as well ...."

Job Description titled "Registered Nurse" revealed: " ...Assesses patient physical, psychological, developmental, cultural and discharge planning needs. Reviews patient history with patient/family and assures completion within appropriate timeframe. Reviews diagnostics and laboratory data and reports abnormal results to the physician(s) and other appropriate caregivers. Completes assessment and reassessments according to patient need and as outlined in policy ... Documents assessment, planning, implementation and evaluation in the patient record. Documentation is legible, timely and in accordance with policy. Documentation reflects objective/subjective data, nursing interventions and patient's response to treatment. Notes physician orders accurately and in a timely manner ....Provides care based on the best evidence available ...."

Hospital document titled "Transfer Event Checksheet" revealed: " ...Instructions to Follow for Transfer to Higher Level of Care: ...Immediate assessment of the patient by the RN (documented in the multidisciplinary note). Focused assessment according to medical presentation by the patient. Medications provided within the last 4 hours. Pain assessment if applicable. EKG in event of chest pain, Neurological assessment if neurological event (change in LOC, seizure, head injury). Vital signs including oxygen saturation. Treatment being provided (oxygen, breathing treatments, inhalers, current lab values) ...Provide appropriate immediate care based on assessment findings (oxygen for chest pain, or NTG if already ordered) ...Call the physician for orders and transfer orders ...Obtain and follow physician orders for care ...Call EMS for transport ...Complete any transfer communication documents ...Make chart copies to send ...Notification of family/guardian as appropriate ...Documentation of assessment and care provided ...documentation of report to EMS personnel responding ...Completion of incident report ...Update the patient's treatment plan ...Once completed, sign and send this sheet, completed incident report form, and a copy of the transfer communication documents, to the DON by the end of your shift ...."

Hospital document titled "Transition Transfer" revealed: " ...Transition Transfer dated 2/9/2022 revealed: " ...patient Condition: patient may be at risk for deterioration from or during transport signed by Employee #32 time 2038 ...reason for transfer: for equipment or services not available at this facility ...Hospital acceptance: Name of destination hospital Banner Thunderbird, accepted by Amanda, RN time 2130, accepting MD: ER physician ...Discharge vitals: Time: 1930 BP 142/95, pulse 117, Respirations 17, Temp 97.5 ...Risks for transfer: COVID +, hemoptysis ...Mode of Transport: ALS ambulance; Service contacted: Fire department (911) by Employee #32 at 2030 ETA 2 minutes; ...Patient consent: mother called 2040 ...."

Patient #44 Nursing Note dated 02/08/2022 2:32 a.m. revealed: " ...Patient resting in bed quietly at the start of 2300 shift. Pt woke up at 0130 and threw up twice the meatball sub he had eaten earlier ...."

Patient #44 Nursing Note dated 02/09/2022 10:38 a.m. revealed: " ...Patient reported this morning that he threw up blood. RN looked and patient had phlem (sic) pit up with a trace amount of bright red blood. Previous shift reported that patient threw up his dinner. Patient is isolated in his room until seen by medical ...."

Patient #44 Quick Note dated 02/09/2022 4:08 p.m. revealed: " ...Patients mother called at 1550 on 2/9/21 to talk to patient and then to this RN. Patients mom states she is concerned we are not taking her son seriously with being sick. This RN informed parent that the medical provider had just seen him and was currently putting in orders for him. This RN let mom know that so far orders were for routine labs and c/s on his urine. Mom asked when results would be in this RN informed her labs were scheduled as routine not STAT and would be sent our tomorrow morning with the lab collection and would have results the following day. Mom asked if she could take him to a medical facility instead, and was informed it would be an AMA discharge. Mom stated she feels we are doing well with his mental health but nor his medical health and is concerned. This RN assured her we are testing and treating him for his current symptoms ...."

Patient #44 Progress Note Internal Medicine dated 02/09/2022 16:05 p.m. revealed: " ...Pt seen for ? threw up ? some blood streaks c/o dark urine ...fever no, chest pain no, vomiting yes, chills yes, HEENT mild tonsillar enlargement, Assessment/Plan: 1. ? Dark Urine- Dehydration will check UA, lytes; 2. Vomiting- ? some mild streaks check cbc, cmp; 3. Sore throat/chills r/o covid ? chills, taste issues; 4. Diarrhea- resolved ...."

Patient #44 Quick Note dated 02/09/2022 4:26 p.m. revealed: : ...Lab orders changed to STAT and order placed to COVID test Mom was notified ...."

Patient #44 Quick Note dated 02/09/2022 5:07 p.m. revealed: " ...COVID test was positive, patient placed on isolation precautions, mom was informed ...."

Patient #44 Nursing Note dated 02/10/2022 1:35 a.m. revealed: " ...RN gave pt medications pt stated "I threw up again and it's bloody" RN looked in toilet and large amt of bright red blood noted confirmed by 2 nurses also emesis had a blue cast as pt drank power aide also refused supper this evening. Pt + for covid in isolation at this time. Dr notified orders to sent pt to ED Pt's mother was notified Pt escorted in W/c to intake area to await transport to ED ...."

Patient #44 Nursing Note dated 02/10/2022 11:06 p.m. revealed: " ...Late Entry: Patient was initially taken to Banner Thunderbird Emergency room for evaluation re: dehydration and hemoptysis. Sydney Burgess RN/night shift supervisor called the ER to inform them of patients arrival and conditions requiring evaluation. Sydney called the ER 2-3 hours later for an update on this patient and was informed that he had been transferred to Phoenix Childrens Hospital Emergency room. Sydney called the ER at PCH to obtain a status report. The staff acknowledged that the patient was there and they would have to call us back with a status report. The return phone call never presented itself before our shift ended ...."

