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Based on review of Governing Body minutes, facility documents, and interview, it was determined that the Governing Body failed to ensure the following:

(057) the Chief Executive Officer(CEO) required that the facility maintained an on-going quality management program that evaluated and reported any issues related to ligature risks identified within the quality review for hospital services, and environmental services provided related to patient care. This deficient practice poses a high risk to the health, and safety of psychiatric patients, when the CEO/Governing Body have not been notified of ligature risks, as required per CMS: S&C Memo: 18-06-Hospitals (issued 12/08/2017), and directed immediate action to remove the identified ligature risks, specifically door closures, and door hinges.

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 that protects patients and their safe well-being.

Based on review of Governing Body minutes, facility documents and staff interview, it was determined the Chief Executive Officer(CEO) failed to require that the facility maintained an ongoing quality management program that evaluated and reported any issues identified related to ligature risks identified within the quality review for hospital services, and environmental services provided related to patient care. This deficient practice poses a high risk to the health, and safety of psychiatric patients, when the CEO/Governing Body have not been notified of ligature risks, as required per CMS: S&C Memo: 18-06-Hospitals (issued 12/08/2017), and directed immediate action to remove the identified ligature risks, specifically door closures, and door hinges.

Findings include:

Documents titled: Maricopa County Special Health Care District, Board of Director's Meeting, dated: 01/24/2018, 02/28/2018, 03/28/2018, and 04/25/2018, identified no documented evidence of discussion regarding ligature risk issues on the Behavioral Health Units.

Document titled: Maricopa County Special Health Care District, Board of Director's Formal Meeting, District Wide Risk Management Report, dated: 04/25/2018, identified no documentation specific to patient safety under the categories labeled "Risk Identification" or "Risk Mitigation".

Document titled: Maricopa Integrated Health Services (MIHS) Desert Vista & Psychiatric Annex, Bi-Monthly BHT II Meeting, dated: 01/02/2018 & 01/04/2018, revealed the following documentation: "...Admin is looking at how we can be more conscious of what we're doing regarding ligatures...would like staff to look at potential ligature risks, i.e. doors...patients are prone to use the door to tie clothing or sheets onto it to use as a potential hanging/strangling device...make sure you're looking for these when doing rounds...we will be working with our Risk Management company to find a tool to help us evaluate the facility for potential ligature points...."

Document titled: MIHS Desert Vista & Psychiatric Annex, Bi-Monthly BHT II Meeting, dated: 03/06/2018 & 03/08/2018, revealed the following documentation: "...Environmental Safety Check Tool (Ligature Risk)...current tool was handed out to the group...there should be regular reviews of the units to ensure that all safety measures are in place...glass in doors on the units will be replaced...TV frame was a concern, and Facilities is looking into this...plastic bags are used on the units in trash cans...most are not locked...patients are grabbing items off the precaution carts...."

Document titled: MIHS Desert Vista & Psychiatric Annex, Bi-Monthly BHT II Meeting, dated: 05/01/2018 & 05/03/2018, revealed the following documentation: "...the Thursday night group saw a video on soft suicide prevention doors...thinking of doing a trial with these soft suicide doors for the bathrooms at Maryvale...Ligature Risk/Safety Assessments...want to make sure that you're looking for anything that could be a ligature risk...some BHT II's have been assigned to take the tool to units they're not used to working on...fresh eyes looking for safety issues...more will be assigned to complete a risk assessment on other units...if you are assigned to complete this tool while you're working...either fix what you can fix, or complete a work order to have the issue corrected as soon as possible...make sure to note if you have informed the charge nurse/nursing supervisor...Administration is taking this very seriously...."

Senior Vice President #2 confirmed during an interview conducted 06/15/2018 (1114-1143), that the hospital was made aware about ligature risks for psychiatric patients (to include door closures, and door hinges), by a CMS S&C Memo: 18-06-Hospitals dated 12/08/2017. It was revealed that Registered Nurse (RN)/Regulatory Compliance #5 gathered materials for ligature risks, to include the CMS C&S Memo: 18-06-Hospitals, and that a "Ligature Risk" team was established to address ligature risk issues, and the team met in February 2018. Senior Vice President #2, confirmed that it was his/her impression that all door closures were originally removed, but patients complained, and maintenance installed the sliding door closures. When the slanted door hinges were installed, it was known that these "weren't perfect". Senior Vice President #2 confirmed, that the Ligature Risk team discussed, and evaluated soft suicide doors, to be used for an up-coming building remodel, and planned to use these soft suicide doors on all psychiatric inpatient bathroom doors. It was revealed that the Governing Body had not been provided information regarding the ligature risk issues identified by CMS, or the Ligature Risk team, specifically regarding the ligature door closures, and door hinges.

