HospitalInspections.org

Based on clinical record reviews, facility documentation, and staff interviews, it was determined the Hospital failed to develop, implement and maintain an effective hospital-wide quality assessment and performance improvement program by failing to ensure there were on-going hospital-wide performance improvement activities for the improvement of quality of care and that the activities were evaluated.

Findings Include:

Policy titled "Organizational Performance Improvement Plan" (Policy: 9985870) revealed: "...The Governing Board is ultimately responsible for the quality of care provided...Quality improvement measures will be coordinated by the Director of Quality through the facility's Quality Council, and will be communicated via regular reports to the Medical Staff and Governing Body...Each department is responsible to address patient care problems...."

Document titled: Medical Behavioral Hospital of Northern Arizona Quality Assurance & Performance Improvement Workplan (QAPI) revealed: "...2021 PI Priories identified by Leaders
Department: PI project:
Infection Control Influenza vaccine for patients, HBIPS
Pharmacy, Nursing Overrides
Contracted Services, Nursing LabCorp Quality Reporting & Specimen Acceptability

A review of hospital document "Medical Executive Committee Meeting 1Q 2021"(0900) dated May 6, 2021 revealed: "...1. Report was disturbed regarding falls...2. The hospital has been utilizing infection control due to COVID-19. The COVID team is working to enhance the hospitals in place infection control measures and prepare the hospital to open visitation. 3. RL Datiz is being utilized for incident reporting. 1. The 2020 Evaluation of Management Plan was presented, reviewed, and approved as is with no changes...."

A review of hospital document "Governing Board Meeting 1Q 2021" dated May 6, 2021 (1000) revealed: "...A revised OPIP was presented for review and approval. Moet Nakajo-Robbens will assume the quality role for the hospital system. Quality indicators will be input through smart sheet. Quality dashboards were submitted to the board for review of trends. The hospital is continuing COVID-19 infection control efforts with visitation opening to patient families...."

A review of hospital document "Governing Board Meeting 1Q 2021" dated May 6, 2021 (1300) revealed: "...Report was disturbed regarding falls and send outs for the hospital. The hospital has been enforcing infection control initiatives due to COVID-19. The COVID team is working to enhance the hospital's infection control measures. RL Datix is being utilized for incident reporting. The 2020 EOC Evaluation of Management Plans were presented, reviewed, and approved as is with no changes.

No Performance improvement data for the indicators was received.

Employee #1 and employee #6 confirmed during separate interviews conducted on 09/30/2021, (1515) that not all hospital departments, including the dietary and housekeeping services are involved in the hospital -wide, data-driven quality assessments and performance improvement program.

Based on review of Appendix A of the State Operations Manual (SOM), hospital policies and procedures, patient records, facility documents, Department documents, and interviews, the Department determined the facility failed to require registered nursing staff to complete the one to one (1:1) patient monitoring form for patient #4 to document the patient monitoring orders were carried out as ordered and per facility policy. This deficient practice poses a risk to the health, and safety of the patients, when a provider orders 1:1 monitoring and there is no documentation of that monitoring as required and according to policy.

Findings include:

Review of the SOM section 482.23(b)(5) revealed: " ...A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the specialized qualifications and competence of the nursing staff available ...."

Review of a policy "Patient Observation" (PolicyStat ID: 9742509 last revised 05/2021), revealed: " ...1. The provider will order one of two observation levels ...B.2. Level II 1:1 Observation ...2. a. The patient is to be under constant visual observation ...regardless of other unit activities ...6. Staff will complete the patient observation record ...Patient Observation Monitoring Form ...."

Review of physician orders revealed that on September 09, 2021 provider #2 gave an order for 1:1 monitoring for patient #4.

Review of Department survey documentation revealed that during the unannounced on-site State Compliance survey, on September 28, 2021 to October 01, 2021, a copy of the 1:1 Patient Observation Monitoring Form for September 10, 2021 was requested for patient #12.

Staff #7 revealed in an interview conducted on September 29, 2021 at 1:30 pm that the facility was unable to provide a 1:1 Patient Observation Monitoring Form for patient #12 for September 10, 2021 and there should be one. Staff #7 further agreed that l:1 monitoring was a higher level of monitoring and required additional documentation and the facility requires a 1:1 Patient Observation Monitoring Form to be completed to document the monitoring care provided. Staff #7 stated that it was their expectation and the policy of the facility that the 1:1 form be completed and given to the RN after each shift.

At the time of the survey exit on October 05, 2021 at 10:30 am no evidence was provided documenting patient #12 received care as ordered and per facility policy.

Based on review medical records and interviews, it was determined that the hospital failed to ensure psychosocial group notes were documented in patient's medical records accurately, and the Psychiatric Evaluations documented in the medical records are inaccurate. This deficient practice poses the potential risk for the health and safety of patients that the medical record would not contain pertinent information needed to provide care to the patient.

Findings include:

A policy on therapy/counseling documentation was request. None was provided.

