HospitalInspections.org

Based on review of policies, procedures, physician credential files, medical staff bylaws, rules and regulations, interviews with staff, meeting minutes, and hospital documents, it was determined:

(Tag A0046) the governing body failed to appoint medical staff members as demonstrated by not having documentation of participation of the governing body approving the medical staff appointments with privileges documented from the hospital's governing body appointing them to the medical staff. Failure to appoint medical staff poses a high potential risk in unqualified medical staff members providing patient care;

(Tag A0048) the governing body failed to approve the medical staff had bylaws, rules and regulations for this hospital's campuses. Failure to have approved Medical Staff Bylaws Rules and Regulations for medical staff to follow poses a high potential risk to the health and safety of patients treated by the medical staff, who do not have guidance from medical staff bylaws;

(Tag A0049) the governing body failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients, as evidenced by:

1. the governing body has not approved the QI plan;

2. the medical staff cannot demonstrate the governing body periodically apprised the medical staff and evaluated the patient care services provided by the hospital, at every patient care location of the hospital;

Failure to ensure the medical staff is accountable to the governing authority poses the high potential risk for unsafe medical care provided by the medical staff;

(Tag A0057) the governing body failed to appoint the chief executive officer (CEO). Failure to appoint a CEO poses the high potential risk in the ability of the hospital to meet the Conditions of Participation by lack of leadership; and

(Tag A0085) the governing body failed to maintain a list of all contracted services which included the scope and nature of the services provided. This failure poses the potential risk that services provided by contract are not identified and/or evaluated to ensure compliance with the Conditions of Participation.

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

Based on review of policies, procedures, medical records, personnel files, physician credential files, hospital documents, observations by the State Agency, and interview with staff, it was determined the hospital failed protect and promote each patient's rights as evidenced by:

(Tag A0144) the hospital failed to ensure patients received care in a safe setting as evidenced by:

1. Patient #1 eloped out of the hospital on 03/13/17 at approximately 0840 hours, when s/he removed the telemetry leads, and was discovered to be off the hospital premises at 1130;

2. RN #7 assigned to the 3rd floor medical/surgical unit on 03/17/17, left the unit to obtain medications, leaving the unit without staff;

3. None of the RN's, LPN's or CNA's working during the day shift at the Phoenix campus on 03/17/17, knew if they were assigned to the code team/rapid response team, to respond if an emergency occurred with a patient, on that day;

4. The following observation on the 4th floor of the Phoenix Hospital campus on 3/17/17 @ 1550 hours, revealed that the CCO identified a patient alarm as a "bathroom" alarm, and it was determined to be the ventilator low pulse oxygenation alarm; and

5. Ten (10) of 24 staff, consisting of RN's LPN's, CNA's and Monitor Technicians, did not have documentation of competencies (Staff #'s 6, 13, 14, 23, 28, 32, 36, 42, 43, and 54).

Failures identified above pose a high potential risk for patient harm.

(Tag A0167) the hospital failed to require 3 of 3 patients reviewed for restraints, were restrained according to policies, physician orders, and patient needs (Patient #'s 2, 3, and 20).This deficient practice posed the high potential risk for violation of patients rights to be free of restraints when not required, to ensure the safety of patients.

The cumulative effect of these systemic deficiencies resulted in the hospital's inability to promote and protect the patient's rights in a safe environment.

Based on review of hospital policies, documents, medical record for Patient #1,and staff interview, it was determined:


(A0273) the hospital failed to establish, implement, and maintain a Quality Program. Failure to maintain a Quality Improvement Plan poses the high potential risk that issues effecting patients are not identified, tracked, and addressed that impact health outcomes, patient safety, and quality of care.

The cumulative effect of these systemic deficiencies resulted in the hospital's inability to implement and maintain an effective ongoing Quality Assessment Performance Improve Plan.




The Director of Quality provided the following during an interview conducted on 03/22/17:

1. Quality Improvement (QI) Plan (dated 01/2017) requires, "...This company wide quality improvement process includes identifying and implementing opportunities to improve the quality of patient care ...quality improvement efforts will focus on direct patient care delivery processes and support processes that promote optimal patient outcomes...."

