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Based on review of policy and procedure, record review, observation, and interview, it was determined the patient's right to care in a safe setting was not protected, when one (1) of one (1) patients admitted to the Emergency Department (ED) for suicidal ideation with a plan and intent did not receive the 1:1 level of observation ordered for the patient (Patient #20). The risk of failure to ensure constant 1:1 observation of the patient could potentially lead to a suicide attempt by the patient while under the care of the Hospital's nursing staff.

Findings include:

The Oro Valley "Suicide Risk Assessment and Intervention in Acute Setting Policy" revealed: "I. PURPOSE: To identify patients at risk for suicide and provide safety interventions...III. Levels of supervision 1. Continuous Visual Surveillance: One Observer to one Patient (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately...."

Patient #20 presented to the hospital ED with a Chief Complaint/Precipitating event: "...according to patient...which led client to see (sic) treatment at this time."

The Physician assessment of the patient revealed: "Patient is a (young middle-aged) male who comes to the ED today due to suicidal ideations. The patient said he's been feeling suicidal since yesterday and confirmed a past history of suicidal ideations/depression. The patient believes that his kids and family are better off without him and had plans to jump off a building. However, he decided to come (to) the ED after voices in his head told him to do so...."

The ED physician ordered the recommended "Level One psychiatric placement due to SI (suicidal Ideation)."

The Licensed Clinical Social Worker (LCSW) who evaluated the patient in the ED, documented that: "...the patient had current legal difficulties. The patient reported that he was hearing voices that are demons, and that he had thoughts in his brain that he could not control...." The patient tested positive in the ED for cannabanoid and amphetamine.

The "Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting" revealed that the patient "Reported" with an "X" in front of the verbiage: "Verbal commands to do self harm to self or others (command hallucinations) and "Behavior that has resulted in harm to self or others, including actual suicide attempt...Psychotic symptoms: hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior...." The "Interventions" for the "Reported" symptoms required "Continuous visual surveillance 1:1."

On 09-19-17 at 8:40 AM, Patient #20 was observed lying on a gurney/bed in Room #5, the room first used most frequently for behavioral health patients. The gurney/bed was observed to have a raised stationary intravenous (IV) pole which was affixed securely to the bed, and the patient was observed to be lying on a cloth sheet. Staff #46, a Registered Nurse (RN), was standing inside the patient's room. The RN was then observed to leave the patient and her ability to have constant visual surveillance was no longer available. The RN walked over to the nurses station and answered an incoming phone call. The RN appeared engaged in the call, and was not viewing the monitor that would have revealed visually what the patient was doing in her absence.

The ED Nursing Manager acknowledged, during interview conducted on 09-19-17 at 8:40 AM, that the RN should not have left the patient while he was on 1:1 observation. The Manager acknowledged that the stationary IV pole on the gurney/bed, with the cloth sheet as a bed covering, could have been used for the patient to attempt suicide by hanging.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined for 1 of 6 clinical records reviewed of patients who were restrained in the total sample of 44, the hospital failed to ensure the restraints were released at the earliest possible time. (Patient #33). This deficient practice poses the risk of physical and/or emotional harm to patients restrained without justification.

Findings include:

The hospital's policy titled "Restraint and Seclusion Policy" included: "A restraint is either a non-violent...or violent self destructive restraint...Violent/self-destructive behavioral reasons for the use of restraints are primarily to protect the patient against injury to self or others because of an emotional or behavioral disorder with violent or self-destructive behavior...Staff is expected to assess and monitor the patient to ensure the patient is released from restraint or seclusion at the earliest possible time."

