HospitalInspections.org

Based on review of hospital policies and procedures, clinical records, hospital documents, records including committee meeting minutes and interviews, it was determined the Governing Body failed to assume responsibility for all hospital operations as determined by non-compliance with the following:

A-094: failure to assure that the medical staff has written policies and procedures which are in effect for the appraisal and management of patients' medical emergencies in the Palo Verde Behavioral Health units;

A-115: failure to protect and promote each patient's rights related to restraints and obtaining informed consent prior to medical procedures performed under anesthesia; and

A-263: failure to maintain an effective, ongoing-hospital-wide, data driven quality assessment and performance improvement program.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on review of hospital policy/procedure, medical record and interviews, it was determined that the hospital's governing body failed to assure that the medical staff has written policies and procedures which are in effect for the appraisal and management of patients' medical emergencies in the Palo Verde Behavioral Health units.

Findings include:

Review of hospital policy/procedure titled Medical Emergency Response and Resuscitation Classification revealed: "...Purpose...To provide appropriate medical emergency response for all persons...Emergency Response Teams...Also known as the Rapid Response Team...Called if an Inpatient, staff or visitor becomes unstable or the nurse is worried about the patient...Call 44444: Tell operator 'PIT Crew to Unit ____'...Code Team...Called for Respiratory Arrest or Cardiopulmonary Arrest (A Code may be called if patient is a pre-code also)...Call 44444...Call for Help...Call 44444 to call Code...Palo Verde will also call 911 for transport-TMC personnel will accompany patient if transferred to the Emergency Room...."

Review of Pt # 67's medical record revealed:

On 9/24/12, at 2021, an RN documented: "...this patient was found on the floor in the dayroom with a laceration to the forehead...911 was called and pt was transported by EMS (Emergency Medical Services) to the ED (Emergency Department) for treatment and medical clearance...Paramedics applied pressure and bandage. BHT (Behavioral Health Technician)...accompanied pt to ED...."

Pt # 67's medical record contained documentation completed by (name of ambulance) personnel and Fire Department personnel. Documentation included "Assessments," record of patient vital signs and narrative: "...Pt found at Palo Verde Hospital...Pt was assaulted by another pt. who slammed his head into a door jam...Pt's head was bandaged...by (fire department) and bleeding controlled...Pt was cooperative en route...pt care transferred to RN...in triage...."

The Associate Administrator of Clinical Practice confirmed, during interview conducted on 11/28/12 that the hospital Rapid Response Team does not go to Palo Verde because if the team was in the Palo Verde unit it would not be accessible to the main hospital building for a patient emergency. The Palo Verde staff is to call 911.

The Director of Nursing for Behavioral Health Services confirmed, during interview conducted on 11/28/12 that the hospital Rapid Response Team and/or Code Team does not provide emergency service to the Palo Verde unit. The staff is to call 911 for medical emergencies. A BHT accompanies EMS when the patient is transported to the ED. The Palo Verde Unit no longer has a "Code Cart" since the Code Team does not come to the unit.

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

A-131: ensure that informed consent was obtained from a minor child's parent(s) prior to performing a secondary procedure while the patient was under anesthesia (Patient #76);

A-144: ensure that all patients received care in a safe setting by failing to provide documentation of follow-up on a fire started by a staff member on the psychiatric in-patient unit; and failure to provide a safe environment free of fixtures, surfaces, and/or equipment conducive to patient self-injury or suicide on the psychiatric in-patient unit and the behavioral health annex in the Emergency Department;

A-154: ensure that restraints are used only to ensure the immediate physical safety of a patient, staff or others, and implemented according to hospital policies and procedures;

A-168: ensure that a physical escort restraint was perform in accordance with the order of a physician for Patient #69

A-176: develop and implement policies and procedures that specified required restraint training for physicians and other LIP's;

A-178: ensure that all patients who were restrained received the face-to-face evaluation by a physician, other Licensed Independent Practitioner, Registered Nurse, or Physician's Assistant (Patient #69);

A-194: ensure that staff utilized approved techniques/methods during the restraint of a patient who sustained a right fibular fracture during the restraint (Patient #72);

A-196: ensure there was documented training of all RN's who complete the initial face-to-face assessments of patients after initiation of restraints (Patients #68 and 72) and

A-205: ensure that hospital policies and procedures were followed to assess patients in restraints at least every two hours (Patient #19).

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on clinical record review, review of hospital policies and procedures, and interviews, it was determined for one patient (Patient #76), the hospital failed to require that informed consent was obtained from the minor child's parent(s) prior to performing a secondary procedure while the patient was under anesthesia.

Findings include:

The Hospital's Procedure #17.01.01 titled Consents included: "The Practitioner is responsible for: Obtaining informed consent for the patient or legal representative including identifying and explaining the procedures requiring informed consent to the patient. Documenting the patient has given informed consent. Disclosing to the patients information the patient needs to know, or should know, that would be regarded as significant by a reasonable person in the patient's condition and circumstances in order to accept or reject the proposed treatment or procedure...If the Practitioner contemplates secondary surgery or procedures during the course of the primary surgery or procedure, the specific consent form shall so state."

Patient #76, a pediatric patient, was admitted to the hospital's Ambulatory Surgery Center on 3/1/2012 for a scheduled bilateral hernia repair. The clinical record included the Consent form signed by the patient's parent prior to the surgery. The procedures consented to were: "Repair right inguinal hernia with peritonoscopy, possible left inguinal hernia." The surgeon's operative report included: "Procedure Name: Diagnostic laparoscopy with hernia repair - bilateral inguinal herniorrhaphy peritonoscopy...Counseled patient and received consent from patient prior to surgery." There was no documentation that there was any other licensed practitioner in the operating room who assisted the surgeon prior to, during, or after the procedure.

There was information provided to the Arizona Department of Health Services by an anonymous source that an additional procedure was performed on the pediatric patient without prior consent by the parent(s). That procedure was described as a "re-circumcision" of the patient.

A telephone interview was conducted on 11/28/2012 with the surgeon named on the operative report. The surgeon reported that after the pediatric patient was placed under anesthesia, the Nurse Practitioner who works with his medical group noted he had "filmy penile adhesions" and took the opportunity to "peel them back" while the patient was asleep. The surgeon reported he was not in the room at the time and was not aware that the Nurse Practitioner did this until he was contacted by the parent after the surgery. The surgeon reported it was not an invasive procedure that involved an incision but it is a procedure that he "typically would not do without parental consent."

A telephone interview was also conducted on 11/28/2012 with the Nurse Practitioner documented above. She acknowledged that she performed the procedure stating when she noticed the adhesions, it was "reflex" to "correct it." Her recollection of the incident was that the surgeon was present and aware of it at the time.

There was no documentation in the clinical record of the removal of the penile adhesions while the patient was in the operating room, nor documentation of prior discussion with and consent obtained from the parent(s) prior to the procedure. There was also no documentation in the operative report or perioperative record that the Nurse Practitioner was in the operating room at any time while the patient was there.

