HospitalInspections.org

Based on a review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined the hospital failed to ensure:

Cross-reference: A0021: Allegations of suspected abuse against a minor residing in the facility were documented and reported to the appropriate authorities, including but not limited to the parents and guardians of the minor, the police department, and the Arizona Department of Child Safety.

Cross-reference: A0022: Policies and procedures related to transitioning a state-licensed pediatric inpatient unit and converting it to an overflow unit for adult inpatient psychiatric were in place.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the condition of Participation for Compliance with Laws requirements and provide a safe environment for patients to protect them from harm.

Based on a review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined the hospital failed to ensure allegations of suspected abuse against a minor residing in the facility were reported to the appropriate authorities. This deficient practice poses the risk of potential abuse occurring in the facility without the proper investigation and/or mandatory reporting to appropriate authorities taking place, including but not limited to the parents and guardians of the minor, the police department, and the Arizona Department of Child Safety.

Cross-reference tags: A-0020, A0145

Findings include:

The policy titled "Abuse and Neglect," received on 12/29/2022, identifies: " ...It is the policy of Sonora Behavioral Health Hospital (SBH) that any staff who witness or suspect a patient has been abused either physically or verbally will report such abuse to the appropriate authority IMMEDIATELY. This includes patient-to-patient, staff-to-patient ...Staff who witness or suspect the patient has been abused either physically or verbally will report such abuse to the Administrator on Call (AOC) IMMEDIATELY after notifying the appropriate authorities. This includes patient-to-patient or staff-to-patient abuse or neglect ...If the patient is an adolescent or an adult with a legal guardian, SBH will inform legal guardian of their right to contact law enforcement and will also provide them with the Pima County Sheriff's Office non-emergency phone number ...."

USC 5106a reveals: "...an assurance in the form of a certification by the Governor of the State that the State has in effect and is enforcing a State law, or has in effect and is operating a statewide program, relating to child abuse and neglect that includes- (i) provisions or procedures for an individual to report known and suspected instances of child abuse and neglect, including a State law for mandatory reporting by individuals required to report such instances...."

ARS 13-3620 identifies: " ...Any person who reasonably believes that a minor is or has been the victim of physical injury, abuse, child abuse, a reportable offense or neglect that appears to have been inflicted on the minor by other than accidental means or that is not explained by the available medical history as being accidental in nature ...shall immediately report or cause reports to be made of this information to a peace officer, to the department of child safety or to a tribal law enforcement or social services agency for any Indian minor who resides on an Indian reservation, except if the report concerns a person who does not have care, custody or control of the minor, the report shall be made to a peace officer only ...For the purposes of this subsection, "person" means: 1. Any physician, physician's assistant, optometrist, dentist, osteopathic physician, chiropractor, podiatrist, behavioral health professional, nurse, psychologist, counselor or social worker who develops the reasonable belief in the course of treating a patient ...6. Any person who is employed as the immediate or next higher level supervisor to or administrator of a person who is listed in paragraph 1, 2, 4 or 5 of this subsection and who develops the reasonable belief in the course of the supervisor's or administrator's employment, except that if the supervisor or administrator reasonably believes that the report has been made by a person who is required to report pursuant to paragraph 1, 2, 4 or 5 of this subsection, the supervisor or administrator is not required to report pursuant to this paragraph ...."

A hospital document titled "Incident Log," revealed for the dates 11/03/2022 through 12/21/2022, there were 13 incidents involving adolescents with the description of physical abuse by staff, misconduct/body exposure patient/patient, patient attacked other patient, boundary violation/issues-patient/patient and misconduct/body exposure patient/staff.

Of the 13 incidents described above, six of the Incident Report Forms were completed by RNs, one was completed by a behavioral health technician (BHT), one by a social worker, and three by the risk manager, with two of those listing RNs, social workers, and/or BHT's as witnesses to the event.