Patient #33:

Nursing documentation in a Restraint Documentation Flow Sheet in the clinical record revealed the patient had restraints applied to all four extremities at 5 p.m. on 09/03/2017 while in the Emergency Department (ED) because of "Violent behavior from the patient." Further documentation revealed the patient remained in the 4-point restraints until 5 a.m. on 09/04/2017, a period of 12 hours. The patient's "Level of Awareness" during that time was documented to be "2" which according to the code key was "Sleeping/Sedated" and a handwritten entry was added that the patient was sleeping/sedated " with alcohol." The physician documented in the Violent/Self-Destructive Restraint Progress Note on 09/03/2017 at 5 p.m., that the patient's immediate situation was "intoxicated," he had "no response" to the restraints, and the patient would continue to be restrained for "patient & staff safety." At 9 p.m. on 09/03/2017 the physician's documentation included: "pt is sedated with Etoh (alcohol) now...need to restrain until he wakes & we know he won't hit staff."

The record was reviewed with the Director of Emergency Services who acknowledged the documentation in the record did not support the need to keep the patient restrained for 12 hours.

Based on review of policy and procedure, RN Behavioral Health job description, observation, and interview, it was determined that the Director of Nursing (DON) failed to be responsible for the operation of nursing services, when nursing personnel on the Senior Behavioral Health Unit (SBHU) documented they had checked the crash cart appropriately, but the oxygen tank was at 1500 pounds per square inch (psi), instead of the required 2000 psi. The potential risk is that in the event of a code or respiratory emergency, on a behavioral unit housing patients with medical comorbidities, there may not be the required level of oxygen to care for patients in cardiac or respiratory distress, leading to a negative patient outcome.

Findings include:

The Oro Valley Hospital "Code Cart Maintenance" policy, last reviewed in June, 2017, revealed: "I. PURPOSE: To maintain code carts which provide life support medications, supplies and equipment in the event of an emergency or cardiac/respiratory arrest. II. POLICY: Code carts are maintained in patient care areas by...Nursing...III GUIDELINES:...E. Code carts are checked each shift by nursing or designated department staff...IV. PROCEDURE:...Check the proper operation and readiness of the equipment listed...3. If the code cart is not complete, the assigned staff member alerts the following: a. RN (Registered Nurse)/Charge person...." The "Attachment B-Code Cart Maintenance Checklist" revealed that the oxygen tank on the Code Cart should maintain oxygen tank levels at 2000 psi.

The Behavioral Health RN job description revealed: "...12. Comply with safety & security policies...."

Observation of the Code Cart on the SBHU, conducted on 09-15-17, revealed that from 09-01-17, through 09-15-17 A.M., the oxygen level was recorded as 1500 psi on 25 occasions (each 12 hour shift). "Staff Initials," many of which were illegible, revealed that at least 16 different staff members documented 1500 psi instead of the required 2000 psi, and failed to follow the policy or rectify the situation.

The DON acknowledged, during interview conducted on 09-15-17 at 12:30 PM, that the policy required that 2000 psi of oxygen was required by policy to be on the code cart. The DON acknowledged that each of the nursing personnel who checked the cart failed to be responsible to ensure the Code Cart policy was followed to ensure the safety of patients admitted to the unit.

Based on review of hospital policies and procedures, review of clinical records, and staff interviews, it was determined:

1. that a registered nurse (RN) responsible for the care of a patient with Suicidal Ideation, failed to assess and supervise the patient's care, when a patient on a 1:1 observation level in the Emergency Department (ED) was not provided continual visual surveillance as ordered (Patient #20). The potential risk is that the patient with suicidal ideation could attempt to hang himself with the cloth bedsheet using the stationary raised intravenous (IV) pole on the bed as a ligature point.

2. that a registered nurse failed to supervise and evaluate the care of two (2) of two (2) patients on the Senior Behavioral Health Unit (SBHU) who had been admitted to the unit requiring detoxification from alcohol, when the physician's orders for the use of the CIWA protocol for assessment and treatment of the patients was not followed (Patients #8 and #9). The potential risk of failure to assess and evaluate the care of patients experiencing alcohol (ETOH) withdrawal, is the potential for Alcohol Delirium and increased mortality risk to the patients.