Based on review of hospital documents, policy/procedure, direct observation, and interview, it was determined that the hospital failed to ensure the patient's right to receive care in a safe setting as evidenced by:

1. failing to provide documentation of follow-up staff education and follow-up with individual staff member who started a fire in a Palo Verde microwave by heating a dry towel and incontinence pad to make a heating pad for a patient; and

2. failing to provide a patient care environment that is free of fixtures, surfaces, and/or equipment conducive to patient self-injury or suicide for all patients admitted to the Palo Verde Behavioral Health Units and the Palo Verde ED Annex.

Findings include:

1. Review of hospital document revealed a letter of notification to Arizona Dept of Health Services regarding an incident on 3/11/12 at 2200, when the fire alarm sounded at Palo Verde Mental Health Services-West unit: "...one of the BHT's was heating up a dry towel and incontinence pad in the microwave to make a heating pad for a patient which caught on fire...Patients were immediately evacuated from the unit at approximately 2210...Tucson Fire Department Engine 7 arrived at 2211...patients were escorted back onto the West unit without incident or injuries between 2300 and 2310...."

The hospital was unable to provide any documentation related to staff education or follow-up with the employee who created the fire hazard.

2. Review of hospital policy/procedure titled TMCH Safety Procedures: Subject: TMCH Commitment to Safety revealed: "...To assure that the environment is maintained in a safe manner for all patients, visitors, and staff...Hazard: A condition or situation existing within the working environment that is capable of causing harm, injury, and/or damage...Procedure: 1. TMCH will make every reasonable effort to provide an environment free of recognized hazards to our patients...."

The surveyor directly observed the following environmental safety hazards while on site in Palo Verde during tour conducted 11/27/12:

Exposed plumbing fixtures on the toilet and exposed pipes under the sink in a patient bathroom located on Palo Verde East. These fixtures and pipes provide ligature surfaces and present hazards for use by patients for self harm and/or suicide.

During tour conducted on 11/27/12, the Administrator of Palo Verde Behavioral Health confirmed that all 26 patient bathrooms throughout Palo Verde are equipped with the same fixtures and pipes.

On 11/28/12, the surveyor also directly observed exposed plumbing fixtures on the toilet in the Palo Verde ED Annex bathroom and a style of door handle which includes approximately 1.5 to 2 inches of ligature surface in the bathroom.

Based on review of hospital policy/procedure, medical records, hospital documents and interviews, it was determined that the hospital failed to ensure that restraint is used only to ensure the immediate physical safety of a patient, staff or others, and is implemented according to hospital policy and by hospital staff utilizing approved hospital restraint devices.

Findings include:

Review of hospital policy/procedure titled Transportation of Palo Verde Mental Health Patients revealed: "...This procedure is to establish the methods for transporting patients from Tucson Medical Center to Palo Verde Mental Hospital. This procedure will also address transporting patients from Palo Verde Mental Hospital Inpatient units to Tucson Medical Center...All security officers involved in the transportation of patients, to and from Tucson Medical Center and Palo Verde Mental Hospital will remove and secure their handcuffs before contact is made with the patient to be transported...Security will transport all patients leaving...ER Annex to go to PVH (Palo Verde Hospital)...When transporting Petitioned Patients one officer should be in front of patient and one behind, while walking patient in and out of building at a distance that discourages elopement, but that does not encourage assault...."

The Associate Administrator of Clinical Practice confirmed on 11/28/12, that Palo Verde is a unit of the medical center. It is not a separate hospital.

Review of hospital policy/procedure titled Restraint revealed: "...Skill level: RN, CNP, CNA, PCT, BHT, Paramedic...To protect a patient's right to be free from restraint/seclusion, or any restraint imposed as a means of coercion, discipline, convenience, or retaliation by staff...Forensic and correction restrictions used for security...refer to 'Care of the patient in custody of law Enforcement'...."

The Restraint policy did not contain any approved use of police officers or handcuffs for restraint and or transport of admitted patients, who are not prisoners or in police custody, to a unit of the hospital.

Review of Pt # 69"s medical record revealed:

Documentation of EMS transport of the patient to the hospital: "...At destination 00:02 06/12/12...."
At 0012, on 6/12/12, an ED RN documented: "...Reason for visit...SI (Suicidal Ideation), possible overdose on Xanax, pts wife petitioning pt for SI...Had standoff with police since 1 pm...."

At 1937, on 6/12/12, a Palo Verde ED Annex RN documented: "...Patient continues to pace and demand...we are holding him against his will, pt is petitioned...Patient waiting to transfer to PVH (Palo Verde Hospital) East Unit...."

At 2007, a Palo Verde ED Annex RN documented: "...Patient transferred to PVH East Unit...."

Review of Security Services report revealed: "...At 1930 on 6/12/12...searched for a petitioned patient that ran from security vehicle west bound...."

At 2148, on 6/12/12, a Palo Verde ED Annex RN documented: "...Patient transferred from Triage after returning...with TPD (Tucson Police Department). Patient with superficial abrasions to right knee and soles on both feet...."

At 0324, on 6/13/12, a Palo Verde ED Annex RN documented: "...Patient transferred to PVH East unit...." The medical record did not contain documentation that the patient was in the custody of police at the time of transfer or a prisoner of the police.

A Palo Verde RN documented on 6/13/12 at 0429: "...Admitted...male...was petitioned by his wife...."

Review of Security Services Daily Radio Log, 06/13/12, at 0338 revealed: "...Transport completed prior to arrival...TPD transports patient from annex to PVH...."

Security Officer # 44 confirmed during interview conducted on 12/4/12, that TPD transported Pt # 69 to PVH from the ED Annex.

The Director of Clinical Informatics confirmed during interview conducted on 12/5/12, that the medical record did not contain documentation regarding the mode of transport from the Palo Verde ED Annex to PVH. She also confirmed that the medical record did not contain a physician's order for the patient to be transported by police.

RN # 21 confirmed during interview conducted on 12/2/12, that the Palo Verde ED Annex RN determines the method of transport between the ED Annex and Palo Verde. She stated that she has never been offered an option to transport patients by means other than Security. If the patient is petitioned and refuses to go to Palo Verde, TPD transports the patient and usually applies handcuffs.

Review of Pt # 66"s medical record revealed:

The patient arrived at the ED on 9/20/12 at 1602 and Triage was completed at 1619. On 9/20/12 at 1832, an LCSW documented in the Psycho-Social Evaluation Note: "...female...brought to the emergency department by a friend for suicidal ideation and an attempt to stab herself with a knife...was disoriented and hallucinationing (sic)...initially non-verbal...recently gave birth to a baby girl...."

On 9/21/12 at 0016, a Palo Verde ED Annex RN documented: "...Pt now refusing to go to PVH...She then sat up and said, 'Okay, I go'...She was escorted with officers, but then refused to get into vehicle so she was brought back to PV Annex...No PV Annex evaluator available to start petition process at this time...."