Based on review of the hospital's policies and procedures, the patient medical record, observations, and interview, it was determined that the hospital failed to:

(A0144) ensure the nursing staff and behavioral health technicians (BHT's) monitored the patients at the frequency set as the minimum standard of care for patient's at this behavioral health facility. This deficient practice posed a high potential risk to the safety and well being of psychiatric patients when the patients were not visualized at the required time intervals, and Patient # 1 resulted in cessation of life due to this deficient practice.

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of Patient Rights was provided in a safe environment that protects patients and their safe well-being.

Based on review of the hospital's policies and procedures, the patient medical record, observations, and interview, it was determined that the hospital failed to ensure the nursing staff and behavioral health technicians (BHT's) monitored the patients at the frequency set as the minimum standard of care for patients at this behavioral health facility. This deficient practice posed a high potential risk to the safety and well being of psychiatric patients when the patients were not visualized at the required time intervals and Patient # 1 resulted in cessation of life due to this deficient practice.

Findings include:

The facility's policy titled Behavioral Health: Patient Safety Rounds requires: "...Patient Safety Rounds are defined as...A visual check of each patient with requisite documentation of location and status at a minimum of every fifteen minutes...Patient Safety Rounds will be completed and documented a minimum of every fifteen minutes on all patients...."

The facility's policy titled Maricopa Integrated Health System (MIHS) Behavioral Health Nursing Standard of Care revealed: "...The Department of Psychiatry Standards of Care provided in this document is the minimum nursing care provided for patients at Desert Vista...see Behavioral Health policy...Patient Safety Rounds...."

The facility's policy and Procedure titled "Behavioral Health: Standard and Special Behavioral Precautions" defines "Rounds Board" as: "...A form on which an assigned staff member documents their observation of each patient every 15 minutes, except those patients whose precaution level requires documentation on a patient-specific Behavioral Health (BH) Special Precaution Flow Sheet...." Standard Behavioral Precautions is defined as: "...A systematic approach to observing all patients within the psychiatric setting, at least every fifteen minutes, as a least restrictive measure to ensure safety. These observations are documented by an assigned staff member on the Rounds Board...."

The procedure contains: "...All patients will be monitored through Standard Behavioral Precautions unless an increased risk is identified and a special precaution level is ordered...."

A required intervention of this procedure is that patients on Assault Precaution (AP2) require: "....additional supervision to ensure the safety of others...The staff will check on the patient at least every 15 minutes and will document on the Rounds Board, paying close attention to any verbal or non-verbal signs of potential aggressive behavior...."

Medical record review for Patient #1 identified the following: the patient was hospitalized from 5/25/2018 through 6/8/2018, and given a risk/precaution designation of Suicide Risk 2 (SR2) and AP2 for his/her entire hospitalization of 15 days. This requires, pursuant to facility policy, a visual check every 15 minutes by Nursing staff as a minimum standard of care. The medical record of Patient # 1 revealed in the nursing notes at least four (4) times when the patient was classified as having suicidal ideation; at least fifteen (15) times Patient # 1 stated s/he was having audio hallucinations telling him/her to hang or harm self, stating on 5/29/2018 "...hearing voices to hang myself...." The medical record documents eight (8) times the patient requested a 1:1 or that staff stay with him/her in the room because s/he was afraid for his/her safety. Physician notes record three (3) times that the patient wanted to hang self, had suicidal ideations, heard voices telling him/her to harm self, and on 6/5/2018 stated "...I want to die...." Two (2) times it was noted by physician # 6 in the face to face assessment documentation to " adjust medication and change precaution level " but no order was ever written to change the precaution level.

Observation and tour of unit 7 of the facility was conducted daily throughout the survey 6/11/18, 6/12/18, 6/13/18, 6/14/18, 6/15/18 and 6/18/18. The safety rounds were observed to be done in an inconsistent manner.