An untitled document (dated 12/2016) with raw data that included both Phoenix and Northwest hospital campuses with percentages figures for October, November and December 2016, in categories including but not limited to:

"...History and Physical (H&P) within 24 hours OCT.
Catheter Associated Urinary Tract Infection (CAUTI)
Central Line Associated Blood Stream Infection (CLABSI)
Skilled Nursing Facility (SNF) Discharges
Falls-All Patient falls (not lowered to floor)
Fall Rate
Wean Rate...."

The document did not identify what the percentages listed for each category referenced. The Director of Quality was unable to verify what the percentages indicated.

2. Two documents titled "Northwest (NW)" and "Phoenix (Phx)" respectively dated 2017 with additional raw data for categories and subcategories with percentages included in a column for the month of January. The Quality Director was unable to verify what the percentages indicated.

3. The 45 page "Kindred Hospital Leadership Committee Minutes Report" for July, 2016 through September, 2016. The Quality Director verified that this Report was created by the prior ownership and not CuraHealth Hospitals.

4. Quality Council Meeting Minutes dated 12/29/2016 (hours: 1403-1530) included a table containing columns for Topics; Discussion/Conclusion; Responsible Party; Recommendations; Follow up Action; and Due Date. Topics listed included: Introductions; Minutes Approval; Leadership Dashboard; PSR Dashboard; Performance Improvement (PI) Teams; Policy Review; and New Business. The "responsible party" column did not include a name for 4 of 7 topics. The "recommendations" column did not include recommendations for 4 of 7 topics. The "follow up action" column was blank for 6 of 7 topics. The "due date" was blank for 3 of 7 topics.

Quality Council Committee Meeting attendance record dated 12/29/16 confirmed the following excused/absent members: Medical Director (Phx), Chief of Staff, Medical Director (NW), Infection Control Practitioner (NW), and Chief Clinical Officer (COO).

5. CuraHealth Policy, PolicyStat ID: 2944498, last approved 11/2016, included: "...Purpose...Focus on continuous improvement systems that foster a culture of safety. Provide a confidential mechanism of identification, tracking, trending and follow up of all incidences that pose an actual or potential safety risk...An incident report will be submitted for any circumstance not consistent with the standard routing operations or care of a patient...."

Incident Reports require the following documentation: Type of incident (i:e: fall, acute care transfer, medication variance, equipment-related, patient death, miscellaneous, code blue) injury sustained, and medical treatment. The Report requires Description of Incident/Treatment Administered and Investigation Comments to include the investigator's signature, name and title.

Incident Reports for both campuses dated 10/01/16 to current revealed:

Phx. campus: 3 of 3 incidents were not investigated.
NW campus: 17 of 20 incidents were not investigated.

Patient #1's medical record revealed the following: "...03/13/17, 0945 (hours) Patient not in room, telemetry pack found on top of Med locker, nursing supervisor and security informed. Unable to find pt. (patient) inside building (hospital). Found to be off telemetry since 0840...03/13/17, 1130 Patient found by security outside of hospital property. Assisted back to the hospital/unit via wheelchair...."

The Director of Quality confirmed on 03/22/17, that the hospital does not have an inicident report for Pt. #1 eloping off the hospital's premises and confirmed the hospital has not investigated this incident.

The Director of Quality indicated that she had been employed for only two weeks (date of hire 03/06/17) since replacing the previous Director of Quality, and had not participated in any Quality Meetings as yet. The Director indicated that s/he would expect Quality to meet every 5 - 6 weeks but was unable to confirm that the committee met since 12/29/2016. S/he indicated that any information that may be available for Quality would be in the hospital's computer system but s/he has not have access since 03/19/17 due to technical issues. In addition, the Director stated that no Quality information was archived, and no measurable data was collected that s/he could locate.

The hospital's Quality committee had no meeting minutes or data to demonstrate if/what the hospital(s) have accomplished for Quality, and the Director of Quality could not articulate because she was newly employed and had no access to previous quality information.