The hospital document titled "Incident Report Form,"
1. dated 12/06/2022, involving an allegation made by Patient #13, a minor patient, of physical abuse by a staff, revealed no family or guardian notification,
2. dated 12/10/2022, involving an allegation made by Patient #7, a minor patient, of physical abuse by a staff, revealed no family or guardian notification, and
3. dated 11/09/2022, involving Patients #8, #4, #15, and #16, minor patients, all the incidences were involving a patient attacking another patient, which resulted in a fight. The aforementioned documents further revealed that no contact was made with any of the family or guardians' for Patients #8, #4, #15, and #16.

Employee #1 confirmed in an interview on 01/03/2022, that the hospital does not notify the police or the Department of Child Safety when allegations of suspected abuse are made. The process for notifying allegations of suspected abuse for this facility is as follows: 1. The parents or guardians of the child are notified of the incident, 2. The police department's phone number is given to the parents or guardians of the child involved in the incident, and 3. The parents or guardians are responsible and are given the option to call the police department about the alleged or suspected abuse of a minor taking place in facility. Employee #1 further confirmed that staff including RNs, social workers, BHTs, and supervisors do not report any incidences of suspected abuse to appropriate authorities including but not limited to the police department or Department of Child Safety and only expected to inform the parents and guardians of the involved minors.

Based on the review of hospital documents, observations during a facility tour, and staff interviews, it was determined the hospital failed to ensure that policies and procedures related to transitioning a state-licensed pediatric psychiatric inpatient unit and converting it to an overflow unit for adult psychiatric inpatients were in place. This deficient practice poses the risk of not having appropriate emergency supplies and or other related equipment related to incidences for the specific patient population admitted in the state-licensed space designated as the pediatric psychiatric inpatient population as well as inappropriate provision of quality care to patient population admitted into the licensed area.

Cross-reference tag: A0020

Findings Include:

The hospital document titled "Sonora Behavioral Health Census-November" revealed the Rincon unit licensed by the state as a pediatric inpatient psychiatric unit had adult patients admitted from 11/01/2022 through 11/30/2022.

The hospital document titled "Sonora Behavioral Health Census-December" revealed the Rincon unit licensed by the state as a pediatric inpatient unit had the following admissions:
1. From 12/01/2022 through 12/07/2022 - Adult psychiatric inpatients
2. From 12/08/2022 through 12/20/2022 - Pediatric psychiatric inpatients
3. From 12/21/2022 through 12/29/2022 - Adult psychiatric inpatients

Observations during a tour of the facility on 01/03/2023, the Rincon unit a licensed pediatric psychiatric inpatient unit by the state has adult psychiatric inpatients admitted within the licensed space.

Employee #6 confirmed in an interview on 01/03/2023, that the Rincon unit is primarily used for pediatric patients and licensed by the state as a pediatric psychiatric inpatient unit. However, if there is a need for additional adult psychiatric beds, the pediatric psychiatric inpatients are moved to another unit, and the Rincon unit, licensed by the state as a pediatric psychiatric unit will be converted to an adult psychiatric inpatient unit.

Employee #8 confirmed in an interview on 01/03/2023, that there is no policy that is established, documented, and approved by the Governing Body regarding how to convert the Rincon unit to accommodate adult psychiatric inpatients. Further, Employee #8 confirmed that the Rincon unit is licensed as a 10-bed pediatric psychiatric inpatient unit.

Based on a review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined the hospital failed to ensure:

Cross-reference: A0144: 1. A patient's level of observation was changed from every 15 minutes to every five minutes per facility procedure after a patient-to-patient abuse incident occurred to prevent escalation. 2. The supervision of patients of the opposite sex/gender identification was not performed correctly.

Cross-reference: A0145: Documentation of potential sexual abuse or abuse in general in a patient's medical record.

Cross-reference: A0168: Each episode of restraint and/or seclusion of a patient has a medical practitioner order in place.