Further review of the medical record revealed no documentation regarding Patient #44 after 02/09/2022 5:07 p.m. quick note until 02/10/2022 at 01:35 a.m. Further review did not reveal any required Modified Early Warnings Signs (MEWS) assessment for a change in condition. Further review did not reveal any nursing assessment documented on the patient after the medical provider had seen the patient at 16:00 on 02/09/2022. Further review did not reveal any documentation regarding a change in patient condition after 1700 on 02/09/2022 that required patient to be sent to the Emergency Room at Banner Thunderbird via ALS ambulance.

Patient #44 Transfer Event Checksheet dated 02/09/2022 revealed: " ...X Documentation of assessment and care provided ...." Review of the medical record did not reveal any assessment or care provided documentation from 1700 until transfer at 2130 on 02/09/2022.

Patient #44's medical record revealed that the provider ordered a "CMP" on 02/01/2022 at 0545 and a "Basic Metabolic Panel w eGFR" at 1600.

The medical record revealed that the labs ordered on 02/01/2022 were not collected until 02/03/2022 at 1426. The labs were not received for processing by CCL for 32 hours until 02/04/2022 at 2246. The lab results were not reported until 02/07/2022 at 1724 and were not noted by the nurse until 02/08/2022. The timeframe from when the labs were ordered until they were reported was 6 days and not noted by a nurse until the following day.

Patient #44's medical record revealed that the provider ordered STAT labs to include "Basic Metabolic Panel w eGFR", "CBC w Diff w Plat" and "Urinalysis & Urine Culture" on 02/09/2022 at 1600. The lab order was noted by the nurse at 1709. The labs were not collected until 02/09/2022 at 1830. The labs were not received for processing by CCL until 02/09/2022 at 2255. The labs were reported on 02/10/2022 at 0039.

Employee #14 confirmed on 04/27/2022 that a MEWS assessment was not done on Patient #44and stated per policy it should have been completed.

Employee #3 confirmed on 04/27/2022 that if there is a change in condition on a patient, it is documented in the medical record and the patient is placed in the IM log for exam by the medical provider. Employee #3 stated that staff considered Patient #44 as having complications from COVID as it was present in several patients on the unit with the patient. Employee #3 confirmed there was no MEWS assessment and further stated s/he had no knowledge as to what a MEWS assessment was. Employee #3 stated that documentation regarding what proceeded prior to Patient #44 transfer was not present in the medical record.

Employee #27 confirmed on 04/27/2022 that when a patient experiences a change in condition, the nurse should document an assessment in the medical record. Employee #27 confirmed the nurse should document in the medical record the time the physician was notified, what the physician ordered, and the patient's response to the interventions. Employee #27 confirmed that if a patient becomes ill and needs to be transferred to the ED, the nurse should document in the medical record what was occurring with the patient prior to the transfer.

Employee #3 confirmed on 04/28/2022 that if there is a STAT lab drawn, staff call the lab to pick it up; otherwise any labs collected were picked up on the next scheduled service call. Employee #3 confirmed she did not know the turn around times for STAT or routine labs or the lab pick up schedule.

Employee #14 confirmed on 05/09/2022 that stat labs are expected per the time frame outlined in the CCL turnaround times for STAT labs but was unsure of the process or what was outlined in the contracted agreement.

Based on review of policy and procedure, facility documents, observation, and interview, it was determined that the facility failed to ensure that:

1. BHTs did not use their personal cell phones excessively while performing job duties and monitor patients appropriately; and

2. BHTs did not use rolling chairs to propel themselves down the unit hallway while performing patient monitoring;

These deficient practices pose a potential risk to the safety of patients if staff are not focused on their job duties while providing patient care.

Findings include:

1. The facility policy titled "Use of Cell Phones While Conducting Company Business" requires: "...It is the expectation that employees use professional judgment related to the use of cell or land-based telephones for personal matters during times when they are scheduled to be conducting company business. Employees are prohibited from using these phones when the employee should be performing patient care...Meal and break periods are permissible times when an employee may use a cell phone for personal matters in approved locations...."

Observation of video surveillance footage dated 04/11/2022 from 2025 to 2315. The staff member unlocked the patient's room to allow the patient in and then sat in a chair at the doorway at 0828. The staff member pulled a cell phone out of her pocket and began scrolling the phone and texting until 2115. A second staff member relieves her at 2115. The second staff member sits in a chair in the patient's doorway and pulls out her cell phone and uses it until the first staff member returns to take back over at 2123. The first staff member is seen pulling her phone out and using it continuously until 2313.

Observation of video surveillance footage dated 04/11/2022 from 2315 to 2329 revealed three staff members, one sitting in a patient's doorway, another leaning against the door frame, and another standing just outside a patient's room having an animated conversation. The conversation continues for 15 minutes when one staff pulls a cell phone out of her pocket and begins scrolling while walking away and a second staff takes a cell phone out of her pocket and is seen making a call before walking away leaving the third staff member at the patient's room.