The Psychiatry Safety Rounds sheet dated 6/8/2018 revealed that Patient #1 was given a Risk/Precaution rating of [AP2, SR2] which required the patient be visualized at a minimum of every 15 minutes. At 15:00 on 6/8/18 the patient was documented as being in his/her room. At 15:15 the patient was documented as being in the bathroom not visualized but responding verbally. At 15:30 the patient was found in the bathroom, with a linen bed sheet wrapped around his/her neck, with the linen attached to the inside bathroom door closure.

Patient #1 was never elevated to a higher level of observation. The medical record consistently stated the patient would be visually monitored every 15 minutes. The patient was not visualized for approximately 30 minutes prior to being discovered and resuscitation efforts begun.

The DON confirmed in a private interview on 6/12/2018 at 09:25 that all staff does safety rounds on all of the patients. Specific staff are assigned to do the 15 minute rounds, however if that staff member needs to leave the unit or is involved with another patient, then the rounds board is handed off to another staff member.

RN, Clinical Resource Lead (CRL) # 13 confirmed in a private interview on 6/12/2018 at 10:40 that safety rounds are done every 15 minutes, to see where the patients are located and what they are doing. If the patient is in the bathroom, the staff member will knock and get a verbal response but on the next check the staff member must visualize the patient If the BHT (techs) are unavailable the nursing staff will fill in. The charge RN looks at the rounding sheet about every hour and will document in progress notes the trends, or tell doctors things like: the patient is staying in bed and not going to groups. At the end of the day the form goes into a notebook. At the end of the month the forms from the notebook are put in a box and stored in a supply room.

The facility staff fails to document the findings of the 15 minute rounds in the individual patient charts.

RN CRL # 18 confirmed in a private interview on 6/12/2018 at 13:46, that if the patient is in the bathroom with the door closed at the time of the 15 minute check, the policy is to knock on the door and get a response, then move on. At the next 15 minute check the staff are required to visualize the patient.

With regard to the 15 minute checks on Patient #1 on the afternoon of 6/8/2018, RN CRL # 18 identified that at the 15:15 (P.M.) check the BHT said that the patient was in the bathroom, and the patient was not visualized.

BHT # 14 revealed in a private interview on 6/13/2018 at 10:20, that the patients have access to their room at all times, and BHTs are assigned two (2) hour shifts to do the 15 minute rounds. BHT # 14 stated that he/she looks for each person on the list, and if s/he can't find them then s/he asks others, checks the bathroom, makes sure someone has a visual, every 15 minutes on the hour. This is done to make sure eyes are on the patient and if something seems unusual, they must report the patients behavior. If the tech has to leave the floor for another assignment they are to hand off the board to someone. Nurses help if BHTs are not available.

BHT II # 23 revealed in a private interview on 6/14/2018 at 11:10, that even if the patient is a one to one (1:1) you still must visualize the patient. If the patient is in the bathroom staff are expected to knock and if they get a verbal response, they can move on. BHT II # 23 identified that s/he prefers to visualize the patient.

BHT # 24 revealed on 6/14/2018 at 11:45, in private interview that sometimes s/he takes 15 minutes to complete the safety round. So s/he turns around and starts the next 15 minute round, starting at the room s/he just finished and going back to the first room.

The surveyor confirmed with this BHT, the effect of this type of round would have the patient in the first room seen approximately every 30 minutes and the patient in the last room seen twice in the same minute, BHT #24 agreed that was a true statement.

MD Attending # 3, confirmed in a private interview conducted 6/13/2018 at 13:30, that all patients are visualized at the very least every 15 minutes.

MD Attending # 4, confirmed in private interview on 6/13/2018 at 14:38, that their understanding of every (Q) 15 minute checks is that staff would have a visual on the patient every 15 minutes.

MD Attending # 5, confirmed in private interview on 6/13/2018 at 14:48, that the purpose of the Q 15 minute checks are to see where the patient is. If the patient is in the bathroom the staff will look/visualize the patient or get a BHT of the same gender to do so.