Patient #10 medical record contains no progress note for 09/21/2021, for "Boundaries Group" and "Sensory Stimulation Group" and 09/22/2021, for "Cognitive Functioning Group" and "Social Skills Group." Which is inconsistent with sign in sheets titled "Social work daily groups and individual sessions" in which Patient #10 signed in for attending "Boundaries Group" and "Sensory Stimulation Group" on 09/21/2021, and for "Cognitive Functioning Group" and "Social Skills Group" on 09/22/2021.

Patient #13 medical record contains a progress note for 09/22/2021, that states " ...Participated in a game ...." Which is inconsistent with sign in sheets titled "Social work daily groups and individual sessions" in which Patient #13 is marked as "discharged" for groups on 09/22/2021.

Patient #20 medical record contains a progress note for 09/03/2021, that states " ...Groups did not occur ...." Which is inconsistent with sign in sheets titled "Social work daily groups and individual sessions" in which Patient #20 signed in for attending groups "Coping Skills" and "Cognitive Functioning" on 09/03/2021.

A review of 21 out of 21 medicals records conducted 09/29/21 through 10/01/21, revealed that the Psychiatric Evaluations are documented on a previous provider's form and are not documented on the facility's current form.

Employee #10 and Provider #2 confirmed during separate interviews conducted on 09/30/21 that the Psychiatric Evaluations are documented on a previous facility's form because of software problems.

Employee #19 confirmed in an interview conducted on 09/29/2021, that the medical record documentation was inconsistent with the "Social work daily groups and individual sessions" sheets that the patients sign into group with.

Based on review of hospital policy and procedure, medical records, and interview, it was determined that the hospital failed to require that verbal or telephone orders given by a medical provider were authenticated, to include the medical provider's signature, date, and time, within the required forty-eight (48) hours after the verbal or telephone order was given. This deficient practice poses a risk to the health and safety of patients, when verbal/telephone orders are not authenticated by the medical provider ensuring that the verbal or telephone orders are accurate, and that patients receive accurate, and timely care or treatment.

Findings include:

A policy titled "Rules and Regulations of the Medical Staff" revealed: " ...Telephone orders must be authenticated within 48 hours with the signature dated and timed...."

Medical Record review conducted 09/29/2021 and 09/30/2021, revealed the following specific to verbal/telephone orders:

Patient #10 - 09/20/2021 - A verbal/telephone order, not authenticated by a provider;

Patient #13 - 08/17/2021 - 08/28/2021 - A total of four (4) verbal/telephone orders, none authenticated by a provider.

Staff #19 confirmed during an interview on 09/29/2021 and 09/30/2021, the verbal/telephone orders for patient #10 and #13 were not authenticated by a provider.

Based on review of Appendix A of the State Operations Manual Appendix A (SOM), hospital policies and procedures, patient records, facility documents, Department documents, and interviews, it was determined that the Administrator failed to ensure that all patients received documented informed consent, including date and time, for psychotropic medications before the medications were administered. This deficient practice poses a risk to the health and safety of patients, when all of the side effects and risks of a psychotropic medication are not understood by a patient or patients representative before taking psychotropic medication.

Findings include:

Review of the SOM section 482.24(c)(4)(v) revealed: " ...Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent ...."

Review of a policy "Informed Consent" (PolicyStat ID: 10239455 last revised 08/2021) revealed: " ...Procedure ...The informed consent process includes at least the following ...Date and time consent is signed by the patient or the patients legal representative/guardian ...Written authorization...including changes in medication therapy or addition of new medications both psychotropic and non-psychotropic shall be placed on (sic) the patient's medical record prior to the initiation of care, treatment or services...."

Review of physician orders revealed that on September 09, 2021 provider #2 gave orders for psychotropic medications.

Review of the patient record #8 on September 29, 2021 at 9:30 am together with staff #19 revealed no informed consent for psychotropic medications psychotropic medication in the patient electronic medical record (EMR).

On September 30, 2021 at 11:00 am staff #7 provided copies of the record for patient #8. Contained in the copies was an informed consent for psychotropic medications. Upon further observation, it was noted that the informed consent was not dated or timed as required by facility policy.

On September 30, 2021 at 11:00 am staff #7 provided copies of the record for patient #8. Contained in the copies was an informed consent for psychotropic medications. Upon further observation, it was noted that the informed consent was not dated or timed as required by facility policy.

By the time of the survey exit on October 05, 2021 at 11:30 am, no evidence documentation was provided by the facility of informed consent, including date and time, as required by facility policy.

Review of physician orders revealed that on 3/16/2021, provider #3 gave orders for psychotropic medications for patient #14.

Review of the patient record on October 1, 2021 together with staff #19 revealed no informed consent for [Quetiapine 25mg qhs] in the patient electronic medical record (EMR) for patient #14.

Review of physician progress notes on 6/15/2021, provider #3 documented continued medications for one psychotropic [Sertraline 25mg Qam] and one non-psychotropic [Lamotrigine 25 mg daily] for patient #16.

Review of the patient record on October 1, 2021, together with staff #19 revealed no informed consent for the psychotropic medications and the non-psychotropic medication in the patient electronic medical record (EMR).