Cross-reference A0185: The use of restraints and/or seclusion were documented in a patient's medical record.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on the review of hospital policies and procedures, hospital documents, medical records, and staff interviews, it was determined the hospital failed to ensure:

1. A patient's level of observation remained unchanged from every 15 minutes to every five minutes per facility procedure after a patient-to-patient abuse incident occurred. This deficient practice poses the risk of creating an unsafe and non-therapeutic environment for patients in the facility.
2. The supervision of patients of the opposite sex/gender identification was performed correctly. This deficient practice poses the potential threat for inappropriate sexual conduct to occur between patients.

Cross-reference: Tag A0115

Findings include:

1. The hospital policy titled "Abuse and Neglect," received on 12/29/2022, revealed: "...Patient-to-Patient Abuse...The registered nurse will place the patient committing the offense on Q 5-minute observations or 1:1 observation...."

Observations of the documents for the incident reporting revealed that in incidences involving patient-to-patient abuse, the level of monitoring was unchanged from every 15 minutes to every five minutes per policy for the following patients:
1. 11/09/2022, identified Patients #4, #8, #16, and #15 were all involved in a physical altercation.
2. 12/09/2022, identified Patient #2 as committing an offense against another patient.
3. 12/09/2022, identified Patient #4 as committing an offense against another patient.
4. 11/08/2022 identified Patient #17 as committing an offense against another patient.

Employee #2 confirmed in an interview conducted on 01/03/2023 that the patients' level of monitoring for the aforementioned patients was not changed from every 15 minutes to every five minutes per the facility policy even after they were involved in potential patient-to-patient abuse allegations.

2. The policy titled "Room Assignments," received on 01/03/2023, revealed: " ...It is the policy of Sonora Behavioral Health to ensure patients who are assigned to a bedroom are compatible according to licensing and regulatory requirements, and according to the patient's ...gender ...."

The hospital documentation, dated 12/14/2022, identified: " ...On 12/14 patient asked BHT to go lay down in quiet {sic} room as [she] expressed [she] felt [she] was getting angry and needed a voluntary time out to avoid an outburst. [BHT] was conducting rounds and noticed patient {sic}sitting across the room from where [male] peer was sleeping. Following the round check patient, (Patient #4) approached the nursing station and made the allegation [a male] peer had pulled down [her] pants and assaulted [her] ...."

Observations during the tour of the unit conducted on 01/03/2023 revealed rooms delegated as seclusion rooms were used as quiet rooms. Further, the seclusion area has no cameras for video monitoring of patients that are in seclusion rooms. Two seclusion rooms that are adjacent to each other have an anteroom and a self-closing door, which could potentially lead to patients being unmonitored when they are placed on 1:1 monitoring or direct observation by a BHT is necessary.

Employee #1 confirmed in an interview conducted on 01/03/2023, that Patients #4 and #26 were both in different seclusion rooms on 12/14/2022 for quiet time. Employee #1 further confirmed that a BHT was assigned to check on Patients #4 and #26 as well as assigned to check on the other patients located in the day room, which is located in another area of the hospital. Employee #1 further confirmed that Patients #4 and #26 were behind a closed door without direct observation by the BHT during the time an allegation of potential sexual abuse occurred.

Based on the review of hospital policies and procedures, documents, medical records, and staff interviews, it was determined the hospital failed to ensure there was documentation of potential sexual abuse or abuse in general in a patient's medical record. This deficient practice poses the risk of not reporting, recording, documenting, and addressing timely incidences of potential allegations of abuse that occurred in the facility between patient-to-patient and staff-to-patient.

Cross-reference tags A0115, A0021

Findings include:

The hospital policy titled "Incident Reporting-Risk Management Program," received on 12/30/2022, revealed: " ...An "incident" is an unanticipated event which was not consistent with the standard of care and/or operation of the facility ...it results in, or nearly causes, a negative impact on a patient(s) receiving care at the facility ...If the incident involves a patient, staff must chart relevant information in the patient's medical record ...."