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

(Tag A0396) failed to develop and keep current a nursing care plan for 3 of 3 patient records that were evaluated for nursing care plans. (Patient #'s 1, 2, and 3 ) This failure could jeopardize the colaboration of the patients' care team with the patients' goals and discharge needs;

(Tag A0397) failed to require the Registered Nurse assigned patient care according to the qualifications and skills of the staff, and patient acuities. This deficient practice posed the risk for inadequate staff skills mix required to meet the needs of patients with varying acuities and co-morbidities;

(Tag 0398) failed to ensure non-employee nurses had supervision and evaluation of their clinical skills for 1 of 1 registry, non-employee nurses (Staff #7) observed working on 03/17/17. This failure has the potential risk of unskilled nurses providing unsafe care to patients risking their health and safety; and

(Tag A0405) nursing failed to ensure medications orders were complete to include, the symptom or indication for use, the frequency, the minimum and maximum dosages, incremental dosing changes allowed and nursing did not follow a physician's order for a sedation vacation for 1 of 1 patient (Patient #3) receiving medications in the ICU. This failure could result in harm to a patient if a medication was improperly administered or if orders were not followed.

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

Based on review of 5 of 5 physician credential files, interviews with a medical staff member and the Regional Corporate Compliance Officer, it was determined that the governing body failed to appoint medical staff members as demonstrated by not having documentation of participation of the governing body approving the medical staff appointments with privileges documented from the hospital's governing body appointing them to the medical staff. Failure to appoint medical staff poses a high potential risk in unqualified medical staff members providing patient care.

Findings include:

Review of physician credential files for Providers #1 through 5 (inclusive) was conducted on 03/21/17, with the Regional Corporate Compliance Officer.

The Regional Corporate Compliance Officer confirmed the following during an interview conducted on 03/21/17: the governing body of this hospital has not appointed members of the medical staff. He explained that they have taken what the previous hospital had provided for the appointment of their medical staff. He confirmed that this governing body had not officially met to adopt the credentialing or privileges approved for the current medical staff. He added they will have an emergency meeting later today (03/21/17).

The hospital's president of the medical staff confirmed the following during an interview conducted on 03/23/17; s/he has not attended any medical staff or governing body meetings since this provider began operations on 10/01/16, until 03/21/17, when the hospital had emergency meetings of the medical executive committee and governing body meeting.

The governing body of this hospital has not appointed any of their medical staff members currently practicing at both hospital campuses or held a governing body meeting after taking ownership on 10/01/16, until 03/21/17, after the arrival of the State Agency for a Complaint Validation survey.

Based on review of the medical staff bylaws, and interview with the Regional Corporate Compliance Officer, it was determined that the governing body failed to approve the medical staff bylaws, rules and regulations for this hospital's campuses. Failure to have approved Medical Staff Bylaws Rules and Regulations for medical staff to follow poses a high potential risk to the health and safety of patients treated by the medical staff, who do not have guidance from medical staff bylaws.

Findings include:

The Medical Staff Bylaws requested and provided to the State Agency included the following document titled: "...Bylaws of the Medical Staff of Kindred Hospital Arizona - Phoenix and Kindred Hospital Arizona - Northwest Phoenix..." The document has an unsigned signature page.

The Regional Corporate Compliance Officer confirmed the following during an interview conducted on 03/22/17: the medical staff bylaws presented were from the last owner, and that this hospital's governing body had not adopted these bylaws until 03/21/17, after the arrival of the State Agency for a Complaint Validation survey.

Based on review of the Quality Improvement (QI) Plan (dated 01/2017), medical executive meeting minutes, and interview with the Director of Quality, it was determined that the governing body failed to ensure that the medical staff is accountable to the governing body for the quality of care provided to patients, as evidenced by:

1. the governing body has not approved the QI plan, and;

2. the medical staff cannot demonstrate the governing body periodically apprised the medical staff and evaluated the patient care services provided by the hospital, at every patient care location of the hospital.

Failure to ensure the medical staff is accountable to the governing authority poses the high potential risk for unsafe medical care provided by the medical staff.