Staff #19 confirmed in an interview on 10/1/2021 that the medical records did not contain all the informed consents for the current psychotropic medication and non-psychotropic medication for patient #14 and #16.

Based on hospital policies and procedures, review of medical records, and staff interviews, it was determined the hospital's administrator failed to ensure that the medical record contained documentation of treatment plans which poses a risk to patients that hospital staff and patients are not able to access the current plan for treatment.

Findings include:

Review of a policy "Patient Treatment Plan" (PolicyStat ID: 8816970 last revised 01/2020) revealed: " ...Procedure: Under the direction of the provider, existing and any additional problems will be addressed and documented in the interdisciplinary plan treatment planning meeting. Information from the interdisciplinary assessments will be utilized to develop...goals...interventions...frequency of interventions...goals and progress reassessment...."

The electronic medical record for #15 did not contain documentation of a treatment plan.

The electronic medical record for #18 did not contain documentation of a completed treatment plan, the form was blank with no signatures.

Employee #19 confirmed in an interview on 10/1/2021 , that the electronic medical record did not contain documentation of treatment plans.

Based on observation, policy review and interview, the hospital failed to keep all drugs and biological in a secure area locked. This practice poses a risk to the staff, patients and visitors when all drugs and biological are not in a secure area locked.

Findings include:

On 09/28/2021, at approximately 8:35 a..m., while on tour of the hospital, an unsecured bin was observed on the floor by all of the surveyors, at the sliding double door main entrance to hospital containing 7 boxes of varying drugs, Fluconazole 200 mg tablets, 0.1 Clonidine Hydrochloride tablets, 2 boxes of 10 mg Donepezil Hydrochloride tablets, Fluoxetine Capsules 20 mg, and Cyclobenzapine Hydrochloride 5 mg tablets.

Employee #6 confirmed during an interview conducted on 09/28/2021, at 0837 a.m. that the bin containing the drugs should be in a secured locked location and in the custody of a licensed medical professional. Employee #6 surrender the bin to a licensed employee.

Based on review of Appendix A of the State Operations Manual (SOM), hospital policies and procedures, hospital documents, and staff interviews, it was determined the hospital failed to provide organized dietary services to meet the nutritional needs of the patients as evidenced by no documented alternatives for patient meals or patient nutritional screenings. This deficient practice poses a risk to the health and safety of the patients, when there is no nutritional screenings or assessments to evaluate a patient's nutritional need.

Findings include:

Review of the SOM section §482.28 revealed: " ...The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietician who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment ...."

A review of 21 clinical records conducted on September 29, 2021 through October 01, 2021 revealed no evidence of patient nutritional screenings or assessments.

A review of Department survey documentation revealed that the Food/Dietary Service policy was requested but not received.

Documents titled "Menu 2021 Week 1, Week 2," revealed no food alternatives or substitutions listed or calorie counts.

Employee #14 confirmed during an interview conducted on September 30, 2021 at 3:15 pm that there is no system for diet ordering or accommodation of non-routine occurrences like diet change orders, early/late trays or supplements are in place. Employee #14 confirmed during the same interview that there is no integration of food service into the hospital wide Quality Improvement and Infection Control Plans.

At the time of the survey exit on October 05, 2021 at 10:30 am no evidence was provided documenting the facility provides organized dietary services to meet the nutritional needs of the patients.


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Based on review of Appendix A of the State Operations Manual (SOM), personnel file, documents, and interviews, it was determined that the person in charge of dietary services was not qualified or trained by education and/or experience for the position. The deficient practice poses a risk to the health and safety of the patients, when the person in charge of dietary services is not trained by education and/or experience, to understand the requirements of storing, handling or serving food provided to patients.

Findings include:

Review of the SOM section 482.28(a)(1) revealed: " ...The hospital must have a full-time employee who ...(i) Serves as director of the food and dietetic services ... (ii) Is responsible for daily management of the dietary services ...(iii) Is qualified by experience or training ...."

Staff #7 confirmed in an interview conducted on September 28, 2021 at 9:00 am that the current director of food and dietetic services is staff #1.

Staff #1 confirmed in an interview conducted on September 30, 2021 at 1:30 pm that they were not an employee but a contracted staff through a facility vendor. Staff #1 also confirmed they had no training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients. Additionally, staff #1 confirmed that they had conducted no training or evaluation of the dietary staff or food service contract for the last 12 months.

Review of Department survey documentation revealed that during the survey, September 28, 2021 to October 03, 2021, a copy of the job description of the current director of the food and dietetic services was requested and was not received.

Review of the personnel file for staff #1 on September 28, 2021 at 2:30 pm revealed no evidence that staff #1 had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

Staff #7 confirmed in an interview conducted on September 28, 2021 at 12:00 pm that the facility was unable to provide documentation that the current director of food and dietetic services had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

By the time of the survey exit on October 05, 2021 at 11:30 am, no evidence had been provided by the facility documenting that the current director of food and dietetic services had training, education, or experience to understand the requirements of storing, handling, or serving food provided to patients.