3. the hospital failed to ensure for 2 of 3 clinical records reviewed of patients who had cardiac catheterization procedures (Patients #37 and #38) in the total sample of 44, that physician orders and hospital policies and procedures were followed for the care of the patients after the procedures. This deficient practice poses the risk of arterial bleeding after the procedure not being identified and addressed which could result in harm to the patient up to and including death.

Findings include:

1. Cross reference Tag A0144 relative to an RN failure to ensure that a patient with Suicidal Ideation, ordered on 1:1 observation, was under continual visual surveillance in a room with a stationary elevated intravenous pole and a cloth sheet covering the gurney/bed (Patient #20).

2. An internal document titled "CIWA" revealed background statistical information regarding Alcohol Withdrawal Syndrome (AWS) and the protocol from which the psychiatrist based his/her orders for patients in the process of detoxification from alcohol (ETOH).

The "CIWA Orders" revealed the following:

"Alcohol assessment documented in chart
Seizure precautions
Initial CIWA-Ar (revised) performed and documented
if Initial CIWA-Ar score < or=7, CIWA assessment and VS (vital signs) q (every) 4 hours
If initial CIWA-Ar score > =8, CIWA assessment and VS q (every) 1 hour times 8 hours
then every 2 hours for 8 hours if score is decreasing and symptoms improving
then every 4 hours if score decreasing and improving
CIWA assessment discontinued if 72 hours of scores of 7 or less
Any addition (sic) nursing orders the provider writes should be completed
IMPORTANT NOTE
If at any time the CIWA-Ar score is 8 or higher the 8 hours of hourly reassessment and VS is (sic) reinitiated."

Measurement of the CIWA score is derived from numerical values assigned to the following measures: "Nausea and Vomiting, Tremor, Agitation, Anxiety, and Paroxysmal Sweats, Orientation and Clouding of Sensorium, Tactile disturbances, Auditory Disturbances, Visual Disturbances, and Headache. Total Score is then computed and appropriate medication or treatment is completed and documented immediately."

The CIWA protocol, unless otherwise ordered by physician, was 1 milligram (mg) of Lorazepam for a score of 8-13, and 4 mg of Lorazepam for a score of 14-20 at specifically ordered intervals.

Patient # 8

Patient #8 was admitted to the SBHU with acute alcohol intoxication, alcohol withdrawal symptoms, and suicidal ideations. The patient had a history of chronic atrial fibrillation with pacemaker placement. The patient's psychiatric history and physical revealed: "...states "it's never been this bad, the shaking and physical discomfort is the worst it's ever been...."

Record review revealed that on 09-06-17, beginning at 8:00 AM, the patient should have begun hourly CIWA scores with vital signs, as the CIWA score was 11. The patient was administered 2 milligrams of Ativan for a one time dose. The patient's hourly CIWA assessments should then have been done hourly 8 AM through 4 PM. On 09-06-17, the next assessment after the 8 AM assessment did not occur until 12 noon, at which time the score had risen to 18. Only three (3) total CIWA assessments were conducted on 09-06-17 between 8 AM and 9 PM. that evening. It is unable to be determined what doses of Lorazepam should have been administered during that 8 hour period, as the CIWA assessments were not done hourly as ordered. The hourly reassessments were not restarted as ordered when the CIWA score was above 8 at 9:00 PM that night. Vitals signs were not aligned with the times the CIWA assessments were done per orders. On 09-06-17 at 9 PM, with a score of 13, the hourly assessments should have been reinitiated, and were not. RN #43 was assigned the care of the patient, and had no current competencies in the care of patients on CIWA protocol.