The medical record contained a form titled Application for Emergency Admission for Evaluation, dated 9/21/12.

On 9/21/12 at 0312, a Palo Verde ED Annex RN documented: "...Pt resting quietly in no acute distress...."

On 9/21/12 at 0500, a Palo Verde RN documented: "...pt was brought to unit with 3 male staff, one escorted pt to unit in handcuffs...."

Review of Security Services report revealed: "...Date/Time Reported 09/21/2012 0424...I, S/O (Security Officer)...was dispatched to PV annex for a patient transport...Staff stating that the patient (Pt # 66) is petition (sic) and refusing to leave. At that time Tucson Police was to transported (sic) the patient to PVH West Unit. Officer...arrive to transport the patient. At that time Officer...place handcuffs on (Pt #66) and transported the patient with security to PVH West...."

The Director of Security confirmed during an interview conducted on 12/2/12 at 1615 that Palo Verde ED Annex staff decide if a patient needs police transport. If the patient is transported by police, Security follows in their vehicle. Police determine if handcuffs are necessary.

RN # 21 confirmed during interview conducted on 12/2/12, that neither the ED physician, nor the admitting psychiatrist determine the method of transport from the Palo Verde ED Annex to Palo Verde. She has never observed a patient to be transported by any other means than Security or TPD.

The Director of Clinical Informatics confirmed during interview conducted on 12/4/12 that Pt # 66's medical record did not contain nursing documentation between 9/21/12 at 0312 and 9/21/12 at 0500. It did not contain documentation of the method of transport or a physician's order for the patient to be transported by police. The medical record did not contain documentation that the patient was in police custody or a prisoner.

Security Officer # 25 confirmed during interview conducted on 12/4/12, that TPD is called to transport admitted, petitioned patients who are not cooperative, because TPD can use handcuffs. If TPD is involved, the patient rides in the police car and TPD decides whether to apply handcuffs. Hospital Security follows in the Security vehicle. Patients who are transported to another hospital are transported by ambulance.

Security Officer # 44 confirmed during interview conducted on 12/4/12, that TPD are allowed to use handcuffs on admitted, petitioned patients in their transport capacity.

The Director of Claims stated during interview conducted on 12/5/12, that she was not aware that patients admitted to the medical center are transported between the ED and a hospital unit by police and in handcuffs. However, she confirmed that the use of handcuffs for psychiatric patients may be a safe method of transport.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 12/5/12, that nursing maintains responsibility for the patient during transport when police officers determine the use of handcuffs for petitioned patients who are not in police custody.

The Associate Administrator of Clinical Practice confirmed on 12/5/12, that the hospital does not have a policy/procedure for use of police to transport admitted patients between the hospital ED and an inpatient unit.

Based on review of hospital policy/procedure, medical record and staff interview, it was determined that the hospital failed to require that the use of physical restraint via physical escort be in accordance with the order of a physician or other licensed independent practitioner for 1 of 1 patient escorted to the Palo Verde ED Annex after an elopement attempt (Pt # 69).

Findings include:

Review of hospital policy/procedure titled Restraint revealed: "...Definitions...Restraint...Any method, (physical, mechanical, or chemical) that reduces the ability of a patient to move his/her arms, legs, body, or head freely...Violent/Self-destructive restraints...The restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others...Restraint shall be ordered by an (sic) LIP (Licensed Independent Practitioner)...Violent or Self-Destructive Behavior Restraint...Time-limited written order for restraints must be obtained from an (sic) LIP...Types of restraints used at Palo Verde are physical hold, chemical, 4-point locked Velcro restraints, and/or seclusion...."

Review of Security Services report revealed: "...6/12/2012 1745...At 1745 on 6/12/2012, I...informed security that a petitioned patient escaped out of the emergency annex front door that staff member...the social worker accidentally allowed out...started searching the area and received a report from triage staff that nurse...patient care techs...used the Two person Crisis Prevention Intervention (CPI) escort to bring him back from the lobby area to the emergency annex...Ofc...assisted standing by in the area as (Pt # 69) was put back in bed 3...."

The Associate Administrator of Clinical Practice confirmed during interview conducted on 12/4/12, that the CPI escort is a method of restraint.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 12/4/12, that the CPI escort is a method of restraint.

Review of Pt # 69's medical record revealed that it did not contain documentation of the restraint escort or order for restraint.

The Director of Clinical Informatics confirmed during interview conducted on 12/4/12, that Pt # 69's medical record did not contain documentation of the restraint or order for the restraint.

Based on review of hospital policy/procedure, Professional Staff Rules, Regulations and Bylaws, Psychiatrist Position Description and interview, it was determined that the hospital failed to specify required restraint training for physicians and other LIPs.

Findings include:

Review of the hospital policy/procedure Restraint revealed that it did not contain any information regarding required restraint training for physicians and/or other LIP's.

Review of the Position Description for Job Title Psychiatrist revealed that it did not contain any information regarding required restraint training for psychiatrists.

Review of the Professional Staff Rules, Regulations and Bylaws revealed that they do not contain information regarding required restraint training for physicians and/or other LIP's.

Review of the Behavioral Health Procedure: Subject: Behavioral Health Non-Violent Crisis Intervention Training revealed that the procedure does not list physician requirements for training specifically. This procedure does include: "...the Behavioral Health Unit requires all clinical staff to successfully complete annual nonviolent Crisis Intervention Training (CIT)...."

The Administrator of Palo Verde Behavioral Health confirmed during interview conducted on 11/28/12, that all of the psychiatrists employed in Behavioral Health order restraints and none of the psychiatrists have documentation of current training provided by the hospital.

Based on review of hospital policy/procedure, medical record and staff interview, it was determined that the hospital failed to require that a patient be seen and evaluated face-to-face within 1 hour after a physical restraint via escort by a physician, other licensed independent practitioner, RN or Physician's Assistant for 1 of 1 patient physically escorted to the Palo Verde ED Annex after an elopement attempt (pt # 69).

Findings include:

Review of the hospital policy/procedure titled Restraint revealed: "...Violent or Self-Destructive Behavior Restraint...An LIP/trained RN must assess the patient face-to-face within one hour of initiation of the restraint...."

Cross reference Tag # 0168 for information regarding the escort utilized to return Pt # 69 to the Palo Verde ED Annex when he "escaped" and confirmation that the escort is a restraint.

Review of Pt #69's medical record revealed that it did not contain documentation of the required face-to-face assessment within one hour of initiation of the restraint escort.

The Director of Clinical Informatics confirmed during interview conducted on 12/4/12, that Pt # 69's medical record did not contain documentation of the required assessment within one hour of initiation of restraint.