Based on review of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to provide organized dietary services and assess patients for special nutritional needs.This deficient practice poses a risk to the health and safety of the patients, when there is no nutritional screenings or assessments to evaluate a patient's nutritional needs.

A review of 21 clinical records conducted 09/29/2021 through 10/01/2021 revealed no nutritional screenings or assessments in the records.

A Nutritional Assessment policy was requested but not received.

Employee #14 confirmed during an interview conducted on 09/30/2021, at 3:15 P.M. that nutritional screenings should occur upon admission, and as needed to ensure the hospital meets the nutritional needs of the patients. Employee #14 confirmed during the same interview that the 21 records reviewed have no nutritional assessments or screenings in the record, and s/he is unsure if the posted meal menu meets the nationally recognized USDA recommended dietary intake for the hospitalized patient population.

Based on review of hospital documents, and staff interviews, it was determined the hospital failed to have a Utilization Review committee with two or more practioner's. This deficient practice poses a risk to the health and safety of the patients, when there is not at least two doctors on the Utilization Review Committee to evaluate a patient's continued hospital stay and/or discharge.

A review of the "Utilization Review Plan" revealed: "...The Board of Directors has the ultimate responsibility for the establishment, maintenance and support of the Utilization Review Plan...The committee consists of active Medical staff members...committee reviews may not be conducted by any individual who: is professionally involved in the case of the patient being reviewed...

A review of the Utilization Review Committee Meeting Minutes, dated May 5, 2021, revealed: "Outlier is considered a patient that is in house greater than 20 days...Average Length of Stay - slide numbers for previous averages - 12 to 14 days is goal - based on medical necessity...." Per the meeting minutes one provider was present.

Provider #1 revealed during an interview conducted on 09/30/2021, at 1:30 P.M. that s/he does not have a Utilization Review process role, and s/he has never attended a meeting, and each Provider certifies the need for their individual patients extended stay greater than 7 days and/or as needed.

Employee # 8 revealed during an interview conducted on 09/28/2021, at 10:15 A.M. that s/he meets with a Nursing representative and another Utilization Review person Tuesday's at 12:00 P.M. to review patients and on Thursday's at 1:30 P.M. outlier patient cases are reviewed by the same two staff and when requested the Practioner's will certify the outlier patient's need to continue inpatient treatment, this weekly practice continues until the patient can be safely discharged.

Employee #7 revealed that 2 people are as assigned to complete Utilization Reviews and no Providers are involved in the review process.

Based on observation, review of policies and procedures, hospital documents and interviews, it was determined that the hospital failed to ensure:

1. a patient bathroom shower panels containing the shower head and shower valve were installed flush with the shower wall to minimize and/or eliminate ligature risks. Failure to correctly install anti-ligature shower panels against the wall provide opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients;

2. a patient bathroom handrails were installed correctly to minimize and/or eliminate ligature risks. Failure to correctly install anti-ligature handrails were mounted flush against the wall provide opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients.

Findings include:

Review of a policy "Maintenance Request" (PolicyStat ID: 8857513 last revised 08/2021) revealed: "...All damage to the patient care, public areas or equipment involved in the care of the patients or operation of the facility should be reported immediately to the Director of Plant Operations or their designee...Any damage or disrepair to any area of the facility will be reported through the the maintenance request system...."

1. Observation of rooms identified on the floor plan, signed and dated on 9/29/2021 as room #108 and #123 on 9/29/21 , revealed that the shower panels were not flush with the shower wall and now were a tie off point as you could now place a a string behind it.

Employee #22 and Employee #23 confirmed on 9/29/2021 , that the incorrectly installed shower panel was a ligature risk as it created an opportunity for a patient to use it as a tie-off point.

2. Observation of rooms identified on the floor plan, signed and dated on 9/29/2021 as room #108 and #123 on 9/29/21, revealed the hand rails near the toilet and in the shower area were not flush with the wall in areas and could be a tie off point as you could now place a a string behind between the hand rail and the wall.

Employee #22 and Employee #23 confirmed on 9/29/2021, that the bathroom hand rails created an opportunity for a patient to use as a tie-off point.

Based on review of the facility's Infection Control Plan, Medical Executive Committee Meeting Minutes, Governing Board Meeting Minutes, and interview, it was determined that the hospital does not have an active hospital wide program for surveillance, prevention and control of hospital acquired infections and other infectious diseases. This deficient practice poses a risk to the health and safety of the patients when the hospital does not have a hospital wide nationally recognized infection prevention and control program.

Findings include:

Policy titled "Medical Behavioral Hospital of Northern Arizona Infection Control Plan 2021" (#9827839) revealed: "...The Director of Nursing has overall authority and responsibility for the Infection Prevention Control Plan. The Chief of Infection Prevention & Control (IPC) is responsible for implementing and management the Infection Prevention Control Program. The Medical Director assists as needed...This program identifies risks for the acquisition and transmission of infectious agents on an ongoing basis and attempts to reduce Medical Behavioral Hospital of Northern Arizona acquired infections to an irreducible minimum...."