Findings include:

1. The document titled Quality Improvement (QI) Plan (dated 01/2017) requires: " ...This company wide quality improvement process includes identifying and implementing opportunities to improve the quality of patient care...quality improvement efforts will focus on direct patient care delivery processes and support processes that promote optimal patient outcomes...The Governing Body delegates the implementation of the plan to Administration and the Medical Staff through the Quality Council, Medical Executive Committee and the hospital's Leadership Team...The Governing Body will review a quarterly summary of QI activities...Departmental indicators will be collected monthly and shared with Corporate...Hospital leadership will actively analyze, trend and address plans for improvement on a continuous basis...Quality will be reviewed quarterly by the Chief Quality Officer, CEO (Chief Executive Officer) and Quality Council, Medical Executive Committee and Governing Body...."

The Director of Quality/Chief Clinical Officer confirmed during an interview on 03/22/17, the Quality Plan dated 01/2017, has not been approved by the Governing Body.

2. The hospital provided two Medical Executive Committee Meeting (MEC) Minutes to the State Agency for review. One MEC meeting was held on 12/29/16, and another meeting on 02/22/17.

The Medical Executive Committee Meeting (MEC) minutes dated 12/29/16, did not contain evidence of peer review or ongoing professional practice evaluation (OPPE), focused professional practice evaluation (FPPE) or peer review. The MEC agenda for this meeting indicated the "Routine Business" included "OPPE / FPPE...Peer Review...."

The MEC meeting minutes for 12/29/16, did not include any notes regarding OPPE, FPPE or Peer Review.
The MEC Meeting notes dated 02/22/17, did not contain evidence of OPPE, FPPE, or peer review.

The President of the Medical Staff confirmed during an interview conducted on 03/23/17, that he has not participated in peer review with this hospital.

Based on review of governing body meeting minutes and interview with the Regional Corporate Compliance Officer, it was the determined the governing body failed to appoint the chief executive officer (CEO). Failure to appoint a CEO poses the high potential risk in the ability of the hospital to meet the Conditions of Participation by lack of leadership.

Findings include:

The hospital identified employee #29, as the CEO on 03/20/17, for both hospital campuses.

The Regional Corporate Compliance Officer confirmed the following during an interview conducted on 03/21/17: the governing body of this hospital has not appointed the CEO. He confirmed that this governing body had not officially met to appoint the CEO. He added they will have an emergency meeting later today (03/21/17), after the arrival of the State Agency for a Complaint Validation survey.

Based on review of hospital documents and interview with staff, it was determined the hospital failed to maintain a list of all contracted services which included the scope and nature of the services provided. This failure poses the potential risk that services provided by contract are not identified and/or evaluated to ensure compliance with the Conditions of Participation.

Findings include:

On 03/20/17, the State Agency requested a list on contracted services. On 03/23/17, the hospital provided a list with 86 names on it. The list did not contain the scope and nature of the services provided. The Regional Corporate Compliance Officer identified that Loyola University New Orleans School of Nursing Affiliation Agreement and Luby's Fuddruckers Restaurant were not for this location. He confirmed the list was for CuraHealth Corporation and they have hospitals in other parts of the nation.

The list did not contain the scope and nature of the services for each name on the list provided.

Based on review of the review of Patient #1's medical record, policy/procedures, hospital documents, observations and interview with staff, it was determined the hospital failed to ensure patients received care in a safe setting as evidenced by:

1. Patient #1 eloped out of the hospital on 03/13/17 at approximately 0840 hours, when s/he removed the telemetry leads, and was discovered to be off the hospital premises at 1130;

2. RN #7 assigned to the 3rd floor medical/surgical unit on 03/17/17, left the unit to obtain medications, leaving the unit without staff;

3. None of the RN's, LPN's or CNA's working during the day shift at the Phoenix campus on 03/17/17, knew if they were assigned to the code team/rapid response team, to respond if an emergency occurred with a patient, on that day;

4. The following observation on the 4th floor of the Phoenix Hospital campus revealed on 3/17/17 @1550 hours that the CCO identified a patient alarm as a "bathroom" alarm, and it was determined to be the ventilator low pulse oxygenation alarm; and

5. Ten (10) of 24 staff, consisting of RN's LPN's, CNA's and Monitor Technicians, did not have documentation of competencies (Staff #'s 6, 13, 14, 23, 28, 32, 36, 42, 43, and 54).

Failures identified above pose a high potential risk of harm to patients.