Observations made to the documents for incident reporting revealed no documentation of the incident was made in the medical records for the following patients:
1. 11/07/2022 Patient #11, the description of physical abuse by staff.
2. 11/08/2022 identified an incident involving Patient #14 and Patient #17, with the description of patient-to-patient misconduct or body exposure.
3. 11/27/2022 identified an incident involving Patient #19 and Patient #20, with the description of a patient attacking another patient.
4. 12/02/2022 identified an incident involving Patient #21 and Patient #22, with the description of a patient attacking another patient.
5. 12/16/2022, identified an incident involving Patient #1 and Patient #2, with the description of patient-to-patient misconduct or body exposure.
6. 12/20/2022, identified an incident involving Patient #12 attacking his/her roommate.
7. 12/20/2022, identified an incident involving Patient #9 and a patient who was only identified as the roommate, with the description of the patient attacking another patient. The patient accused of committing the offense could not be identified, therefore, no follow-up interventions could be verified.

Employee #5 confirmed in an interview conducted on 01/04/2023, that there were no notes documented in the medical records of patients who were involved in incidents with alleged or confirmed abuse.

Based on a review of hospital policy and procedure, medical records, and staff interviews, it was determined the hospital failed to ensure that each episode of restraint and/or seclusion of a patient has a medical practitioner order in place. This deficient practice poses the risk of patients being improperly restrained and/or placed in seclusion without adequate monitoring and supervision by a licensed independent practitioner.

Cross reference: Tag A0115

Findings Include:

Hospital policy titled "Seclusion and Restraint (Chemical and Physical)," received on 12/30/2022, revealed: "...Restraint may only be ordered by a licensed independent practitioner (LIP) ...A trained Registered Nurse may initiate restraint without an order in the absence of a Practitioner when a patient poses an imminent danger to self or other. The attending/covering Practitioner will be contacted during the restraint or immediately (within a few minutes) of the initiation of the restraint to confirm and obtain orders to be written by a registered nurse ...Seclusion may only be ordered by a LIP...."

The records of 19 instances of the use of chemical or physical restraints in adolescent patients were reviewed for the months of November and December 2022. There were 15 instances, (Patients #28, 29, 30, 31, 32, 23, 33, 34, 4, and 13), of physical restraint with no orders present and one instance of chemical restraint with no orders present.

A review of four instances of the use of seclusion in adolescent patients, for the months of November and December 2022, revealed three of these instances, (Patients #25, 27, and 4), did not have an order for seclusion.

Employees #5 and #2 confirmed in an interview conducted on 01/04/2023, that there were no orders present for the use of restraints and/or seclusion in the aforementioned medical records.

Based on a review of hospital policy and procedures, medical records, and staff interview,it was determined the hospital failed to ensure the use of restraints and/or seclusion were documented in a patient's medical record. This deficient practice poses the risk of patients requiring the use of restraint and seclusion not having adequate assessments, patients not being monitored appropriately during the seclusion and/or restraint episode, no evaluation of the use of the restraint and/or seclusion, and an incomplete history of the use of restraint and/or seclusion within the hospital.

Cross-reference tag: A0115

Findings include:

Hospital policy titled "Seclusion and Restraint (Chemical and Physical)," received on 12/30/2022, revealed: "...The RN will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion Assessment packet...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion Packet...Staff debriefing is to be documented on the Staff Team Debriefing Form. Restraint episodes will be documented on the following forms: Restraint/Seclusion Practitioner Order, RN Restraint/Seclusion Assessment, Restraint/Seclusion Progress Note, Restraint/Seclusion Flow Sheet, and Patient Debriefing. Restraint documentation will be completed no later than the end of the shift...."

A review of the use of restraint and seclusion in adolescents, taking place in November and December 2022, identified four patients, Patients #4, 23, 24, and 25, that had no restraint and seclusion packet documented.

Employees #2 and #5 confirmed in an interview on 01/04/2023, that the medical records for these patients were missing the Restraint/Seclusion Packet, which included all of the documentation required for restraints and seclusion.