Observation of video surveillance footage dated 04/11/2022 at 2332 revealed a staff member who is sitting in the patient's doorway on her cell phone scrolling media and texting. At 2336 a second staff brings a rolling office chair down the hallway for the staff to sit on. The second employee stays at the end of the hall with the first staff member and has an animated conversation at the patient's doorway. She has her cell phone out and is scrolling media and sharing what is on her phone with the other staff member for 15 minutes. During the 15 minutes both staff have their cell phones out for several minutes comparing screens and are seen talking and laughing. At 2349 one staff member is seen partially entering the patient's room to show the second staff member something. The staff member is seen laughing and talking in an animated manner. The staff inside the patient's room comes out of the doorway but remains in the hall and continues to talk and laugh with the other staff member, pulling her phone out of her pocket periodically to share something on the phone with the other staff member. This continues until 2357 when one staff member walks away. The remaining staff is seen sitting in the doorway in a rolling office chair while scrolling her cell phone. The staff member not sitting in the patient's doorway returns at 0027 (04/12/2022). A conversation starts between the two staff members, one takes her cell phone out of her pocket and is seen scrolling media and sharing with the other staff member. The conversation is animated and lasts until 0038 when one staff walks away.

Observation of video surveillance footage dated 04/12/2022 at 0058 a staff member has wheeled herself into the doorway further and lays her head up against the door frame. Very little movement is seen until 0111. The staff member repositions herself at 0112. There is no movement by staff until 0122 when she repositions herself again. Movement is not seen again until 0126 when she repositions again with her head against door frame at 0138. The staff then repositions again at 0140 in such a way as it appears she is trying to sleep. Her head is facing into the door hinge until 0143 when she repositions to the other side of the door frame. No movement is seen until 0147 when a second staff walks down the hall and starts a conversation.

At 0201 staff change out and the second staff is seen wheeling herself further into the patient's room. She is on her cell phone and has earbuds in. At various points you can see her feet up in the door frame and her spinning around in the chair and rolling in and out of the room.

Employee #43 confirmed on 05/10/2022 after viewing footage with the surveyor that staff did not follow facility policy for cell phone use.

2. "Levels of Observation" requires: "...It is the policy of the facility to provide a safe environment and utilize levels of monitoring and observation matched tot eh patient's individualized needs and based on assessed risk...."

"Census Check" requires: "...An accurate record of the whereabouts of all clients on the units will be maintained during each shift...."

Observation of video surveillance footage dated 04/09/2022 at 2245 revealed a BHT doing a 15-minute census check. A second BHT checked in the patient rooms on her was out of the unit at 2249. Another census check was not conducted until 1114.

Observation of video surveillance footage dated 04/07/2022 at 2214 revealed a BHT in a large rolling office chair conducting census checks. The BHT sat in the office chair and was seen kicking her feet off on the floor and pushing with her hands on the walls to propel the chair down the patient room hallway to conduct 15-minute census checks. The BHT did not get up from the chair during the checks.

The same BHT was also seen conducting checks in the same manner at 2232 and 2254 on 04/07/2022.

Video surveillance footage dated 04/07/2022 through 04/19/2022 revealed significant variations in how staff performed 15-minute census checks. The majority of staff conducted the check in less than 30 seconds for the entire unit. Some staff used flashlights to view patients in rooms, most did not. Some staff briefly stopped at the patient's doorway to look in while others didn't glance in as they walked by. On 04/19/2022 at 0129 a staff member was observed walking down the hallway with a flashlight then pulling a cell phone out of her pocket. She was seen scrolling on her phone when she walked down the length of the hall and back. The staff member spent 20 seconds walking the length of the hall while on her phone and did not look in some of the rooms while doing her rounds.

Employee #43 confirmed on 05/10/2022 that staff are not allowed to use rolling chairs as it is a safety issue, and that staff did not conduct safety checks appropriately and within the 15-minute time frame.

Based on review of policies and procedures, medical records, and staff interviews, it was determined the nurse executive failed to ensure nursing personnel documented properly on Census 15 Minute Checks, changes in patients' conditions and treatment plans. This deficient practice poses a risk to the health and safety of patients by not providing a proper record of the patient's progress during hospitalization.

Findings include:
Policy titled "Admission Assessment Guidelines: Provisions of Care, Treatment, and Services" revealed: " ...RN staff are required to complete daily assessment and progress note of each patient and document by the end of his/her shift in the medical record ...."

Policy titled "Change in Patient Condition" revealed: " ...If the RN determines that a patient may be experiencing a change in condition or any form of physical deterioration from their baseline, they will complete the Modified Early Warning Score (MEWS) form ...Changes in condition include, but are not limited to: Alteration in mental status; pallor, diaphoresis; sudden onset of pain; rapid or slowed heart or respiratory rate; systolic BP>180 or< 80; Decreased urinary output; Any other sign or symptom the RN determines with their clinical judgement to be a change in baseline ...This policy is not meant to limit the RN's ability to use their judgement to call a Code Blue at any time ...."

Policy titled "Medical Record Documentation, Record of Care, Treatment and Services (Outpatient/Inpatient)" revealed: " ...medical records are adequately maintained in order to provide documentary evidence of the course of the patient's medical evaluation, treatment, and change in condition ...Documentation Additions ...Additions to the patient record, made after completion of the patient's care, shall be dated, timed, and signed by the person making the addition along with a "late entry" notation ...."

Policy titled "Level of Observation" revealed: " ...Each patient's location and behavior, regardless of level of observation, is documented on the patient's Census 15 Minute form by the assigned staff ...."
The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual ' s clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

Review of Patient #44 medical record revealed the patient had experienced a significant change in condition. A review of the nurse progress notes revealed no evidence of a MEWS assessment or an assessment of the patient's condition at time of transfer to the Emergency Department in the medical record. The Census 15 Minute Check for 02/09/2022 was not present in the medical record. The Census 15 Minute Check for 02/10/2022 revealed the patient was in the ED from 0000 to 0530. It is documented that from 0530-0730 the patient was back in the facility asleep in the patient's room and from 0730-0830 was back in the ED. The patient was transferred to the ED on 02/09/2022 at 2030 and never returned to the facility. A review of the treatment plan revealed no parent involvement documented and the patient, a minor, signed the treatment plan.