A document review of Meeting Minutes, (05/05/201 & 08/06/2021 & 05/06/2021), revealed no evidence that any current employee was recommended and approved, at the following meetings:

i. Governing Board Meeting Minutes (05/05/201 & 08/06/2021);
ii. Medical Executive Committee Meeting Minutes (05/06/2021);

Employee #14 confirmed during an interview conducted 09/28/2021, no one in the hospital has attended a nationally recognized infection prevention and control program; as well as to best practices for improving antibiotic, and for reducing the development and transmission of hospital acquired infections and antibiotic resistant organisms. Infection prevention and control problems and antibiotic use issues identified by employee #1 are not with the hospital-wide quality assessment and performance improvement (QAPI) program.

Based on review of the facility's Infection Control Plan, Medical Executive Committee Meeting Minutes, Governing Board Meeting Minutes, and interview, it was determined that the Infection Control Preventionist had not been recommended by Medical Staff, and approved by the Governing Board. This deficient practice poses a risk to the health and safety of the patients, when the credentials and knowledge of the person in charge of over-seeing infection control practices for the facility are not reviewed, verified, and approved.


Findings include:

Policy titled "Medical Behavioral Hospital of Northern Arizona Infection Control Plan 2021" (#9827839) revealed: "...The Director of Nursing has overall authority and responsibility for the Infection Prevention Control Plan. The Chief of Infection Prevention & Control (IPC) is responsible for implementing and management the Infection Prevention Control Program. The Medical Director assists as needed...."

A document review of Meeting Minutes, (05/05/201 & 8/06/2021 & 05/06/2021), revealed no evidence that Personnel #3 was recommended and approved, at the following meetings:

i. Governing Board Meeting Minutes (05/05/201 & 08/06/2021);
ii. Medical Executive Committee Meeting Minutes (05/06/2021);

Employee #14 confirmed during an interview conducted 09/28/2021, that s/he will be the on-site manager for infection control, and recently spent several weeks doing training prerequisites specific to infection control. Additionally, employee #4 revealed during the same interview that to his/her knowledge, s/he had not been recommended by the Medical Staff or approved by the Governing Board and s/he has not completed a training course from a nationally recognized infection prevention and control program. Furthermore, employee #14 revealed s/he not reside in the State of Arizona.

Based on review of Appendix A of the State Operations Manual (SOM), policies and procedures, documents, and interviews, it was determined that the facility failed to ensure facility staff implemented infection control practices as required by facility policy. This deficient practice poses a potential risk to the health and safety of patients, when infection control practices are not implemented by clinical staff.

Findings include:

Review of the SOM section §482.42(a)(2) revealed: "... The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings ...."

Review of a policy "Infection Control and Prevention" (PolicyStat ID: 9286500 Last Revised 01/2020) revealed: "...Adherence to the practice of Standard Precautions is expected of nursing staff. Nursing staff serves as a role model for all healthcare workers in the use of personal protective equipment and adherence to established guidelines...."

Review of a policy "Rest periods and Meal Breaks" (PolicyStat ID: 8804589 Last Revised 01/2020), revealed: "..."No employee is to consume food or beverages in work areas...."

An observation of staff #05 conducted on September 29, 2021 at 10:00 am revealed staff #05 in the dining area behind the food preparation area. Staff #05 was observed eating in the food preparation area and then taking the vital signs of all patients in the dining area. Staff #05 was not observed to have performed hand hygiene after eating or between patient vital signs. Staff #05 was not observed to have cleaned the vital sign machine between patients.


Review of the personnel file for staff #05 revealed orientation and training in infection control practices and Standard Precautions.

Staff #05 confirmed in an interview conducted on September 29, 2021 at 10:30 am that they should have not been eating in the patient dining area, they should have performed hand hygiene between patients, and cleaned the vital sign machine between patients.

Based on review of hospital policies/procedures, observation, and staff interviews, it was determined that the hospital failed to ensure that everyone entering the facility be screened and triaged for signs and symptoms of COVID-19. The deficient practice poses a risk to the health and safety of the patients when anyone entering the facility is not screen for COVID-19; facility failed to require that expired supplies and medications used for patient care were discarded and not used after the expiration date. This deficient practice poses a risk to the health and safety of the patients when the facility fails to monitor the outdates of supplies, with the potential of expired supplies and visitors are not screened for COVID-19.

Findings include:

1. A review of the hospital policy titled "Interim Recommended Routine Infection Prevention and Control (ICP) Practices During Covid-19 Pandemic" (PolicyStat ID: 9158245) revealed: "...everyone entering the facility shall be screened and triaged for signs and symptoms of COVID-19...."

Observation on 09/28/2021 at 8:30 A.M. the survey team consisting of 6 members was not screened or triaged for Covid-19.

Employee #6 confirmed during an interview on 09/28/2021 that everyone entering the facility must be screened and triaged for Covid-19.



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2. Review of the SOM section §482.42(a)(3) revealed: "...The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities...."