MD Attending # 6, confirmed in private interview conducted 6/13/2018, at 15:01, that the 15 minute checks are the responsibility of unit nursing staff making sure the patients are safe on the unit. S/he identified that the patients are visualized (observed) every 15 minutes.

All four (4) of the four (4) physicians interviewed had the expectation that their patients were visually observed every 15 minutes at a minimum.

Based on review of hospital policies, and procedures, documents, and interview, it was determined that the facility failed to:

(A273) require that a documented report was submitted from the Patient Care and Safety Committee, to the Quality Management Council, and that the Quality Management Council provided a documented report to the Governing Body, that listed the identified ligature risks per CMS C&S Memo: 18-06-Hospitals (issued 12/08/2017), which specifically identified door closures, and door hinges. This deficient practice posed a significant risk to the health, and safety of the psychiatric patients, when the hospital failed to take immediate, corrective action to avoid patient harm, and/or death.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provisions of Quality Performance Improvement Assessments were maintained to ensure that quality health care was provided in a safe environment that protected patients and their safe well-being.

Based on review of hospital policies, and procedures, documents, and interview, it was determined that the facilty failed to require, that a documented report was submitted from the Patient Care and Safety Committee, to the Quality Management Council, and that the Quality Management Council provided a documented report to the Governing Body, that listed the identified ligature risks per CMS C&S Memo: 18-06-Hospitals (issued 12/08/2017), which specifically identified door closures, and door hinges. This deficient practice posed a significant risk to the health, and safety of the psychiatric patients, when the hospital failed to take immediate, corrective action to avoid patient harm, and/or death.

Findings include:

Policy and procedure titled: Quality/Care Management - MIHS Patient Safety Evaluation System, #62010S, effective date: 03/2016, requires: "...Patient Safety Evaluation System (PSES)...means the collection, management, or analysis of information for reporting to or by a Patient Safety Organization (PSO)...Patient Safety Work Product (PSWP)...means any data, reports, records, memoranda, analyses, such as root cause analyses, and care reviews documention or written or oral statements, or copies of any of these material, which could improve patient safety, health care quality, or health care outcomes...Patient Safety Activities...efforts to improve patient safety...development, and dissemination of information...to improving patient safety...such as recommendations, protocols, or information regarding best practices...the PSES...shall be used to reduce mortality, and morbidity...to improve patient care, and patient safety...oversight of the PSES is performed by the Patient Safety Committee...."

Policy and procedure titled: Quality: Occurrence Reporting, #13502S, last revised: 09/2017, requires: "...It is the policy of MIHS to report any occurrence/event which is inconsistent with the routine operations of MIHS...or the routine care of a patient...all...occurrences...hazardous conditions...should be reported...MIHS employees, and staff play an active role in the detection, and reporting of occurrences...hazardous events...to assist in the identification of underlying system-based issues in the work environment...Types of Reportable Occurrences/Events...Equipment/Property...unsafe conditions...."

Policy and procedure titled: Administration: Safety Commitment Policy, #01754S, last reviewed: 07/2016, revealed : "...this policy reinforces the commitment that MIHS...to ensure that we do all that we can to prevent injury...any form of harm or loss to...patients...MISH will...maintain safety...standards that equal or exceed the best practices in the industry..."safety" is one of the seven MIHS Behavior Standards which reflect the Mission and Vision of MIHS...MIHS is committed to developing a...safety culture where the inherent safety risks in our environment are controlled and reduced...MIHS recognizes the responsibility to...comply with relevant health, and safety regulations...."

Documents titled: MIHS Quality Management Council Minutes, dated: 01/25/2018, 02/22/2018, 03/22/2018, and 04/26/2018, failed to contain documentation regarding ligature risks.

Documents titled: MIHS Patient Care and Safety Committee Minutes, dated: 02/21/2018, 03/21/2018, and 04/12/2018, failed to contain documentation regarding ligature risks.

Document titled: MIHS Unit Based Council Minutes, dated: 02/06/2018, revealed: "...Action item follow-up/Loop Closures/Unfinished Business...Topic...Environmental Safety Check...there are regulatory mandates that require us to pay attention to all of our safety risks and how we're limiting the risk to patients, or eliminate them all together...." Additional review of the document reveals no documentation under the categories: Conclusion/Action or Responsible, specifically no follow-up.