Review of Patient #1 Census 15 Minute Check for 04/25/2022 revealed the BHT assigned to the patient had pre-charted on the form one (1) hour ahead. The treatment plan had not been updated as per policy.

Review of Patient #12 Census 15 Minute Check forms revealed missing documentation on 02/14/2022 at 2200, 04/10/2022 at 1745, 04/19/2022 at 2330 and 2345, and on 04/22/2022 at 2200.

Review of Patients #8-33 treatment plans revealed the treatment plans were missing required information including short and long-term goal target dates, reviews and updates to the treatment plans at required intervals and missing required signatures.

Employee #3 confirmed on 05/10/2022 that the reviewed medical records had missing required documentation.

Based on review of policy and procedure, facility documents, and interview, it was determined that the Hospital failed to ensure staff were knowledgeable about the acuity plan and how to implement it. This deficient practice poses a potential risk to the health and safety of patients when the registered nurse does not know how to utilize, and implement the acuity plan for the purpose of determining a patient's acuity and safe patient assignments.

Findings include:

The facility policy titled "Staffing/Acuity Plan" requires: "Policy: Patient Acuity and Tool, Assignment of Patient Care......Assignment of patient acuity is completed by the charge nurse on each unity daily up to 4 hours prior to the end of the shift. If changes occur on the unit that impact staffing additional acuity calculations may be completed...Purpose: To provide guidelines for the appropriate assignments of patient care based on patient acuity...Roles and Responsibilities of Personnel Who Determine Staffing Needs and Assignment of Patient Care...The Assistant Director of Nursing posts the nursing schedule for the department with adequate staff to meet the staffing needs for the average daily census, provides support to the Shift Supervisor to project department staffing needs, discusses staffing needs with the units, and assists with daily staff need fluctuations as required...The Supervisor functions in cooperation with and as an extension of the Chief Nursing Officer...It is the responsibility of the Chief Nursing Officer to develop approve and implement criteria for employment, deployment and assignment of nursing staff members...."

Lotus, Phoenix, Koi, Cicada, and Monarch Acuity sheets(tool) were reviewed for 04/16/2022 through 04/26/2022. The sheets were found to be incomplete, have missing information, conflicting information, and no actions noted for increasing or addressing acuity concerns in the documentation.

The tool lists columns for each patient that include utilization, behaviors, mobility, and toileting. The scores are used to calculate a number that indicates the number of nursing and BHT staff needed for the shift. The bottom of the tool lists the average RN and average BHT staff needed. The tool includes a "key" to outline whether to decrease, maintain, or increase the number of staff needed. The tool includes a box labeled "plan" that should be completed to indicate whether to "drop staff", "add BHT", "add Nurse", or "Stay as is." This is to be indicated with a yes or no. Additionally, the tool is required to be completed for day shift, evening shift, and night shift by the registered nurse.

The acuity sheets for Lotus unit were found to be incomplete, had conflicting information on acuity/staffing needs, or were entirely missing from 04/15/2022 through 04/26/2022.

The acuity sheets for Monarch unit were found to be incomplete, had conflicting information on acuity/staffing needs, or were entirely missing from 04/16/2022, and 04/19/2022 through 04/25/2022.

The acuity sheets for Phoenix unit were found to be incomplete, had conflicting information on acuity/staffing needs, or were entirely missing from 04/15/2022, and 04/19/2022 through 04/25/2022.

The acuity sheets for Koi unit were found to be incomplete, had conflicting information on acuity/staffing needs, or were entirely missing from 04/15/2022 through 04/24/2022.

The acuity sheets for Cicada unit were found to be incomplete, had conflicting information on acuity/staffing needs, or were entirely missing from 04/15/2022 through 04/24/2022.

Employee #63 and 64 confirmed on 04/24/2022 that staffing is set and that regardless of the results of the acuity tool staffing does not change.

Employee # 3 confirmed on 05/10/2022 that nursing staff do not understand how to use the facility's nursing acuity plan and tool.

Based on review of policy and procedure, manufacturer's recommendations, observation, and interview, it was determined that the facility failed to ensure:

1. staff discarded a 10 ml vial of Sterile Water for injection after single use. This deficient practice has the potential risk of patient harm if staff reuse a contaminated solution for multiple patients; and

2. staff label glucose control solutions with an expiration date which has the potential risk that the solutions may not be effective when calibrating blood glucose meters used for patients.

Findings include:

1. The facility policy titled "Medication Administration" did not address handling and disposal of single use medication vials for injection.

Observation on 04/24/2022 revealed an open, used 10 ml vial of Sterile Water for injection in the Phoenix/Lotus medication room. The vial was not discarded after use.

Employee #4 confirmed that nursing staff did not discard the open, used single dose vial of Sterile Water after use.

2. The manufacturer's directions for use for "McKesson True Matrix Control Solution" requires: "...Check Expiration Dates on control solution bottle...Discard control solution if 3 months past written opened date or past printed label Expiration Date, whichever comes first...."

The facility did not provide a policy on labeling and discarding glucose meter control solutions.