Based on review of hospital policy/procedure, medical record and staff interviews, it was determined that the hospital failed to ensure that staff utilize approved techniques/methods in the physical escort of 1 of 1 Behavioral Health patient who sustained a nondisplaced spiral fracture of the right fibula during restraint (Pt # 72.)

Findings include:

Review of hospital procedure titled "Behavioral Health Procedure...Subject: Behavioral Health Non-Violent Crisis Intervention Training" revealed: "...the Behavioral Health Unit requires all clinical staff to successfully complete annual non-violent Crisis Intervention Training (CIT). Certification consists of a CIT course for newly-hired employees, followed in every subsequent year of employment by a refresher class that reviews verbal and physical non-violent crisis intervention skills. CIT training is mandatory for staff to be able to work unsupervised, and is the only technique approved for use by Behavioral Health staff...Behavioral Health staff will use only CIT methods when dealing with individuals who physically act-out or who, by threat, present a clear and present danger to themselves or others that may warrant physical intervention when less restrictive methods fail...deviation by staff from CIT standards/practice may result in disciplinary action...."

The Associate Administrator of Clinical Practice confirmed during interview conducted on 12/4/12, that the CPI escort is a method of restraint.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 12/4/12, that the CPI escort is a method of restraint.

Review of Pt # 72's medical record revealed:

A Physician Assistant documented on 6/3/12 at 2359: "...patient presents to the emergency room...right ankle pain...While he was at Palo Verde he was involved in a take down and now presents to the emergency room...Discussion...X-ray obtained and patient noted to have spiral nondisplaced fibula fracture...."

Cross reference Tag # 0196 for information regarding the escort utilized for Pt # 72.

The Director of Nursing for Behavioral Health Services stated during interview conducted on 11/26/12, that the hospital was unable to determine when the patient actually sustained the fracture. The BHT and the patient fell, the patient was escorted to the unit and the patient was placed in 4 point restraints while he was kicking.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 11/26/12, that the "CPI" (Crisis Prevention Institute) method of nonviolent crisis intervention was adopted by Behavioral Health Services approximately 2 years ago for training of staff. She provided copies of 2 training booklets. One booklet was titled "participant workbook...nonviolent crisis intervention...a CPI specialized offering." The other booklet was titled "APT Applied Physical Training...Refresher Workbook for Review of the Nonviolent Crisis Intervention Training Program...cpi...Crisis Prevention Institute."

The Director of Security and Security Officer # 27, a CPI Instructor, confirmed during interview conducted on 11/27/12, that Officer # 27 teaches a reverse escort. They stated that the hospital utilized a method of crisis intervention previously which included a reverse escort. The hospital continued the use and training for use of this escort in addition to the current (forward) CPI transport position/method.

BHT # 28, a CPI Instructor, confirmed during interview conducted on 11/28/12, that he does not teach the reverse escort method from the previous crisis intervention training. He teaches the CPI transport position/method, reversed, in addition to the CPI transport method included in the workbook. He stated that his training method and Officer # 27's training method may be different and the trainers do not document whether staff received training in the reverse escort.

RN Educator # 29, a CPI Instructor, confirmed during interview conducted on 11/27/12, that she teaches CPI for the Behavioral Health staff as well as the general hospital staff. She stated that she and the other RN Educator/CPI Instructor do not include a reverse escort in their CPI training since it is not included in the CPI manuals.

Behavioral Health RN # 18 stated during interview conducted on 11/27/12, that Behavioral Health staff do not use a reverse escort currently. S/he stated that staff is not permitted to use the reverse escort.

BHT # 41 stated during interview conducted on 11/27/12, that he recently attended a CPI refresher class and the instructor taught a reverse escort.

Review of both training booklets revealed that neither booklet contained a reverse escort method.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 11/28/12, that for patient safety, the hospital needs to provide consistent standardized training of crisis intervention skills and document the training. Staff receive cards, which provide documentation of CPI training, but since reverse escort is not part of the standard CPI training, additional documentation is needed, if the hospital continues with the reverse escort.

Based on review of hospital policy/procedure, medical records and staff interviews, it was determined that the hospital failed to require documented training of RN's who complete the initial face to face assessment of a patient within one hour after initiation of restraint intervention per policy, for 2 of 2 patients secluded and/or restrained for violent or self-destructive behavior (pt's # 68 and 72).

Findings include:

Review of the hospital policy/procedure titled Restraint revealed: "...Definitions...Trained RN...RN that has completed the 'Verbal de-escalation/face-to-face assessment class' and is trained to:...Assess the physical and psychological status of the violent/self destructive patient...Determines whether the restraint should continue...identifies ways to help the patient regain control by verbal de-escalation skills...Violent or Self-Destructive Behavior Restraint...An LIP/trained RN must assess the patient face-to-face within one hour of initiation of the restraint...Types of restraints used at Palo Verde are physical hold, chemical, 4-point locked Velcro restraints, and/or seclusion...."

Review of Pt # 72's medical record revealed:

On 6/3/2012 at 0826, Behavioral Health Technician (BHT) # 13 documented: "...Writer was struck several times in the face while physically restraining patient...patient was escorted back to unit with a two person reverse escort...Attempted to kick staff several times while being restrained to the bed...four point restraints were applied...."

On 6/3/12 at 0800, RN # 18 documented: "...At 0845, this writer performed a Face to Face assessment...."

Review of Pt # 68's medical record revealed:

On 9/24/12 at 2319, an RN documented a Chemical Restraint and Progress Note: "...During change of shift loud noises were heard down the hall by the Sunrise day room. Patient reportedly assaulted another male patient; peer group stated he grabbed male peer...by scrub top and twisted it pulling him up in the air and then threw him against the door very hard lacerating his forehead...Escorted to the BCR (Behavioral Control Room) by staff security...Walked on his own accord...Face to face assessment performed @ 2000...Door remains unlocked and open with staff present...Order obtained...Zyprexa zydis 10 mg. Po (by mouth)...He has required two male staff to be with him while awake...(MD # 1) called back at 2055...orders for IM (intramuscular) medications obtained and given...."

Review of RN's # 18 and 45 personnel files revealed that they did not contain documentation of training to perform the face-to-face assessment required within one hour of initiation of patient restraint for violent or self-destructive behavior.

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 11/28/12, that the hospital was unable to provide documentation of the training of RNs #18 or 45 to conduct the one hour face-to-face assessment of the patients as required by hospital policy. In addition, she confirmed that 23 Palo Verde RN's are currently performing the one hour face-to-face assessment of patients after restraint for violent or self-destructive behavior and the hospital has no documentation of the training for 22 of the RN's.

Based on review of hospital policy/procedure, medical records and staff interviews, it was determined the facility failed to ensure that hospital policies/procedures that cover restraints are implemented, as evidenced by failing to ensure that patients placed in protective restraints were assessed every 2 hours while in restraints for 1 of 2 patients reviewed (Pt # 19).