Vice President of Quality and Patient Safety #7 confirmed during an interview conducted 06/15/2018 (1308-1320), that s/he attends both the Quality Management Council (senior leadership, and board members), and the Patient Care and Safety Committee (facility directors, and managers). It was revealed that reports from the Patient Care and Safety Committee, are submitted to the Quality Management Council, and reports from the Quality Management Council are submitted to the Governing Body (Board of Director's Meeting). Vice President of Quality and Patient Safety #7 confirmed that reports from environmental rounds are reported to the Patient Care and Safety Committee, and Quality Management Council, but not to the Governing Body. It was confirmed that s/he has not heard discussion regarding ligature risks at either the Quality Management Council or the Patient Care and Safety Committee.

Based on review of hospital policy, and procedure, documents, and interviews, it was determined that the facility failed to require that a Behavioral Health Technician (BHT) receives clinical oversight by a Behavioral Health Professional, Registered Nurse (RN). This deficient practices poses a risk to the health, and safety of the psychiatric patient, when the BHT receives no clinical oversight as required by hospital policy, and job description.

Findings include:

Policy, and procedure titled "Clinical Oversight of Behavioral Health Technicians and Paraprofessionals, #29800T, last reviewed: 06/20017, requires: "Behavioral Health Technician, an individual who is not a behavioral health professional who provides behavioral health services at, or for a health care institution according to the health care institution's polices, and procedures with clinical oversight by a behavioral health professional...clinical oversight is the monitoring, and oversight of behavioral health services provided by staff to ensure that services are provided according to the health care intuition's policies, and procedures, including an on-going review of skills, and knowledge related to the provision of behavioral health services...clinical oversight is provided to behavioral health technicians authorized to provide behavioral health services at MIHS...at least once during each two week period if the...behavioral health technician provides services related to patient care during the two week period...clinical oversight is provided to ensure that patient needs are met and based upon...scope and extent of the services provided...acuity of the patients receiving services...number of patients receiving services...must be documented on an MIHS approved form to include...date of clinical oversight...name, signature, and credentials and/or job title of the staff member receiving clinical oversight...signature, and professional credential, and job title of the individual providing the clinical oversight, and date signed...duration of the clinical oversight...description of the topics addressed...whether the clinical oversight occurred on an individual or group basis...."

Documents titled: MIHS Behavioral Health Technician (BHT) I, and II Job Description, last modified: 09/02/2017, requires: "...Supervision Received...the BHT reports directly to the unit charge nurse for behavioral health, and primary nurse for acute care system...the BHT is required to obtain a minimum of one (1) hour of supervision from a behavioral health professional for every forty (40) hours worked...."

Document titled: MIHS Behavioral Health Technician (BHT) III Job Description, last modified: 09/02/2017, does not list any requirement for clinical oversight of the BHT.

Document titled: MIHS Advanced Clinical Nurse Job Description, last modified: 09/28/2017, requires: "...Supervision Exercised...provides direction, and indirect supervision to licensed, and non-licensed personnel in the activities necessary to provide quality care, and services...." There is no documentation in the job description regarding the provision of clinical oversight.

Document titled: MIHS Clinical Nurse Job Description, last modified: 09/05/2017 requires: "...Supervision Exercised...provides direction, and indirect supervision to licensed, and non-licensed personnel in the activities necessary to provide quality care, and services...." There is no documentation in the job description regarding the provision of clinical oversight.

BHT II #23 confirmed during an interview conducted 06/14/2018 (1110-1136), that there is no specific paperwork that is completed specific to clinical oversight.

BHT I #24 confirmed during an interview conducted 06/14/2018 (1110-1136), that there is no specific paperwork that is completed specific to clinical oversight.

RN #17 confirmed during an interview conducted 06/14/2018 (1045-1110), that s/he occasionally is assigned to be the charge nurse, and that no documentation is required when providing oversight to the BHT.

RN, Director of Nursing #6 confirmed during an interview conducted 06/15/2018 (1050-1105), that there is no documented evidence of clinical oversight of the BHT, provided by the charge nurse.

Based on review of hospital policy, and procedure, documents, and interview, it was determined that the Nurse Executive failed to required that the RN/Charge Nurse received training regarding the acuity plan, and how the acuity plan is to be implemented. This deficient practice poses a high risk to the health, and safety of patients, when the RN/Charge Nurse does not know how to utilize, and implement the acuity plan for the purpose of making accurate, and safe staffing assignments.