Observation on 04/24/2022 revealed three open McKesson glucose meter control solution bottles for "Level 1", "Level 2" and "Level 3." The bottles were in use and were not labeled with an open date.

Employee #4 and 6 confirmed the control solutions had not been labeled to ensure staff did not use the solutions after the expiration date and that the solutions should be discarded.

Based on review of Arizona Administrative Code (A.A.C.), facility documents, policy and procedure, medical records, and interview, it was determined that the Hospital failed to ensure labs were processed and reported in a timely manner which poses a potential risk of patient harm if there is a change in a patient's condition that is not identified and acted upon in a timely manner.

Findings include:

The facility document "Laboratory Services Agreement" 08/27/2020 revealed that the facility has a contract with Central Clinical Labs (CCL) to provide laboratory services.

The facility policy titled "Venipuncture" revised 08/2020 revealed: "...The facility contract with CCL for the processing of lab specimens. Lab processing services occur six days a week...."

The policy revealed that lab services are not provided 24/7.

A policy on timeframes for STAT labs was requested but not provided. A policy titled "Critical Labs" was provided which outlined how the facility communicates critical or potentially life-threatening results of blood work to the physician. The policy did not outline procedures and time frames for collection and transportation to CCL for processing STAT labs.

The facility document titled "CCL Test Available for 4-hour STAT Results" revealed that CBC complete blood count, CMP, and Urinalysis are available for the 4-hour result time.

Patient #44's medical record revealed that the provider ordered a "CMP" on 02/01/2022 at 0545 and a "Basic Metabolic Panel w eGFR" at 1600.

The medical record revealed that the labs ordered on 02/01/2022 were not collected until 02/03/2022 at 1426. The labs were not received for processing by CCL for 32 hours until 02/04/2022 at 2246. The lab results were not reported until 02/07/2022 at 1724 and were not noted by the nurse until 02/08/2022. The timeframe from when the labs were ordered until they were reported was 6 days and not noted by a nurse until the following day.

Patient #44's medical record revealed that the provider ordered STAT labs to include "Basic Metabolic Panel w eGFR", "CBC w Diff w Plat" and "Urinalysis & Urine Culture" on 02/09/2022 at 1600. The lab order was noted by the nurse at 1709. The labs were not collected until 02/09/2022 at 1830. The labs were not received for processing by CCL until 02/09/2022 at 2255. The labs were reported on 02/10/2022 at 0039.

A facility email dated 02/22/2022 at 1643 revealed: "...Hi Steve, We have a stat lab and the nurse called...and was told that they do not perform stat lab services and to call another company. This really has to be fixed as we can not (Sic) operate this way...."

The facility Governing Body meeting minutes dated 02/16/2022 revealed: "...nursing report states lab services: providers and staff are complaining of issues, specifically turn around time, stat labs and reporting...."

Employee #3 confirmed on 04/28/2022 that if there is a STAT lab drawn, staff call the lab to pick it up; otherwise any labs collected were picked up on the next scheduled service call. Employee #3 confirmed she did not know the turn around times for STAT or routine labs or the lab pick up schedule.

Employee #14 confirmed on 05/09/2022 that stat labs are expected per the time frame outlined in the CCL turnaround times for STAT labs but was unsure of the process or what was outlined in the contracted agreement.

Based on review of policy and procedure, observation, and interview, it was determined that the facility failed to ensure full sharps containers were replaced when full which poses a risk for cross contamination infection and injury.

Findings include:

The facility policy titled "Exposure Control Plan" requires: " ...Sharps Container/Sharps Container Disposal ...Contaminated sharps are place immediately (or as soon as possible) in a closable, puncture resistant container that is leak-proof on sides and bottom ...Sharps disposal containers are inspected and maintained/replaced by nursing staff when ¾ full (as indicated by 'full' designation on container) or whenever necessary to prevent overfilling ...Immediately replace with an appropriate container ...Sharps containers must be secured in an appropriate housing or mounting bracket while in use and should not be left sitting on counters or floors ...."

Observation on 04/24/2022 revealed two full sharps containers in medication rooms on the Cicada/Koi and Lotus/Phoenix units. Both sharps containers were housed in a fully enclosed sharps bracket with a locked door. The see-through view window was tabled with a "full" line and both containers were filled above this line. Additionally, there was a door "flap" that was in a closed position with the word "FULL" printed on this flap. One of the medication rooms has two small loose sharps containers placed on the countertop in the medication preparation area.

Employee #4 confirmed that the full sharps containers had not been disposed of and replaced when full. Nursing staff on those units stated that they did not have a key to access the sharps containers to dispose of and replace the full containers and confirmed that the additional unsecured containers on the countertop had been brought to the units because the other sharps containers were full and could not be used any longer.

Based on review of policy and procedure, observation, and interview, it was determined that the Hospital failed to ensure:

1. carpets and floors were cleaned; and

2. nutrition rooms in the patient units were kept clean and free of items unrelated to providing patient nutrition.

These combined practices pose a patient safety risk due to unsanitary environment that may lead to cross contamination and exposure to infections.

Findings include:

1. The policy titled "Exposure Control Plan" revealed: "...It is the policy of the facility to provide a safe and healthy environment for patients, staff, and visitors by means of managing infection control risks and exposure...Elements of the ECP (exposure control plan) include...Housekeeping...."

The policy titled "Housekeeping/Laundry Infection Control" requires: "...This facility strives to maintain a clean and safe environment for all patients...All patient rooms in use will be cleaned daily...."