Findings include:

The facility Restraint policy and procedure #17.03.19 effective 11/14/2012, included: "Purpose:...To eliminate the 'inappropriate use' of restraints if it becomes necessary to restrict patient movement in order to provide medical treatment and/or to keep a patient or staff safe from injury by...Avoiding patient injury of restrained patient by frequent monitoring...Documentation: Document assessments in the electronic medical record using the appropriate restraint navigator/flowsheet. Document rationale for restraint (observed condition or behavior) initially and at least every two (2) hours. Document assessments in the appropriate restraint navigator initially and at a minimum every two (2) hours on the even hours until discontinuation...."

A review of the medical record revealed Patient #19 was admitted to the facility on 07/06/12, with metastatic breast cancer, status/post pleurodesis 2 months ago with progressive B pleural effusion, pericardial effusion and had a pericardial window (cytology positive).

The discharge summary from 07/11/12, revealed: "Patient #19 failed extubation and was ventilator dependent, family finally decided to withdraw support due to her poor prognosis."

Review of the restraint nursing notes revealed Patient #19 was restrained on 07/10/12, at 0130 hours, for pulling at her tubes and Intravenous line. The patient had an endotracheal tube, chest tube, foley catheter, and central line - Portacath. Restraint documentation required every 2 hours was filled out for 0206 hours and 0800 hours, but nothing was found for 0400 hours or 0600 hours.

The restraints were removed at 10:15 a.m. on 07/11/12, and the patient expired at 13:04 p.m. on 07/11/12.

The Nursing IT Specialist verified the restraint documentation was not found for Patient #19 at 0400 hours and 0600 hours on 07/10/12.

The "ACCU" (Acute Cardiac Care Unit) Manager verified the night RN was missing two 2 hour monitoring columns and notes were not completed on 07/10/12, at 0400 hours and 0600 hours.

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

A-273: identify and analyze their current practice of:

1. turning over the care of in-patient psychiatric patients in the Emergency Department to Tucson Police Department for transportation to the hospital's in-patient psychiatric unit. Some of the patients were hand-cuffed during transport; and

2. calling "911" for an emergency and turning over the care of in-patient psychiatric patients on the Palo Verde unit to Emergency Medical Services personnel to relocate the patients to TMC's ED.

A-286:
1. identify and analyze the discharge of a behavioral health patient in the ED with no assessment of transportation needs (Patient #75). The patient had no money, the family was not contacted, and the patient walked 5.5 miles home in 106 degree weather; and

2. record numerous complaints regarding patient #74's care received by a nurse manager who failed to document into the hospital's quality alert system in accordance with hospital policies and procedures.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on record reviews, hospital policies and procedures, reports and records of the hospital's Quality Assurance/Performance Improvement Program, and staff interviews, it was determined the hospital failed to identify and analyze their current practice of:

1. turning over the care of in-patient psychiatric patients in the Emergency Department to Tucson Police Department for transportation to the hospital's in-patient psychiatric unit. Some of the patients were hand-cuffed during transport; and

2. calling "911" for an emergency and turning over the care of in-patient psychiatric patients on the Palo Verde unit to Emergency Medical Services personnel to relocate the patients to TMC's ED.

Findings include:

1. Refer to Tag A-154 for specific details related to the hospital's current practice of releasing the care of psychiatric patients in the ED who were admitted to be in-patients on the hospital's psychiatric unit to Tucson Police Department for transportation from the ED to the in-patient unit. Documentation in clinical records and security reports revealed some of the patients were hand-cuffed by the police during transport.

2. Refer to Tag A-094 for specific details related to the hospital's current practice of handling medical emergencies in their in-patient psychiatric unit. The hospital's current practice is for the staff on the unit to call 911 and care of the patient is turned over to EMS personnel when they arrive to relocate the patient to TMC's ED. The psychiatric in-patient unit has no "code cart" and the hospital's code response team does not go to the unit.

The hospital had no policies and procedures that addressed these practices and there was no documentation in the quality reports and meeting minutes that addressed the practices.

The Director of Claims Management stated during an interview on 12/5/2012, that she was not aware of the practice of Tucson Police Department transporting psychiatric in-patients from the ED to the psychiatric unit and hand-cuffing patients at times. She stated she thought the use of hand cuffs for psychiatric patients may be a "safe method" of transport.

Based on record reviews, policy and procedure reviews, and staff interviews, it was determined:

1. for Patient #75, the hospital failed to identify and analyze the behavioral health patient's discharge from the Emergency Department without assessing the need for transportation. The patient had no money and walked 5.5 miles home in 106 degree heat; and

2. for Patient #74, numerous complaints regarding patient care received by a nurse manager were not recorded into the hospital's quality alert system in accordance with hospital policies and procedures.

Findings include:

The hospital's Procedure #: 01.01.02, Effective Date 08/18/2008, titled, Patient-Related Complaints, Grievances and Service Recovery, included the following: "Definitions: Complaint: A verbal or written complaint is not a grievance if a patient (or patient representative) makes a complaint that relates to the patient's care and hospital personnel can or could have promptly resolved the complaint if brought to their attention...Any staff member who becomes aware of a patient who is dissatisfied with any aspect of their care or treatment should take the necessary action to promptly resolve the complaint...If resolution can not be reached immediately by staff present, the complaint should be brought to the attention of the supervisor or person in charge of the department. All complaints escalated to a supervisor or manager need to be entered into the QAS (Quality Alert System)...Complaints and grievances are tracked, trended and reported following the Quality Assurance/Process Improvement structure within TMC."

The hospital's Procedure #: 08.03.00, Effective Date 04/19/2011, titled Reporting Patient Safety Events, included: "This procedure outlines the process for reporting patient safety concerns, errors, quality concerns, system breakdowns or any event that has either adversely impacted a patient or has the potential to do so. Reportable events are tracked as part of the hospital quality assurance/process improvement function with the goal of preventing reoccurrences or similar occurrences in other areas and improving patient safety...Reportable Events...Any occurrence which negatively impacts patient safety or has the potential to should be reported as a quality alert...Managers or their delegates investigate the event details with staff involved, review the chart or other appropriate documentation, confer with other departments involved and implement corrective actions or preventative measures to reduce the likelihood of the event happening again. The investigation and follow-up is entered into the system...On a routine basis, Quality Alerts are reviewed through the quality assurance/process improvement structure."

1. Patient #75 was taken to the hospital's ED on 6/20/2012 at 10:57 a.m. The patient was triaged by the Registered Nurse (RN) at 11:04 a.m. who documented the patient's reason for visit: "Patient states he feels afraid of people. He denies SI or HI. Report of some paranoia. Thought he was being poisoned yesterday. Sisters are present. Complaint of face itching. Recent change in medication, thyroid and insulin." The patient's documented height was 5-feet 6-inches, and his weight 251 pounds.

The patient was evaluated by an ED physician whose documentation included: "...male with history psychiatric illness with concern for change in symptoms according to family members patient with no suicidal or homicidal ideation patient with history of diabetes glucose well-controlled taking medications as prescribed. Patient is medically cleared for psych."