Patient # 9

Patient #9 was admitted to the SBHU on 09-13-17, with chronic liver disease secondary to Hepatitis C and alcoholism. The admitting psychiatrist documented that the patient "usually has a complicated alcohol detox regimen." On 09-13-17 at 2 PM, the patient scored 8 on the CIWA scale, which would have started the initiation of hourly CIWA assessment and vital signs. The CIWA assessment was conducted hourly until the 8 PM assessment, which was missed. At 10 PM on 09-13-17, the assessments should have been conducted q 2 hours according to the CIWA score starting at 10 PM. The assessments should have been conducted at midnight on 09-14-17, 2 AM, 4 AM, and 6 AM. No CIWA assessments were conducted between 1 AM and 5 AM.

The Director of Nursing acknowledged, during interview conducted on 09-15-17, at 11:00 AM, that the CIWA assessments were not conducted according to the protocol orders on Patients #8 and #9. The DON acknowledged that the CIWA protocols are complex, and require that vital signs be aligned time-wise with the CIWA-Ar assessments. The DON acknowledged that without having the correct sequential algorithm of the assessments, it was challenging to be able to determine if Lorazepam should have been administered more frequently than it was administered to Patients #8 and #9.


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3. The hospital's policy and procedure titled "Arterial Hemostasis" included: "Purpose...To achieve effective hemostasis and prevent complications during and after arterial line removal...Removal of Radial Arterial Sheath Using Radial Occlusion Device...To remove band, slowly loosen/deflate device and observe for bleeding. Remove device from wrist and apply clear dressing. Check site as ordered. Document procedure...Instruct patient to not manipulate wrist for 24 hrs."

Patient #37

Patient #37 had a cardiac catheterization procedure performed on 09/13/2017, during which the patient's right femoral artery and right radial arteries were accessed. The last entry on the Cardiac Cath procedure flowsheet was at 6:12 p.m. and the patient arrived on the Telemetry Unit within 15-20 minutes after that time. Physician's orders at 6:29 p.m. for post catheterization care included site checks and neurovascular assessments of the patients upper and lower extremities including pulse checks every 15 minutes for one hour; every 30 minutes for two hours; and every hour for four hours.

Nursing documentation revealed neurovascular checks were done at 7 p.m., 8 p.m., and 9 p.m., pulses were checked at 7 p.m. and not again until 9 a.m. on 09/14/2017. There was no documentation that site checks were performed at all.

Patient #38

Patient #38 had a cardiac catheterization procedure performed on 09/13/2017, during which the right femoral artery was accessed. The patient was transferred to the Intensive Care Unit after the procedure at approximately 2:30 p.m. with physician orders for post procedure care.

Wound site checks were documented in a nurse's note at 2:40 p.m., and not again until 8 p.m., and then not again until the following morning, 09/14/2017 at 8 a.m. Pulses were documented at 8 p.m. and 10 p.m. on 09/13, and not again until 8 a.m. on 09/14/2017.

The clinical records were reviewed with various nurse leaders who acknowledged there was not documented evidence in the records that hospital policies and procedures and physician orders were followed for post-cardiac catheterization patients.

Based on the Director of Senior Behavioral Health job description, the Behavioral Health Registered Nurse (RN) job description, personnel file review, and interview, it was determined that nursing personnel on the Senior Behavioral Health Unit (SBHU) were not assigned in accordance with the needs of patients receiving alcohol detoxification, when two (2) of two (2) RNs had no current competencies to care for patients on a CIWA protocol (RN #43 and #44).

Findings include:

Cross reference Tag 0395 relative to failure of the nursing staff to conduct CIWA assessments according to the CIWA protocol.

The Director, Senior Behavioral Health job description revealed: "Provides overall management and strategic leadership for the SBHU...7. Analyzes & evaluates nursing and clinical services to improve quality of patient care...."

The RN-Behavioral Health job description revealed: "...Position Specific Essential Functions...5. Determine patients' alcohol or drug toxicity & identify signs of withdrawal...."

Review was conducted of the personnel files of RN #43, and RN #44, respectively. Neither RN had current documented competencies to conduct CIWA protocols.

The Director of Nursing acknowledged, during interview conducted on 09-15-17, that it would be appropriate to conduct CIWA protocols annually since it is a high risk nursing function.