Findings include:

Policy, and procedure titled "Behavioral Health: Psychiatry Staffing Levels and Acuity Plan, #29051T, last revised: 05/2018, requires: "...Staffing Grid...a matrix that identifies the appropriate number of staff members required to meet the treatment needs of the patients served within the department...the number of nurses, and behavioral health technicians scheduled on a given unit...a particular shift...determined based on a combination of the number of patients present on that unit and the number of patients who require additional nursing care or staff supervision to ensure their safety...patient acuity is determined by the number of patients who require additional nursing care or staff supervision to prevent harm...the acuity plan lists minimum numbers of nursing staff based on volume and includes the ability to overlay that staffing mix based on acuity...registered nurses on each unit provide input into the number, and mix of licensed personnel, and BHT's required to meet the needs of each patient...nursing supervisors are present at all time around the clock...they conduct frequent rounds...adjust the staffing levels to meet the care needs of the patients...Unity Acuity Guidelines...low (2%)...average (66%)...high (16%)...extreme (2%)...."

Document titled: MIHS, Psychiatry Department, Scope of Care/Services, dated: 2018-2019, requires: "...The MIHS Department of Psychiatry staffing levels are based on unit census, and patient acuity...patient acuity is determined by the number of patients who require additional nursing care or staff supervision to prevent harm to the patient...other patients...there is a sufficient number of staff members present to provide general patient supervision, and treatment...to provide ancillary services to meet the scheduled, and unscheduled needs of each patient...the acuity plan lists minimum numbers of nursing staff based on volume...includes the ability to overlay that staffing mix based on acuity...."

Document titled: Department of Psychiatric, Unit Staffing Grid, last updated: 04/25/2018, is a staffing grid, listing the number of nurses, BHT's and/or MHW's for the number of patients.

Documents titled: Staffing Sheet- Daily, Unit 7, 7AM-7PM and 7PM-7AM shifts, dated: 05/13/2018, through 06/13/2018, revealed no documented evidence of patient acuity.

Documents titled: Department of Psychiatry/Shift Assignment Shift 7AM-7PM for the following dates: 05/26/2018, 05/27/2018, 05/28/2018, 06/02/2018, 06/05/2018, 06/06/2018, 06/09/2018, 06/10/2018, 06/11/2018, 06/08/2018, 06/14/2018, and 06/15/2018, identified no documented evidence of patient acuity.

Documents titled: Department of Psychiatry/Shift Assignment Shift 7PM-7AM for the following dates: 06/03/2018, and 06/10/2018, revealed no documented evidence of patient acuity.

RN, Nursing House Supervisor #26 confirmed during an interview conducted 06/15/2018 (1158-1214), that the first thing s/he does when coming on shift is to look at the staffing schedule, and unit census. It was revealed that Opti-Link is a computer program that assigns an acuity number, and that every patient is assigned one of the following acuities: low, average, high, or extreme. RN, Nursing House Supervisor #26 confirmed that the floor nurses do not see the daily staffing assignment document, which includes the acuity rating.

RN, Director of Nursing #6 confirmed during an interview conducted 06/15/2018 (1050-1105), that acuity is put into the computer by the Charge Nurse on each shift, and that the acuity numbers are reviewed by the RN, Nursing House Supervisor each shift.

Lead Staffing Clerk #22 confirmed during an interview conducted 06/14/2018 (0847-0900), that all nursing schedules are entered into the Kronos system at the direction of the nurse manager. The nursing schedules are then printed, and reviewed for any variances. If there are any negative variances, the staffing office, looks for available float pool staff, or registry staff to complete the schedule. Additionally, it was revealed, that s/he uses the "Unit Staffing Grid" to determine how many BHT"s, Mental Health Workers, and nurses are needed. Lead Staffing Clerk #22 confirmed that the staffing office, attempts to complete the staffing schedule for the maximum census per each unit, and that the staffing office does not use acuity numbers to complete the staffing schedule. It was revealed that the Nursing Supervisor prints a schedule, which includes acuity numbers and the staffing schedule for each shift.