Review of a policy "Organizational Performance Improvement Plan" (PolicyStat ID: 9985870 last revised 06/2021), revealed: " ..Purpose and Goal...The overarching goal of the program is continual improvement in patient care and safety practices...Effectiveness of Programs, Services, and Processes...Infection Control Program...Laboratory Services...."

An observation conducted at the nurses station on October 01, 2021 at 1:00 pm revealed a box of Abbott Binax NOW COVID-19 Ag Cards (cards) on a counter. Further observation revealed the cards, total 40, had a lot number of 133072A and an expiration date of May 22, 2021.

Staff #17 confirmed in an interview conducted on October 01, 2021 at 1:15pm that the cards were expired and could contribute to inaccurate test results if they were used to test others for COVID-19.



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3. A policy regarding expired medications and supplies was requested. None was received.

Observations on tour conducted 09/29/2021, of the pharmacy area revealed the following:

Senna-S 8.6mg; 50mg Tablet, Lot 455R44 Expired 01-02-2021 (Quantity 30).

Observations conducted on 10/01/2021, (1230) of the emergency cart inside the nursing station revealed, two bags of IV fluids 5% Dextrose and 0.9% Sodium Chloride 1000 ml with an expiration date of August 2021. Employee # 14 and employee #15 confirmed the expired IV medication was expired, and that 12 used lead EKG pads where inside an open envelope next to the clean sealed EKG leads inside a basket on the Vital Signs machine.


Employee #1 confirmed during observations on tour conducted 09/29/2021, that the identified medications were expired. Additionally, on 10/01/2021, employee #14 and employee #16 confirmed that the IV fluids were expired and that used EKG leads were not discarded properly.

Based on review of the facility's Governing Board By-Laws, Infection Control Plan, Quality, Safety & EOC meeting minutes, and interview, it was determined that the governing body failed to have systems in place for the tracking of all infection surveillance, prevention, and control, and antibiotic use activities. This deficient practice poses a risk to the health and safety of the patients, when there is no system in place for tracking infections and antibiotic use.

Findings include:

Policy titled "Medical Behavioral Hospital of Northern Arizona Infection Control Plan 2021" (#9827839) revealed: "...4. Compliance with monitoring and documenting surveillance data...increases productivity by conducting whole-house surveillance for hospital acquired infections (HAI) based on risk analysis & intervening to prevent further HAI.

A document review of Comprehensive Pharmacy Services Key Performance Indicators & Metrics Data Entry 2021, does not include tracking of all infections and antibiotic use activities for the hospital.

A document review of Quality, Safety & EOC Minutes (WESTERN DIVISION: MBHCL, MBHBA & PMPH) Meeting Minutes, dated 04/22/2021, revealed no evidence that a plan was recommended and approved at the meeting, and the minutes do not reflect any review of tracking of all infections for the hospital.

Employee #1 confirmed during an interview conducted 09/28/2021, at 10:00 A.M. that s/he is not involved in the infection surveillance, prevention, and control, and antibiotic use activities. Employee #1 is notified when an antibiotic medication order is filled or if a provider has a question about an antibiotic.

Based on review of the facility's employee and credential files, Infection Control Plan, and interview, it was determined that the facility failed to provide a competency-based training and education for the medical staff. This deficient practice poses a risk to the health and safety of patients, when infection control training and education is not provided to the medical staff.

Findings include:

A review of 2 out of 2 credential files revealed no documented infection control training or education.

Policy titled "Medical Behavioral Hospital of Northern Arizona Infection Control Plan 2021" (#9827839) revealed: "...The Director of Nursing has overall authority and responsibility for the Infection Prevention Control Plan. The Chief of Infection Prevention & Control (IPC) is responsible for implementing and management the Infection Prevention Control Program. The Medical Director assists as needed...."

Employee #20 confirmed during an interview conducted 09/30/2021, at 10:00 A.M. that credential files did not have documented infection control training and education.

Based on review of the facility documentation and interviews, it was determined that the hospital failed to assess the discharge planning process on a regular basis. This deficient practice poses a risk to the health and safety of patients, when proper discharge planning is not coordinated for the needs of the patient post-discharge.

Findings include:

A review of the hospital's discharge planning process documentation was requested but not received.

Employee #7 revealed during an interview conducted on 09/30/2021, at 2:30 P.M. that s/he thought that provider #1 was involved in the discharge planning process.

Provider #1 revealed during an interview conducted on 09/30/2021, at 1:30 P.M. that s/he does not have a role in the development of discharge planning process assessment for the periodic review of the discharge plans including readmissions within 30 days.

Based on review of facility documentation, policy review, interview, and record review, the facility failed to offer therapy services on weekends and several weekdays during August and September 2021. This deficient practice fails to provide therapeutic services to patients on a daily basis.

A copy of the patient activities schedule for August 01, 2021 through September 30, 2021, was requested. An undated calendar schedule of daily groups was provided. Group calendar indicated groups offered 7 days a week with no evening groups.

Review of a policy titled, "Therapy Services" revealed: "...Patients admitted to the hospital will receive therapy on a daily basis...."