Findings include:

1. Patient #1's medical record revealed the following: "...03/13/17, 0945 (hours) Patient not in room, telemetry pack found on top of Med locker, nursing supervisor and security informed. Unable to find pt. (patient) inside building (hospital). Found to be off telemetry since 0840...03/13/17, 1130 Patient found by security outside of hospital property. Assisted back to the hospital/unit via wheelchair...."

The Director of Quality confirmed on 03/22/17, that the hospital does not have an incident report for Pt. #1 eloping off the hospital's premises and confirmed the hospital has not investigated this incident.

2. The State Agency observed on 3/17/17, the following:

-3rd Floor: The Census was 6 patients, of which (1) was a ventilator patient.

-Assignments (1) RN and (1) CNA for the 6 patients.

-The RN (Staff #7) confirmed during an interview on 03/17/17, at 1500 hours, the following: this was his/her first time working at this hospital, s/he is a registry nurse; s/he did not have any orientation prior to taking patients; s/he did not know if s/he was part of the code team; s/he did not have access to narcotics for the 6 patients; s/he had no knowledge of the acuity system for the hospital and s/he was not oriented to the hospital policy's and procedures.

The Interim Chief Clinical Officer (CCO) confirmed the above findings on 03/17/17.

At approximately 1537, on 03/17/17, the only RN assigned to the 3rd floor (Staff #7), left the unit, while the CNA was up on the 4th floor caring for his/her other 3 patients. The RN (Staff #7) left the unit and went to the ICU to have the RN obtain pain pills for a patient. This left the 3rd floor patients unattended without an RN or CNA on the floor. This observation was also observed by the interim CCO, who confirmed that the RN left the 3rd floor medical/surgical unit to obtain pain medications for her patient and the CNA was off the floor as well. No clinical staff were available for the patients.

3. The hospital policy titled Kindred Rapid Response Team, H-PC 07-021, Release date: 06/2016, required: "...The hospital has a designated team at all times who respond when a Rapid Response is called. That team most often consists of nursing supervisor, primary nurse for the patient, an ICU nurse or other ACLS (advanced cardiac life support) credentialed designee, respiratory therapist and pharmacist. The specific RR team members are identified each shift on a designated form (e.g., assignment sheet)...."

Only one of the clinical staff verbalized that they were on the code team/rapid response team on that day. No other staff knew if they were part of the code team/rapid response team, to respond as part of the emergency team for a patient.

A review of the staffing forms for the Phoenix campus revealed the form did not contain assignments for the rapid response/code team.

Staff #13 confirmed the above finding on 03/17/17.

4. At approximately 1550 hours on 3/17/17 , an alarm was heard at the nursing station and observed flashing at the door of the patient's room. No staff responded immediately to the alarm and the Surveyor walked down the hall by the room with the alarm. A CNA was present in another patient's room and came out of the room. S/he said the alarm was a "vent" alarm and ran to the patient's room. The CCO who was accompanying the surveyors remained at the nurses station and then walked down the hall towards the surveyor, who asked what the alarm meant, s/he responded that this was a "bathroom" alarm.

The CCO was acting as the nursing supervisor on this day and confirmed s/he did not know the different alarms and did not have any orientation or training.

5. The hospital policy titled CuraHealth Hospital Competency of Staff, PolicyStat ID: 2775298, last approved: 09/2016, required: "...Policy: To maintain and improve staff competencies, the hospital assures ongoing assessment and demonstration of competencies for all hospital positions. Additionally, a system for assuring the licensure, registration and certification required for patient care staff is continually maintained...Employees are required to complete general orientation provided by the Human Resources Department. To provide guidelines for competencies for all hospital positions. To maintain and improve staff competencies, the hospital assures ongoing assessment and demonstration of competencies for all hospital positions...."

A review of 24 personnel files was conducted on 03/22/17 and 03/23/17. Ten (10) of the 24 files did not contain documentation of demonstration of competencies. The files missing competencies included RN's , LPN's, CNA's and Monitor Technicians.

Staff #13 and #18 confirmed the ten personnel files did not have any documentation regarding competencies as required by policy.