A psychological exam was performed by a Behavioral Health Therapist at 12:34 p.m. whose documentation included: "Final Disposition: This patient's functioning has been determined to NOT require admission to Palo Verde Hospital...Pt is not a danger to self or others, his paranoia is at baseline. Per case discussed with Dr. (name of psychiatrist) pt does not meet criteria for inpatient psychiatric treatment...Pt was discharged home, given referral...."

Documentation in the clinical record revealed the patient left the ED at 12:48 p.m. and was accompanied by "Family;Sibling." However, that was not true, as the patient left alone and his family was not contacted prior to his discharge as documented below.

A telephone interview was conducted with the patient's family who transported him to the ED on 6/20/2012 for evaluation of his increased confusion and change in mental status. She reported family accompanied the patient through the triage process and was told by the triage RN that she would not be able to stay with the patient during the evaluation which would take "a couple of hours." The RN told the family they could leave and they would be called when the evaluation was completed. Family members left and awaited a call from the hospital. After a period of time went by without a call, family contacted the hospital ED and was told the patient had been discharged and they did not know where he was and could not give them any information because of "HIPAA" (Health Insurance and Portability Accountability Act...The family member reported he had approximately $3.00 in his pocket and it was 106 degrees outside on that day. Family members went back to the ED but again were told they could not provide any information because of HIPAA. The family contacted the local bus-line as well as the Tucson Police Department who also went to the ED to inquire about the patient and then issued a "Be on the look-out" alert for the patient. The patient arrived home at approximately 6:30 p.m., over five hours later after walking 5.5 miles from the hospital to home in 106 degrees.

There was no documentation in the clinical record of the above nor other hospital record/report that both the patient's family members and Tucson Police Department went to the ED after the patient was discharged, concerned for his health and welfare.

An interview was conducted on 12/4/2012 with the Behavioral Health Therapist who performed the psychological evaluation on the patient. The Therapist reviewed the clinical record with the surveyor and said he recalled the patient as well as the family members and Tucson Police Department showing up in the ED after the patient's discharge. The surveyor asked the Therapist why family members were not contacted prior to the patient's discharge and he responded that the patient did not want family members called but acknowledged he did not document that in the record. He said he usually asks patients about transportation, and, in fact, the hospital provides taxi vouchers when needed, however, he acknowledged there was no documentation that he addressed the patients transportation needs at the time of discharge. He reported he "heard" that the patient did make it home and he was "fine." He acknowledged there was no documentation of the patient's family or Tucson Police Department coming to the ED inquiring about the safety of the patient, however, that would be the responsibility of the nursing staff or House Supervisor.

Hospital administration had no documentation of the incident or evidence that the patient's discharge was analyzed to ensure policies and procedures were developed and implement for a safe discharge from the ED.

2. Documentation provided to the surveyors by Hospital administration included quality assurance/performance improvement reports related to patient complaints/grievances. One of the reports included a letter dated 5/30/2012 addressed to the hospital's Chief Executive Officer and included concerns from family regarding the care and services provided to Patient #74 who was an inpatient from 4/10/2012 to 4/18/2012. The letter referenced a meeting with the "director of nursing" who wrote down the "many" issues presented by the family. There was no additional documentation of what the issues where and whether or not they were investigated and resolved.

An interview was conducted on 11/29/2012 with the Manager of Patient Relations who was responsible for coordinating the investigation and follow-up with patient/family complaints/grievances. The Manager of Patient Relations stated she was not aware of any complaints related to Patient #74 other than what was documented in the original letter.

An interview was conducted on 12/3/2012 with the Nurse Manager (referred to as "director of nursing" in the letter). The Nurse Manager acknowledged meeting with the family and stated there was a list of concerns she recorded but were not included with the above report. She located the list which was dated 4/16/2012 and itemized twelve "concerns" including patient rights, nursing care, cleanliness, administration of insulin, insulin left at the bedside, restraints, and therapy services. She said the list was placed in two employee personnel records because they were involved with some of the concerns. She reported she did not document the issues in the hospital's quality alert system.

Based on review of the hospital Professional Staff Rules, Regulations and Bylaws, clinical records, hospital policies/procedures, staff interviews and review of the Position Description for Psychiatrist, it was determined that the hospital medical staff failed to enforce bylaws/rules and regulations as evidenced by:

1. the care and discharge of behavioral health patients in the Emergency Department (Pt #75); and

2. 1 of 1 behavioral health inpatient admitted on a Title 36 Petition for danger to self and others who eloped from the hospital (Pt # 65).

Findings include:

1. Documentation in the hospital's Professional Staff Rules and Regulations included: "1.10 Discharge of Patients. Patients shall be discharged only upon the written order of the attending practitioner except under the disaster conditions set forth in the Hospital disaster manual. 2.20.1.1 Any patient who presents himself to the Emergency Services Department for care and who also does not specify or request a private attending practitioner is automatically the responsibility of the Emergency Services Practitioner for care. The patient will be referred to the appropriate specialty practitioner from the list of 'on-call' practitioners for follow-up or continuing care...."

Patient #75 was taken to the hospital's ED on 6/20/2012 at 10:57 a.m. The patient was triaged by the Registered Nurse (RN) at 11:04 a.m. who documented the patient's reason for visit: "Patient states he feels afraid of people. He denies SI or HI. Report of some paranoia. Thought he was being poisoned yesterday. Sisters are present. Complaint of face itching. Recent change in medication, thyroid and insulin."

The patient was evaluated by an ED physician whose documentation included: "...male with history psychiatric illness with concern for change in symptoms according to family members patient with no suicidal or homicidal ideation patient with history of diabetes glucose well-controlled taking medications as prescribed. Patient is medically cleared for psych."

A psychological exam was performed by a Behavioral Health Therapist at 12:34 p.m. whose documentation included: "Final Disposition: This patient's functioning has been determined to NOT require admission to Palo Verde Hospital...Pt is not a danger to self or others, his paranoia is at baseline. Per case discussed with Dr. (name of psychiatrist) pt does not meet criteria for inpatient psychiatric treatment...Pt was discharged home, given referral...."

There was no physician's order in the clinical record to discharge the patient home.

An interview was conducted on 12/4/2012 with the Behavioral Health Therapist who evaluated the patient on 6/20/2012. The therapist reported all behavioral health patients are evaluated by an ED physician for medical clearance. After the patient is "medically cleared" by the ED physician, the patient is transferred to the care of the staff of "Palo Verde" (the hospital's psychiatric department) in the annex of the ED. The therapist stated after the patients are medically cleared, the ED physicians are "done" and turn the care over to Palo Verde to do whatever needs to be done. The Behavioral Health Therapist performs a psychological examination and consults with the on-call psychiatrist who provides orders to discharge or admit as an inpatient. The therapist stated that when the psychiatrist says the patient can be discharged, the therapist performs the discharge planning.