RN #17 confirmed during an interview conducted 06/14/2018 (1045-1110), that s/he occasionally is assigned to be the Charge Nurse, and that s/he has not been trained on staffing by acuity.

Based on review of the medical record, observations, facility documents, CMS Memorandum and interviews, it was determined the hospital failed to:

(A701) ensure that the condition of the physical plant and the overall hospital environment related to ligature risks (rectangular doors with three hinges) were maintained in such a manner that the safety of the patients were protected from harm. Failure to prevent harm to patients from ligature points poses the high potential risk that patients will be subject to patient harm, and Patient # 1 resulted in cessation of life due to this deficient practice.

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of hospital services for diagnosis and treatment in a physical environment that protects the patients and provides for their safety and well being.

Based on review of the medical record, observations, facility policies and procedures, facility documents, CMS Memorandum, and interviews, it was determined the hospital failed to ensure that the condition of the physical plant and the overall hospital environment related to ligature risks (rectangular doors with three hinges) were maintained in such a manner that the safety of the patients were protected from harm. Failure to prevent harm to patients from ligature points poses the high potential risk that patients will be subject to patient harm, and Patient # 1 resulted in cessation of life, due to this deficient practice.

Findings include:

Medical record review for Patient #1 identified the following: the patient was admitted to the hospital on 05/25/2018, with [schizoaffective disorder and paranoia] and assigned to Unit 7. The patient was admitted per [court-ordered evaluation], and during the course of the hospitalization, the patient status changed to [court-ordered treatment]. During the hospital stay, the patient was assessed, evaluated, and treated. The patient was given a risk/precaution designation of [Suicide Risk 2 (SR2) and Assault Precaution 2 (AP2)] for his/her entire hospitalization of 15 days. The medical record of Patient # 1 confirmed that there were four (4) documentation's that the patient had [suicidal ideations.] Due to the patient's [paranoia] and [AP2] designation, s/he did not have a roommate during his/her hospitalization. On 06/08/2018, Patient #1 was found in the bathroom, [with a linen bed sheet wrapped around his/her neck, with the linen attached to the inside bathroom door closure.]

Observation and tour of Unit 7 of the facility was conducted daily throughout the survey 6/11/18, 6/12/18, 6/13/18, 6/14/18, 6/15/18 and 6/18/18. Unit 7 is a 22 bed co-ed adult unit, accessible by key only. There are a total of nine (9) patient rooms. Four (4) patient rooms have three (3) beds per room, and five (5) rooms have 2 beds in each room. Each patient room has a private bathroom which uses a rectangular door with three hinges down the side of the door attached to the wall. Patients were allowed to be in their rooms (and in their beds) at any time during the day or night, and to close their door if they so chose.

The units at the main facility and annex have the same type of rectangular bathroom doors with three hinges regularly keep the bedroom doors open, this includes the Annex, which houses Units 8, 9, and 10, and the one (1) medical/behavioral health unit (Unit 11) located inside the medical center.

The facility's policy titled "Compliance/EOC: Physical Environment Safety Management Program" revealed: "...Purpose: To establish a program that manages safety risks in regards to a physical environment that is functional, supportive and effective for patients...Procedure: (Maricopa Integrated Health System) MIHS will identify and manage safety risks through the Physical Environment Safety Management Plans. The MIHS Physical Environment Safety Management Plans will be evaluated at least annually and forwarded to Quality Management Counsel (QMC)...."

The facility's policy titled "Administration: Safety Commitment Policy" revealed: "...Purpose: This policy reinforces the commitment that MIHS has to ensure that we do all that we can to prevent injury...or any form of harm or loss to...patients...."

MIHS Bi-Monthly BHT II Meeting Minutes dated January 2 & 4, 2018, and attended by RN Regulatory Compliance employee # 5, revealed the following issue under New Business: "...Ligature Risks in our Department - Admin is looking at how we can be more conscious of what we're doing regarding ligatures....would like staff to look at potential ligature risks, i.e. doors....Patients are prone to use the door to tie clothing or sheets onto it, to use as a potential hanging/strangling device....looking for these when doing rounds....We will be working with our Risk Management company to find a tool to help us evaluate the facility for potential ligature points...."