Based on review of hospital policies/procedures, documents, physician credential files, medical records, staff and physician interviews and observations during tour, it was determined that hospital failed to require 3 of 3 patients reviewed for restraints, were restrained according to policies, physician orders, and patient needs (Patient #'s 2, 3, and 20). This deficient practice posed the high potential risk for violation of patients rights, to be free of restraints when not required, to ensure the safety of patients.

Findings include:

The Regional Corporate Compliance Officer provided the following current policies during an interview conducted on 03/24/17:

Kindred Healthcare Patient Rights and Responsibilities, Policy H-PC-09-001(released 06/2016) requires: "...To provide an environment that both respects and protects the rights of patients and patent's families; and to conduct all activities related to care with primary concern for the values and dignity of patients...."

CuraHealth Patient Bill of Rights and Responsibilities requires: "...Be free from restraints or seclusion imposed as a means of coercion, discipline, convenience or retaliation by staff...."

Kindred Healthcare Physical Restraints (Violent and Non-Violent Behavior) and Seclusion, Policy H-PC-07-009, (released 06/2016) requires: "...this policy applies to ensure restraints are used safely, for the shortest possible time and discontinue at the earliest opportunity...Restraint Episode: begins when the physical restraint is applied to the patient's body...ends when the criteria for release are met and the restraint is removed. Non-Violent restraint episodes may not exceed 7 calendar days following the calendar day the order was first obtained (ending at midnight on the 8th day)...Timeframes for Orders. A physician...order for Non-Violent restraint use may not exceed (7) calendar days following the calendar day the order was obtained...."

Kindred Healthcare Physical Restraints (Violent and Non-Violent Behavior) and Seclusion Procedure H-PC 07-009 PRO requires: "...Ongoing assessment (at least daily) by an RN of the patient's behavior, whether the unsafe situation is resolved and whether the criteria for discontinuing the restraints are met...Ongoing Safety Checks & Monitoring (at least every two hours or as noted on the designated forms) by the patient's clinical team of the patient's response to the restraint, including any condition changes...."

The Restraint Monitoring Form requires the staff initial and document the following every 2 hours: safety checks including range of motion offered/ provided; Food/ fluids offered/ provided; toileting offered/ provided; dignity/comfort/hygiene maintained; Managed safety/no injury; mental status unchanged; skin integrity unchanged; temporary release during care given; Geri chair/ side rails in use; circulatory status of restrained extremities unchanged; and pain managed (per policy).

Northwest Campus Medical Director MD #7 indicated during an interview conducted on 03/24/17 that restraint orders are renewed every 24 hours. The physician's credential file included a "Restraint Attestation" dated 12/29/2015 that required: "...Restraints must be re-ordered every 24 hours by the physician after an assessment is done to determine if patient meets the criteria for continuing restraint...."

Patient # 2

Patient #2's medical record contained a restraint monitoring form dated 03/10/17, 0800 through 0600 the next day. No order was written for the continued restraint of Pt. #2.

Staff #6 confirmed the medical record did not have an order for restraint on 03/10/17.

Patient #2's medical record contained a restraint monitoring form dated 03/13/17. The form was blank from 0800 until 1800 hours. No safety checks were signed off as completed. At 2000 hours staff filled out the monitoring form, completing the 2 hour checks. The medical record did not have an order for the restraint applied on 03/13/17 at 2000 hours, or staff did not complete the every 2 hour safety checks as required. Documentation in the medical record was not clear if the patient was in restraints and no safety checks were performed or staff released the restraints and then did not obtain another order to reapply the restraints at 2000 hours.

Staff #6 confirmed the above findings.

Patient #2's medical record contained a Restraint Monitoring Form dated 03/17/17. The form was blank from 0800 until 2000 hours on that day. No safety checks were documented. Staff began documenting safety checks at 2000 hours and every 2 hours until 2400 hours. The medical record did not have an order for the restraint applied on 03/17/17 at 2000 hours, or staff did not complete the every 2 hour safety checks as required. Documentation in the medical record was not clear if the patient was in restraints and no safety checks were performed or staff released the restraints and then did not obtain another order to reapply the restraints at 2000 hours.

Staff #6 confirmed the above findings.

Patient # 3

Patient #3's medical record contained a Restraint Monitoring Form dated 02/23/17, and indicated the patient was placed in restraints of some kind, which are not documented, and those restraints were left on the patient for 14 hours, from 0800 until 2200. The medical record did not contain an order for this restraint episode.