A separate interview was conducted on 12/4/2012 with an RN who is assigned to the care of behavioral health patients in the Palo Verde annex of the ED. The RN also reported the process of care of behavioral health patients including the medical clearance by the ED physician and then the transferring of care to the behavioral health staff in the annex. The surveyor asked the RN how the final disposition of the behavioral health patient is communicated to the ED physician and she responded they "don't need to know" because the patient was "medically cleared."

An interview was conducted on 12/4/2012 with the Medical Director of the ED. He reported the behavioral health patients in the ED whom he evaluates remain his responsibility throughout their ED stay. He reported that he monitors the disposition of the patient through the electronic boards to ensure they receive the psychological examination and what the final disposition is. He added that he spoke for himself and could not speak for the other ED physicians.

2. Review of the hospital's Professional Staff Bylaws revealed: "...Purposes and Responsibilities...The purposes and responsibilities of the Professional Staff are:...To monitor and enforce compliance with these Bylaws, Rules and Regulations, and Hospital policies...."

Review of the hospital Position Description: Job Title: Psychiatrist revealed: "...Essential Functions...Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards...."

Review of hospital policy/procedure titled Behavioral Health-Patient Use of Outdoor Courtyards, Effective 10/18/11, revealed: "...Procedure...Patients on 1:1 level of observation, Assessment Level, Petitioned patients, Court Ordered Treatment...are to remain on the unit at all times, unless an off unit activity is ordered by the attending psychiatrist...The BHT must be present at all times for observation of all patients in the courtyard...."

Review of hospital policy/procedure titled Behavioral Health-Patient Use of Outdoor Courtyards, Effective 8/30/2012, revealed: "...At least two BHT (sic) must be present at all times for observation of all patients in the courtyard...."

Review of Pt # 65's medical record revealed:

Pt # 65 was admitted on 3/5/2012 on a Title 36 Petition due to danger to self and others. On 3/16/12 at 1056, an RN documented: "...As is customary for (MD # 3) he was seeing (Pt # 65) in court yard...(MD # 3) choose (sic) to go out in court yard alone with client. Didn't ask for BHT to go with him...1000-Notified by custodian...that there was a problem in the court yard, this writer ran to court yard, (MD #3) who was seeing patient in court yard, that he had used volley pole (sic) to escape. (MD #3) stated that he had talked to client one time this morning outside but he was angry and so he thought he would talk to him outside again...."

MD #3 stated during interview conducted on 11/30/12 at 1030, that at the time of the incident, it was his understanding that the courtyard was safe and that it was up to his judgment whether he took a patient out to the courtyard. He stated that he was not aware that taking the patient out to the courtyard without nursing staff was against policy. He recalled that the Director of Nursing for Behavioral Health Services had spoken with him afterward regarding his failure to tell staff that he was taking the patient out to the courtyard. He did not recall seeing the revised policy. He currently takes patients out to the courtyard without nursing staff.

The Medical Director of Palo Verde (MD #1) stated during an interview conducted on 11/30/12, that she had spoken with MD #3 after the incident and he was informed that he could not take patients outside without nursing staff. MD #1 stated that MD #3 agreed that he would not take court ordered patients out into the courtyard without nursing staff. MD #1 also stated that the psychiatrists were informed, during a physicians' meeting, regarding the incident and the hospital policy . She confirmed that there are no minutes recorded for those meetings and there is no documentation of her meeting with MD #3.

On 11/30/12, the Director of Nursing for Behavioral Health Services and the Administrator for Palo Verde Mental Health confirmed during separate interviews, that MD #3 did not follow hospital policy when he took a petitioned patient into the courtyard without nursing staff present. They also confirmed that the hospital was unable to provide any documentation of follow-up with the physician for failing to follow hospital policy. The Director of Nursing stated that MD #3 is an employed physician and is expected to review hospital policies/procedures on-line.

Based on review of medical records, interviews and policy/procedure, it was determined that the hospital's nursing service failed to provide the number of nursing staff necessary for patient supervision and required nursing care in the Palo Verde Behavioral Health Services, due to failing to base staffing on an RN's assessment of each patient's care needs and staffing by ratio only.

Findings include:

Review of Pt # 71's medical record revealed:

On 2/13/12 at 1850, an RN documented: "...Pt. Was in dayroom sitting opposite side of room from (Pt # 70). When (Pt #70) reportedly changed channel & (Pt # 71) Got up from chair & hit (Pt # 70) in face 3 times, as reportedly (sic) by another pt. Witness...housekeeping passed by & seen (sic) (Pt # 71's) arm extended to hit (Pt # 70) but stated he did not see (Pt # 71) actually hit (Pt # 70)...."

Review of Pt # 70's medical record revealed:

On 2/13/12 at 1855, an RN documented: "...Pt informed...bht that (Pt # 71) Hit him in the face 3 times...Another pt. in other dayroom witnessed (Pt # 71) get up & go over to (Pt # 70) & hit him 3 times in the face. Witness stated (Pt # 70) laid on the floor at time of being hit...houskeeping (sic) passed by & went into dayroom & took hold of (Pt # 71's) arm extended...."

Pt # 70's medical record contained a physician's order for a Physician/NP consult on 2/15/12 at 0845 and ED notes on 2/15/12 at 2348 by a Nurse Practitioner: "...Patient...presenting with head injury...."

Review of Pt # 67's medical record revealed:

On 9/24/12 at 2021, an RN documented: "...At change of shift when this writer was in report room, a commotion was heard, and this patient was found on the floor in the dayroom with a laceration to the forehead. A peer (Pt # 68) was angry and lashed out, grabbing (Pt # 67) and throwing his head into the door. 911 was called and pt was transported by EMS...."

The Director of Nursing confirmed during interview conducted on 11/28/12, that on 2/13/12 and on 9/24/12, the Palo Verde units did not have a patient acuity plan in place. Staffing was based on a matrix and patient to staff ratio. An RN would assess the general acuity of the unit and request additional staff. If a physician ordered 1:1 monitoring for a patient, an additional BHT would be scheduled. Staffing was not based on an RN's assessment of each patient's care needs.

The Director of Nursing confirmed that the Patient Care Procedure titled Behavioral Health Patient Classification System, Effective 11/26/2012 and in revision on 11/29/2012, is being used on a trial basis. She confirmed that it does not include a method which determines the number and type of nursing personnel required to meet the patients' nursing care requirements.

RN # 33 confirmed during interview conducted on 12/4/12, that the Palo Verde units do not have a patient acuity system. Staffing is based on a grid and patient to staff ratios. S/he stated that sometimes the number of patients exceed the grid. RN's assign their own patients by room numbers, i.e., one RN is assigned to the top half of the patients on the list and the other RN is assigned to the bottom half. BHT's make their own assignments of patients by consecutive room numbers and assignments of tasks and the RN signs that s/he has seen it. Assignments are not based on patient acuity/condition. The classification system that is on a current trial basis does not take into account the medical needs of the patients.