MIHS Bi-Monthly BHT II Meeting Minutes dated March 6 & 8, 2018, revealed the following issue under New Business: "...Environmental Safety Check Tool (Ligature Risk)...There should be regular reviews of the units to ensure that all safety measures are in place and that there isn't a hazard on the floor easily accessible to patients...."

MIHS Bi-Monthly BHT II Meeting Minutes dated May 1 & 3, 2018, revealed the following issue under Standing Business: "...The Thursday night group saw a video on soft suicide prevention doors...thinking of doing a trial with these soft suicide doors for the bathrooms at [name of another acute care psychiatric hospital] ."

MIHS Facilities Department Scope of Care/Services, dated 2018-2019, contained: "...It is the purpose of Facility Operations to provide the best possible service...maintaining the general operation of the health system, 24 hours / 7 days a week. While providing these services we will ensure the following: a. The health system environment is safe and maintained for all...patients...To provide the facilities necessary for MIHS to provide the utmost in quality patient care...The Facility Operations Department is responsible for the condition and function of all MIHS facilities including physical plant...."

MIHS Safety Management Program revealed: "...The purpose of the MIHS Safety Management Program is to define the process by which to reduce the risk of injury to...patients...The Safety Management Program is designed to address the safety risks in the environment that are present to patients...Inspections of the campus grounds and the facilities are conducted at least annually...."

MIHS Environmental Health and Safety, Scope of Care/Services, 2018/2019, revealed: "...Mission/Purpose: Provide a safe, functional, supportive and effective environment for our patients...Ensure a safe environment by facilitating risk assessments...."

Checklist titled "2018 Rounding Checklist", dated 2/21/2018, identified there was nothing on this form to indicate ligature risks were included in the rounding assessment.

Document titled: CMS: S&C Memo 18-06-Hospitals (dated 12/08/2017), the Memorandum Summary identified: "...Ligature Risks Compromise Psychiatric Patients' Right to Receive Care in a Safe Setting....A ligature risk (point) is defined as anything which could be used to attach...material for the purpose of hanging or strangulation...Ligature points include...door frames...hinges and closures...The most common ligature points and ligatures are doors...and...sheets...The presence of ligature risks in the physical environment of a psychiatric patient compromises the patient's safety. This is particularly an issue for a patient with suicidal ideation...."

Senior Vice President (VP) #2 confirmed in an interview conducted 6/15/2018 at 11:14, that the hospital was made aware about ligature risks for psychiatric patients with regard to door closures and door hinges, by the CMS S&C Memo: 18-06-Hospitals dated 12/08/2017. S/he also confirmed RN Regulatory Compliance employee # 5 gathered materials regarding ligature risks, and a 'Ligature Risk' team was established to address ligature risk issues.

Director of Environmental Health and Safety, # 20 confirmed in private interview on 6/15/2018 at 09:56, that the Hospital guidelines provide for environmental safety rounds to be performed two (2) times a year and this would fall under the jurisdiction of Director of Facilities. Employee # 20 revealed that s/he is primarily responsible for monitoring for OSHA standards in the workplace.

VP of Ancillary and Support Services, Employee # 4, confirmed in private interview on 6/15/2018 at 10:38, that the Director of Facilities was in charge of the 'Ligature Risk' team.

Director of Facilities, Employee # 21, revealed during an interview conducted 6/15/2018 at 14:35, that his/her responsibility was to create work orders and the environmental safety rounds are attended by the Facilities Lead.

Facilities Lead, Employee # 37 confirmed in private interview conducted 6/18/2018 at 1400, that s/he attends environmental rounds occasionally, approximately 2 times per year. It was revealed s/he would like to participate more but is not invited or included on all the rounds. S/he received work orders from the Director of Facilities making him/her aware of what work needs to be done.

Sr. Vice President and RN Regulatory Compliance employee, both confirmed in interview they were aware of the ligature issues with the doors and hinges on the psychiatric units at Desert Vista and Maricopa Medical Center Annex. MIHS BHT II meeting minutes from January, March, and May revealed the clinical staff were aware of ligature issues with the doors and hinges on the psychiatric units. A "Ligature Risk" team had been formed to address ligature risk issues. There was no evidence to indicate that Administration, Quality/Compliance, or Facility's department management was monitoring ligature risks on the hospital's psychiatric units.