Review of an internal hospital document, "Social Work Daily Groups and Individual Sessions" dated "Monday, 8/01/2021, 2021, through Tuesday 9/28/2021," revealed that there were no psychosocial patient group activities for the following dates: August 1, 7, 8, 14, 15, 20, 21, 22, 28, & 29; September 4, 5, 12, 18, 24, & 25.

Review of patient #7, #9, #10, #13 & #20's medical records dated 8/01/2021, to 9/28/2021, revealed no evidence that on August 1, 7, 8, 14, 15, 20, 21, 22, 28, & 29; September 4, 5, 12, 18, 24, & 25, patient #7, #9, #10, #13 & #20, participated in any psychosocial group activities.

Employee #7 confirmed during an interview conducted on September 29, 2021, at 3:00 P.M. that the patients were not receiving psychosocial group activities per facility's policy. Employee #16 noted that they were "short staffed" and did not offer groups consistent with the posted group calendar.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the hospital failed to ensure adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide necessary nursing care. This deficient practice poses a risk to the health and safety of patients when there is not an appropriate number of staff to ensure patient safety and necessary nursing care.

Findings include:

Policy titled "Plan for the Provision of Nursing" (Policy: 8808970) revealed: "...Staffing is based upon patient census and precaution levels. Staffing includes a mixture of RN's, LPN, a Unit Secretary, and nursing aides...the needs of each unit are evaluated on a shift or partial shift basis...Staffing adjustments, which may include additional staff...are made by the Director of Nursing or designee and schedules are updated as necessary...Variance between projected needs and actual staffing are described, acknowledged and justified according to census and acuity...."

Policy titled "Nursing Acuity Plan" (Policy ID#8821183; 09/2020), revealed: " ...The staffing and acuity plan are the hospital's method for establishing nursing personnel requirements needed to meet the patient needs/acuity...Each unit has a pre-determined core staffing patient to staff ratio used as a guideline. Staffing for patient care is based on acuity and level of care needed for the medical/psychiatric patient...nursing staff to evaluate the nurse-to-patient ratio...The Registered Nurse on each patient unit completes the acuity classification for each patient prior to the final determination of the next shift. It is the responsibility of the Registered Charge Nurse on the nursing unit to make the nurse staff/patient shift assignments ...."

Core Staffing Matrix per unit:

Inpatient Programs for Days (7am-7pm) - Includes weekends and holidays
1-8 Patients: 1 Nurse; 1 Aide/Tech
9-18 Patients: 2 Nurses; 2 Aides/Tech
19-24 Patients: 3 Nurses; 3 Aides/Tech

Inpatient Programs for Nights (7pm-7am) - Includes weekends and holidays
1-9 Patients: 1 Nurse; 1 Aide/Tech
10-20 Patients: 2 Nurses; 2 Aides/Tech
21-24 Patients: 3 Nurses; 3 Aides/Tech

At all times nursing administration has ultimate responsibility for providing adequate staff coverage...."

Hospital document titled "Day Shift Assignment Sheets" dated 07/15/2021, revealed one registered nurse was assigned to 14 inpatients with 3 Aides/Techs and a "backup person nurse". The patient acuity scores ranged from 1 -9.
Hospital document titled "Day Shift Assignment Sheets" dated 08/19/2021, revealed a patient census of 12 and no tech.
Hospital document titled "Day Shift Assignment Sheets" dated 08/19/2021, revealed a patient census of 11 and one registered nurse.
Hospital document titled "Day Shift Assignment Sheets" dated 08/24/2021, revealed a patient census of 9 and no tech.
Hospital document titled "Day Shift Assignment Sheets" dated 08/26/2021, revealed a patient census of 11 and one tech.
Hospital document titled "Day Shift Assignment Sheets" dated 08/30/2021, revealed a patient census of 14 and one tech.
Hospital document titled "Day Shift Assignment Sheets" dated 09/05/2021, revealed a patient census of 18 and one Aides/Techs.
Hospital document titled "Night Shift Assignment Sheets" dated 09/18/2021, revealed a patient census of 13 and one registered nurse.

Hospital document titled "Night Shift Assignment Sheets" dated 09/20/2021, revealed a patient census of 18 and no Aides/Techs.
Hospital document titled "Night Shift Assignment Sheets" dated 09/25/2021, revealed a patient census of 14 and one registered nurse.

Employee #10 confirmed during an interview conducted on 10/01/2021, that no core staff licensed staff was available to work and the visiting corporate staff provided nursing coverage on the dayshift for patient census of 13.

Based on record review and staff interview, it was determined the facility failed to ensure within their Emergency Preparedness plan that they incorporated documentation to include the needs of the patient population they serve or a delegation of authority as part of the continuity of operations. Failure to develop a continuity plan involving the patient population which includes delegation of authority and succession plans may cause disruption of services to patients/clients during an emergency which could lead to harm.

§482.15(a)(3)
[(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:
(3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the hospital has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.


Findings include:

Observation during review September 28, 2021 revealed .The facility was unable to locate any documentation addressing the needs of the patient population or a delegation of authority within the current written plan .

Employees #4 and #6 acknowledged during the exit conference that the facility was unable to locate any documentation addressing the needs of the patient population or a delegation of authority within the current written plan .