The policy titled "Daily Room Cleaning" requires: "...In use patient rooms will be cleaned daily and as needed...Procedure...Empty Trash....Horizontal Surfaces - disinfected...Spot Clean Walls...Dust Mop...Damp Mop...."

The policy titled "Restroom Cleaning" requires: "...Patient restrooms in use should be cleaned daily...Procedure...Check Supplies...Empty Trash...Dust Mop Floor...Clean and Sanitize Sink and Shower...Clean and Sanitize Commode...Spot Clean Walls...Damp Mop Floor...."

Observation on 04/25/2022 revealed a combination of hard surface and carpeted flooring throughout the facility. Carpeting throughout the patient units day/group rooms and throughout the administration area had visible debris such as small pieces of trash and paper, disassembled ink pens, crayons, and loose dirt. The carpets were also heavily stained from liquid spills and ink and crayon markings.

Additional observations from 04/25/2022 through 04/28/2022 revealed the hallway to locker rooms were not swept for the entire week, same dust bunnies and clump of debris were noted along baseboard the entire week, bathroom floor in locker room not mopped the entire week with dirty foot prints noted daily. The classroom the surveyors used during the week was not vacuumed or cleaned. The carpet had numerous stains from spills and loose debris and dirt. On 04/25/2022, patient rooms on Cicada and Koi were noted to have dirty floors with trash and debris, bathrooms were not clean with pink mold noted in showers and sinks with calcium buildup noted. Employee #10 commented on 04/25/2022 "we need to get the residents to clean their rooms, they are untidy." Floors on in the patient care area hallways had the same dirty spots of dried fluid and dust bunnies on all units, carpets were dirty and not vacuumed. Employee #3 confirmed on 04/28/2022 that s/he did not know housekeeping should be cleaning the patient rooms.

The CEO confirmed on 04/25/2022 that the carpeting and floor throughout the facility was dirty and had not been cleaned.

2. Dietary policies did not address cleanliness of the nutrition rooms.

The facility's infection control policies did not address maintaining a clean environment in the unit nutrition rooms.

Observation on 04/24/2022 revealed that nutrition rooms located on the five patient units. The nutrition rooms contained very little nutritional items for patients which mainly consisted of crackers and other small packaged snacks. Each room had multiple cabinets and drawers which were cluttered with some medical supplies, staff personal items, cell phones, head phones, purses and back packs, open drink cups and travel mugs with beverages belonging to staff, and in one cabinet an open, half eaten pudding cup with a spoon still in it. One of the nutrition rooms was used to store books, crayons, and games as well.

Employee#14 confirmed on 04/24/2022 that the nutrition rooms are used for multiple purposes and that staff store personal belongings along with patient snacks and drinks in the same cabinets and drawers. Additionally, Employee #4 confirmed that the nutrition rooms were cluttered and kept in an unsanitary manner.

Based on CDC (Centers for Disease Control and Prevention) guidelines, review of policies and procedures, facility documents, video review, and interview, it was determined that the Hospital failed to ensure staff wear face masks when providing patient care. Failure to follow established infection control guidelines poses a patient risk for exposure to infectious diseases including exposure to COVID-19.

Findings include:

The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" Updated Feb. 2, 2022, requires: "...CDC ' s COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings...Source control and physical distancing (when physical distancing is feasible and will not interfere with the provision of care) are recommended for everyone in a healthcare setting...."

The facility policy titled "COVID-19 Plan Policy" revised 4/1/2022 requires: "...Personal Protective Equipment...Facemasks (Sic)...b. During all Status colors, facemasks (Sic) are to be worn at all times around patients and in patient care areas by ALL staff at Destiny Springs Healthcare...."

The facility document titled "New Employee Orientation" requires: "...Masks are to be worn in ALL areas of the hospital...."

Observation of video surveillance footage dated 04/07/2022 through 04/19/2022 from 1900 to 0700 revealed that all BHT staff for every night reviewed either did not wear a face mask or did not wear a face mask appropriately over their nose and mouth.

Employees #3 and 43 reviewed video footage with the surveyor and confirmed that BHT staff observed on video 04/07/2022 through 04/19/2022 from 1900 to 0700 did not wear face masks as required.

Based on review of policy and procedure, medical records, and interview, it was determined that the facility failed to ensure (12) of (24) patients were discharged with a physician's order which has the potential risk of inappropriate discharge and discharge planning and may affect the continuity of care for patients.

Findings include:

The facility policies titled "Discharge Criteria", "Discharge Planning", and "Discharge Summary" did not address requiring a physician's discharge order prior to discharging patients.

Patients #5, 8, 9, 11, 13, 15, 17, 19, 25, 28, 29, and 31's medical records revealed that the patients did not have a physician's discharge order prior to being discharged from the facility.

Employees #1 and 14 confirmed on 05/03/2022 that the patients did not have a physician's discharge order prior to discharge from the facility.

Based on review of the facility's polices/procedures, medical records, and interview, it was determined that the Hospital failed to meet the Condition of Participation for Special Medical Record Requirements that required the medical record maintained by a psychiatric hospital to contain the degree and intensity of the treatment provided to the patients as evidenced by:

Findings Include:

A-1640: Failure to implement, develop, review and update comprehensive treatment plans on 24 patients

A-1642: Failure to ensure that short-term and long-term goals with target dates were included and updated on 8 patients,

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Special Medical Record Requirements, which poses a potential risk to the health and safety of patients when the facility fails to ensure that they are providing the degree and intensity of treatment needed for the patients

Based on review of policy and procedure, medical records and staff interview, it was determined that the facility failed to ensure Interdisciplinary Treatment Plans were developed within 72 hours, and reviewed, signed and updated at least every seven (7) days, with each treatment plan review, or within twenty-four (24) hours following any qualifying event for (25) of (27) patients (Patients #1; 8 through 20; 22 through 28; and 30 through 33). This deficient practice poses a potential risk to the patient's health when the treatment plan is not current and/or does not support the patient's recovery.