RN # 18 confirmed during interview conducted on 12/4/12 that the Palo Verde units do not use a patient acuity system to determine staffing. S/he and the other RN on the unit assign patients to themselves by the top half and bottom half of the patient lists. S/he confirmed that BHT's make their own assignments of rotating tasks and patients in consecutive room numbers. The RN signs the form and may question the BHT's regarding rationale for some assignments. The RN does complete assessments of patients, but the assessments do not affect staffing and assignments unless the patient requires a 1:1.

Based on review of patient medical records, hospital policies/procedures and interviews, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to clarify a physician's order for Danger to others precautions for 1 of 1 behavioral health patient who had presented a threat to ED personnel in the originating hospital and was directly admitted to the Palo Verde unit and assaulted a patient the day after admission (Pt # 71); and

2. failing to provide for safe transport between the Palo Verde ED Annex and the Palo Verde unit of a patient, petitioned for evaluation due to danger to self, who eloped during transport by Security Officers and required return by police.

Findings include:

1. Review of Pt # 71's medical record revealed:

On 2/12/12 at 1651, RN # 47 documented: "...The pt was petitioned for DTO (Danger to Others) today by an ED physician at (name of hospital)...Pt. came to (name of hospital) saying that he needed to be hospitalized and then became uncooperative, aggressive and agitated. He tried to use a W/C (Wheelchair) as a means of breaking through the locked ED door. He was throwing things and threatening to harm...staff...he was...placed in 4 point restraints...in restraints for 2 hours earlier today...."

At 2000, RN # 47 recorded a physician's order: "...Danger to others precautions (DTO)...."

Review of hospital policies/procedures revealed that the hospital does not have a policy/procedure for Danger to others precautions. All patients are routinely placed on "Q" (every) 15 minute rounds or One to One Monitoring.

Review of hospital policy/procedure titled Behavioral Health Q 15 Minute Safety Rounding revealed: "...The RN supervises the unit for overall safety, and one of the most important interventions to ensure patient safety is monitoring the patient's location and activities to ensure that our patients are physically safe. Routine visual rounds will be completed on all patients every 15 minutes...The level of observation may change from Q 15 minute rounding to one to one (1:1) level of observation depending on the risk of the patient to harm self or others...."

Review of hospital policy/procedure titled Behavioral Health Patient One-to-One Monitoring revealed: "...To provide a higher level of observation when a patient's behavior becomes disruptive and uncontrollable to managing the milieu, and is at risk for harming themselves or others...To maintain a safe environment for patients and staff members...."

The Director of Nursing for Behavioral Health Services confirmed during interview conducted on 12/5/12, that the hospital does not have a policy/procedure for DTO precautions. RN # 46 should have clarified the physician's order to determine if the physician wanted the patient to be monitored One to One or routinely on 15 minute rounds.

Review of Pt # 71's medical record revealed that he assaulted Pt # 70 on 2/13/12 at 1855.

Cross reference Tag 0392 for information regarding the assault.

2. Review of Pt # 69's medical record revealed:

On 6/12/12 at 1533, a Palo Verde ED Annex RN documented: "...Pt somewhat angry, sarcastic and demanding. pt picked up chair. Pt did not threaten anyone or anything. Pt was redirected. Security called...."

On 6/12/12 at 1745, Security Officer documented on a Security Services report: "...petitioned pt (Pt #69) escaped out of the emergency annex front door...Two person Crisis Prevention Intervention escort to bring him back from the lobby area to the emergency annex...."

On 6/12/12 at 1937, an RN documented: "...Patient continues to pace and demand...we are holding him against his will, pt is petitioned. Patient needs constant redirection. Patient waiting to transfer to PVH East Unit...."

On 6/12/12 at 2007, an RN documented: "...Patient transferred to PVH East Unit...."

The medical record did not contain documentation regarding the mode of transport.

On 6/12/12 at 2206, a Security Officer documented on a Supplement Case Report: "...At 1930 on 6/12/2012...searched for a petitioned patient (Pt #69) that ran from the security vehicle...."

RN # 21 confirmed during interview conducted on 12/2/12, that the Palo Verde ED Annex RN determines the method of patient transport between the Palo Verde ED Annex and Palo Verde.

Security Officer # 44 confirmed during interview conducted on 12/4/12, that he and Security officer # 25 were assigned to transport Pt # 69 and that he was concerned regarding Pt #69 being a flight risk. Officer # 25 confirmed during interview conducted on 12/4/12, that he believed that Pt # 69 was going to attempt to elope because he demanded his shoes.

Based on review of medical records, hospital documents and interviews, it was determined that patient care assignments are not made in accordance with the patient's needs.

Findings include:

Cross reference Tag # 0392 for information regarding Pt's # 70, 71, 67 and 68 regarding assaultive incidents requiring medical care, and regarding the Behavioral Health Patient Classification System, effective 11/26/2012 and in revision.

Review of Palo Verde East Unit Day and Night Shift Assignment Worksheets for 2/13/12 revealed that the BHT's were assigned to consecutive room numbers.

Neither Pt #70 nor Pt #71 were assigned to a BHT for 1:1 monitoring.

Review of Palo Verde East Unit Day and Night Shift Assignment Worksheets for 9/24/12 revealed that the BHT's were assigned to consecutive room numbers.

Neither Pt # 67 nor Pt # 68 were assigned to a BHT for 1:1 monitoring.

Review of Palo Verde East Unit Day Shift Assignment Worksheet for 12/4/12 revealed that the BHT's were assigned to consecutive room numbers.

Review of Palo Verde West Unit Day Shift Assignment Worksheet for 12/4/12 revealed that the BHT's were assigned to consecutive room numbers.

RN # 33 confirmed during interview conducted on 12/4/12, that the Palo Verde West's staffing is based on a grid and patient to staff ratios. S/he stated that RN's assign their own patients by room numbers, i.e., one RN is assigned to the top half of the patients on the list and the other RN is assigned to the bottom half. BHT's make their own assignments of patients by consecutive room numbers and assignments of tasks and the RN signs that s/he has seen it. Assignments are not based on patient acuity/condition or specific staff competence. The classification system that is on a current trial basis does not take into account the medical needs of the patients. In addition, a Palo Verde West BHT may float to Palo Verde East and the other BHT's on Palo Verde West will need to assume care for the patients that the BHT was responsible for on Palo Verde West.

RN # 18 confirmed during interview conducted on 12/4/12 that s/he and the other RN on Palo Verde East assign patients to themselves by the top half and bottom half of the patient lists. S/he confirmed that BHT's make their own assignments of rotating tasks and patients in consecutive room numbers. The RN signs the form and may question the BHT's regarding rationale for some assignments. The RN does complete assessments of patients, but the assessments do not affect staffing and assignments, unless a patient requires 1:1 monitoring.