Based on review of the Emergency Plan (EP), facility record review, and interview, it was determined the facility failed to develop and implement emergency preparedness policies and procedures to describe its role in providing care at alternate care sites during an emergency. Failure to develop emergency policy and procedure at alternative care sites may cause harm to the residents during an emergency.

§482.15(b)(8).
[(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
(8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

Findings include:

During document review on September 28, 2021 it was revealed the facility's Emergency Plan related to the section which addresses policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Employee #4 and #6 confirmed or acknowledged during an interview that the facility EP plan did not include policies and procedures describing the facility's role in providing care and treatment at alternate care sites under an 1135 waiver.

Based on review of the facility Emergency Plan (EP) record review, and staff interview, it was determined the facility failed to develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must include contact information related to staff, entities providing services under arrangement, next of kin, guardian or custodian, other facilities and volunteers be reviewed and updated at least annually. Failure to have an emergency preparedness communication plan that includes specific information could lead to harm to both patients and staff.

Findings include:

Observation while reviewing the facilities Emergency Plan on September 28, 2021 revealed a communication plan that included contact information related to staff, and Physicians. The Emergency Plan did not include an emergency preparedness communication plan that included contact information related to entities providing services under arrangement, and other facilities.

Employee #4 and #6 confirmed the EP plan did not identify an emergency preparedness communication plan that included contact information related to entities providing services under arrangement, other facilities.

Based on review of the facility Emergency Plan (EP) record review, and staff interview, it was determined the facility failed to develop an emergency officials contact list. Failure to have an emergency officials contact list during an emergency could lead to harm to both patients and staff if specific Federal, State, tribal, regional, and local emergency preparedness staff or other sources of assistance are not known if the need to contact them should arise

§482.15(c)(2)
(c) The hospital must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:
(2) Contact information for the following:
(i) Federal, State, tribal, regional, and local emergency preparedness staff.
(ii) Other sources of assistance.

Findings include:

Observations during document review on September 28, 2021 revealed the facility failed to maintain a complete list of Federal, State, tribal, regional, local emergency preparedness staff and Other sources of assistance

Staff members #4 and #6 confirmed during the exit conference the facility failed to maintain a complete list of Federal, State, tribal, regional, local emergency preparedness staff and Other sources of assistance

Based on review of the facility Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to have a primary and alternate means of communication during an emergency. Failure to have a primary and alternate means of communication during an emergency could lead to harm to both patients and staff, if all involved in the emergency situation do not know how to communicate their needs to others in the community
.
(c) The hospital must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:
(3) Primary and alternate means for communicating with the following:
(i) [Facility] staff.
(ii) Federal, State, tribal, regional, and local emergency management agencies.
Findings include:

Observations during document review on September 28, 2021 revealed the facility's Emergency Plan documentation specifically the section related to requirements to identify a primary and alternate means of communicating with provider type staff or Federal, State, Tribal, Regional, and Local emergency management agencies during an emergency was requested. The Emergency Plan did not identify a primary and alternate means of communicating between the ASC's staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency.

Employee #4 and #6 confirmed during and interview the facility EP did not identify a primary and alternate means of communicating between staff or Federal, State, tribal, regional, and local emergency management agencies during an emergency.

Based on review of the Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.


482.15(c)(7)
[(c) The hospital must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years. The communication plan must include all of the following:
(7) A means of providing information about the hospital's occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.


Findings include:

Observations during EP review on September 28, 2021 revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Employee #4 and #6 confirmed during the exit interview that the EP plan for the facility did not include a method for sharing occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

Based on review of the facility Emergency Preparedness Plan, and staff interview, it was determined the facility failed to develop a facility based emergency planning, training and testing program. Failure to provide facility based training and testing tailored to the Emergency Plan may lead to untrained staff in an emergency situation and may result in harm to the patients during an emergency if staff are not aware of what is required by them to do, during an emergency situation.


§482.15(d)
(d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.


Finding include:

Observation while reviewing the facility's Emergency Plan (EP) documentation on September 28, 2021 revealed the documentation related specifically to the facility based training and testing for staff based on the Emergency Plan, facility risk assessment and the communications plan did not include facility based training for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Employee #4 and #6 confirmed during an interview the EP plan did not include facility based training for staff based on the Emergency Plan, facility risk assessment and the communications plan.

Based on review of the facility's emergency plan and staff interview, it was determined the facility failed to have the new and existing staff review the emergency preparedness plan. Failure to have staff review the emergency preparedness plan consistent with their expected roles may cause harm to the residents and/or staff during an emergency.

Findings include:

Observations, interview and record review made on September 28, 2021, revealed the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures. In addition the staff was questioned nobody was able to find the emergency preparedness policies or phone numbers of required numbers. The staff was not familiar the emergency Preparedness program and didn't recall receiving any training. The management was able to find their EP program.

Employee #4 and #6 acknowledged during the exit interview the facility failed to provide documentation that new and existing staff reviewed the emergency preparedness policies and procedures.