Findings include:

The policy titled "Interdisciplinary Treatment Plan Team Meetings" revealed: "...Per the interdisciplinary Treatment Planning (ITP) Policy, all patients shall have an ITP initiated and reviewed by the team within 72 hours of admission. Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner...Patient/Guardian/Caretaker Involvement...Patients and their guardians and/or caretakers are considered active members of the treatment team....When a patient has a legal guardian, the social worker shall attempt to coordinate communication within 72 hours with the guardian to discuss the ITP and elicit the guardian's signature, representing agreement with the ITP...If the guardian is unable or refuses to come to the hospital for a meeting, the social worker may fax the completed master ITP to the guardian via secure fax and a phone call shall occur with the team to discuss the ITP. If no fax is available, the guardian may provide a verbal agreement or disagreement and this is clearly documented on the ITP...."

The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual ' s clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

The treatment plan for each patient included a signature page for members of the treatment team, the "patient/client", the "parent/guardian". Below the signature lines is another signature line that reads "A copy of this treatment plan was: ____ given to the patient/client/family OR ____ declined by the patient/client/family: Date: ____ Clinician: ___________ Title: ________. This was left blank for all treatment plans reviewed.

Patient #1

Patient #1's initial treatment plan was initiated on 03/11/2022 and completed on 03/12/2022 which included long-term and short-term goals all with the same target date of 03/18/2022.

The medical record did not contain an updated treatment plan until 03/31/2022. The long-term goal was not updated and had the same target date on the initial treatment plan of 03/18/2022. The short-term goals had a target date of 04/07/2022. The medical record did not contain documentation that an update occurred on 03/23/2022 involving unwanted sexual activity by Patient #1 to Patients #2 and #3, which resulted in DCS and law enforcement involvement.

The medical record did not contain an updated treatment plan until 04/19/2022.

Patient #8
Patient #8's initial treatment plan was initiated on 03/19/2022. The treatment plan was signed by the ITP team and patient on 03/22/2022. Patient #8 was a minor. There was no signature or documentation that the treatment plan was developed with and signed by a guardian. The plan was not provided to the patient/guardian. The treatment plan was not updated prior to the patient's discharge on 04/12/2022.

Patient #9
Patient #9's initial treatment plan was initiated on 03/19/2022. The treatment plan was signed by the MSW on 03/19/2022 and the RN on 03/22/2022. The signature line for "Patient/Client" was written in "refused." Patient #9 was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. There were no dates for short- and long-term goals for "Danger to Self." The treatment plan was not updated as of 05/03/2022 when the records were reviewed.

Patient #10
Patient #10s initial treatment plan was initiated on 03/17/2022. The treatment plan was not updated at the time of the patient's discharge on 03/29/2022. Patient #10 was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #11
Patient #11 was admitted on 04/12/2022. Patient #11's treatment plan was not initiated until 04/18/2022. Patient #11 was a minor. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent guardian. There were no updates to the treatment plan. The patient was discharged on 05/02/2022.

Patient #12
Patient #12 was admitted to the facility on 01/31/2022 and discharged on 04/27/2022. The treatment plan was initiated on 02/01/2022. Patient #12 was a minor. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent guardian. There were no updates to the treatment plan.

Patient #13
Patient #13 was admitted to the facility on 02/08/2022. A treatment plan dated 04/25/2022 was provided. Patient #13 was a minor. The only signature on the treatment plan was by the MSW. No other treatment plans were provided. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #14
Patient #14 was admitted to the facility on 03/25/2022 and discharged on 04/05/2022. A treatment plan was not initiated until 03/29/2022 and not updated prior to discharge. The short- and long-term goals were missing target dates. The treatment plan signed by the ITP team did not include complete dates and were listed as "3/29". The MD did not date his/her signature. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #15
Patient #15 was admitted to the facility on 03/16/2022 and discharged on 03/29/2022. A treatment plan was not initiated until 03/21/2022 and not updated prior to discharge. The patient was a minor. The treatment plan was not signed by the ITP team or parent/guardian. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #16
Patient #16 was admitted to the facility on 03/19/2022 and discharged on 04/13/2022. A treatment plan was not initiated until 03/25/2022 and not updated prior to discharge. The patient was a minor. The treatment plan was not signed by the ITP team or parent/guardian. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #17
Patient #17 was admitted to the facility on 03/24/2022. A treatment plan was not initiated until 03/29/2022. The short- and long-term goals were missing target dates. The treatment plan was only signed by one individual listed as the MD and not dated. The patient was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian. The treatment plan was not updated as of 05/03/2022 when the records were reviewed.

Patient #18
Patient #18 was admitted to the facility on 03/24/2022. The initial treatment plan was initiated on 03/26/2022. The patient was a minor. The treatment plan was not signed by the ITP team or parent/guardian. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #19
Patient #19 was admitted to the facility on 03/10/2022 and discharged on 03/29/2022. The initial treatment plan was initiated on 03/11/2022. There were no updates to the treatment plan. The patient was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #20
Patient #20 was admitted to the facility on 03/03/2022 and discharged on 04/15/2022. The initial treatment plan was initiated on 03/04/2022. The short- and long-term goals were missing target dates. There were no updates to the treatment plan. The patient was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #22
Patient #22 was admitted to the facility on 03/24/2022 and discharged on 03/30/2022. The initial treatment plan was initiated on 03/25/2022. The short- and long-term goals were missing target dates. There were no updates to the treatment plan. The patient was a minor. No parent/guardian signed as having participated in the development and agreement of the treatment plan. The treatment plan was not provided to the parent/guardian of the minor patient or declined by the parent/guardian.

Patient #23
Patient #23 was admitted to the facility on 03/25/2022 and discharged on 03/31/2022. The treatment plan was not provided to the patient or declined by the patient.

Patient #24
Patient #24 was admitted to the facility on 03/21/2022 and discharged on 03/29/2022. The initial treatment plan was initiated on 03/22/2022. The short- and long-term goals were missing target dates. The treatment plan was not provided to the patient or declined by the patient.

Patient #25
Patient #25 was admitted to the facility on 03/21/2022 and discharged on 03/30/2022. The initial treatment plan was initiated on 03/24/2022. The treatment plan was not provided to the patient or declined by the patient.

Patient #26
Patient #26 was admitted to the facility on 03/27/2022 and discharged on 04/04/2022. The patient signed the treatment plan on an unknown date as the signature was not dated. The treatment plan was not provided to the patient or declined by the patient.

Patient #27
Patient #27 was admitted to the facility on 03/08/2022 and discharged on 04/01/2022. The treatment plan was initiated on 03/09/2022. The treatment plan was not updated prior to the patients discharge. The treatment plan was not provided to the patient or declined by the patient.

Patient #28
Patient #28 was admitted to the facility on 03/19/2022 and discharged on 03/29/2022. The treatment plan was initiated on 03/21/2022. The treatment plan was not updated prior to the patient's discharge. the social worker signed the section that a copy was provided or declined; however, the area was left incomplete whether or not it was provided to the patient or declined.

Patient #30
Patient #30 was admitted to the facility on 04/06/2022 and discharged on 04/15/2022. The treatment plan was initiated on 04/06/2022. The short- and long-term goals were missing target dates. The treatment plan was not provided to the patient or declined by the patient.

Patient #31
Patient #31 was admitted to the facility on 03/28/2022 and discharged on 04/04/2022. The treatment plan provided was incomplete and only contained the last three pages of the document. The patient signed the treatment plan on an unknown date as the signature was not dated. The treatment plan was not provided to the patient or declined by the patient.

Patient #32
Patient #32 was admitted to the facility on 03/28/2022 and discharged on 04/05/2022.The treatment plan was initiated on 03/29/2022. The treatment plan was not provided to the patient or declined by the patient.

Patient #33
Patient #33 was admitted to the facility on 03/28/2022 and discharged on 04/07/2022. The treatment plan was initiated on 03/30/2022. The treatment plan was not provided to the patient or declined by the patient.

Employees #1 and 14 confirmed on 04/28/2022 and again on 05/03/2022, that Patient #1's treatment plans were not reviewed and updated as required by facility policy at a minimum of every seven days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner even with the assault and sexual misconduct incidents last 03/23/2022, which involved law enforcement and DCS, that would require reviews and updates to the patient's treatment plan. Additionally, they confirmed that treatment plans reviewed were incomplete, missing information such as target dates, not provided to patients, not signed by the team and patients/guardians, and not completed every (7) days as required by facility policy.

Based on review of policy and procedure, medical records and staff interview, it was determined that the Hospital failed to ensure Interdisciplinary Treatment Plans were developed with short-term and long-term goals that included target dates. This deficient practice poses a potential risk to the patient's health and safety when the treatment plans are not complete and support the patient's recovery.

Findings include:

The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual ' s clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

Patient #1's initial treatment plan was initiated on 03/11/2022 and completed on 03/12/2022 which included long-term and short-term goals all with the same target date of 03/18/2022. The medical record did not contain an updated treatment plan until 03/31/2022. The long-term goal was not updated and had the same target date on the initial treatment plan of 03/18/2022. The short-term goals had a target date of 04/07/2022.

Patient #9's initial treatment plan was initiated on 03/19/2022. There were no dates for short- and long-term goals for "Danger to Self."

Patient #14 was admitted to the facility on 03/25/2022 and discharged on 04/05/2022. A treatment plan was not initiated until 03/29/2022 and not updated prior to discharge. The short- and long-term goals were missing target dates.

Patient #17 was admitted to the facility on 03/24/2022. A treatment plan was not initiated until 03/29/2022. The short- and long-term goals were missing target dates.

Patient #20 was admitted to the facility on 03/03/2022 and discharged on 04/15/2022. The initial treatment plan was initiated on 03/04/2022. The short- and long-term goals were missing target dates.

Patient #22 was admitted to the facility on 03/24/2022 and discharged on 03/30/2022. The initial treatment plan was initiated on 03/25/2022. The short- and long-term goals were missing target dates.

Patient #24 was admitted to the facility on 03/21/2022 and discharged on 03/29/2022. The initial treatment plan was initiated on 03/22/2022. The short- and long-term goals were missing target dates.

Patient #30 was admitted to the facility on 04/06/2022 and discharged on 04/15/2022. The treatment plan was initiated on 04/06/2022. The short- and long-term goals were missing target dates.

Employees #1 and 14 confirmed on 04/28/2022 and again on 05/03/2022 that treatment plans reviewed were incomplete with missing information such as target dates for goals.