Staff #6 confirmed the above finding on 03/21/17.

Patient #3 had an order for restraints written on 03/16/17, at 0900 hours. Nursing did not document on a Restraint Monitoring Form for this restraint for 14 hours, 0900 through 2300 hours. The patient did not have documentation of the safety checks and every 2 hour monitoring as required.

Staff #6 confirmed the above finding on 03/21/17.

Patient # 20

Patient #20's medical record revealed Medical Director MD #7's telephone order on 03/16/17 at 2000 to initiate bilateral wrist restraints.

The Restraint Monitoring Form(s) confirmed the staff initiated restraints on 03/20/17 at 2100 and documented every 2 hours from 03/16/17 2200 through 03/20/17 0600 (except for the 1400 entry on 03/17/2017). The RN did not document and sign the required "...Daily Assessment to Determine Need for Restraints..." and/or "...Is the need for restraint resolved...." on 03/17/17, 03/20/17, and 03/21/17.

The surveyor observed Patient #20 in bilateral wrist restraints during tours conducted between 1000 and 1600 on 03/22/17 and 03/23/17.

Medical Director MD #7 indicated during an interview conducted on 03/24/17, that Patient #20 was not restrained during the day when the family was at the bedside; however, the nursing staff indicated during interviews that the patient was restrained throughout the day and the restraints were only removed for meals and patient care.

The staff confirmed the patient remained in restraints during the night.

Hospital practices for patient restraints were inconsistent with the staff, physician, and policy.

Based on review of hospital policies, documents, medical record for Patient #1,and staff interview, it was determined that the hospital failed to establish, implement, and maintain a Quality Program. Failure to maintain a Quality Improvement Plan poses the high potential risk that issues effecting patients are not identified, tracked, and addressed that impact health outcomes, patient safety, and quality of care.

Findings include:

The Director of Quality provided the following documentation on 03/22/17: policies and procedures, facility documents and Quality Council meeting minutes.

-Quality Improvement (QI) Plan (dated 01/2017) requires: "...This company wide quality improvement process includes identifying and implementing opportunities to improve the quality of patient care ...quality improvement efforts will focus on direct patient care delivery processes and support processes that promote optimal patient outcomes...."

-An untitled document (dated 12/2016) identified raw data that included both Phoenix and Northwest hospital campuses with percentages figures for October, November and December 2016, in categories including but not limited to:

"...History and Physical (H&P) within 24 hours OCT.
Catheter Associated Urinary Tract Infection (CAUTI)
Central Line Associated Blood Stream Infection (CLABSI)
Skilled Nursing Facility (SNF) Discharges
Falls-All Patient falls (not lowered to floor)
Fall Rate
Wean Rate...."

The document did not identify what the percentages listed for each category referenced.

The Director of Quality was unable to verify what the percentages indicated.

-Two documents titled "Northwest (NW)" and "Phoenix (Phx)" respectively dated 2017,with additional raw data for categories and subcategories with percentages included in a column for the month of January. The Quality Director was unable to verify what the percentages indicated.

- Surveyor was provided the 45 page "Kindred Hospital Leadership Committee Minutes Report" for July, 2016 through September, 2016.

The Quality Director verified that this Report was created by the prior ownership, and not CuraHealth Hospitals.

- Quality Council Meeting Minutes dated 12/29/2016 (hours: 1403-1530) included a table containing columns for Topics; Discussion/Conclusion; Responsible Party; Recommendations; Follow up Action; and Due Date. Topics listed included: Introductions; Minutes Approval; Leadership Dashboard; PSR Dashboard; Performance Improvement (PI) Teams; Policy Review; and New Business. The "responsible party" column did not include a name for 4 of 7 topics. The "recommendations" column did not include recommendations for 4 of 7 topics. The "follow up action" column was blank for 6 of 7 topics. The "due date" was blank for 3 of 7 topics.

-Quality Council Committee Meeting attendance record dated 12/29/16, confirmed the following excused/absent members: Medical Director (Phx), Chief of Staff, Medical Director (NW), Infection Control Practitioner (NW), and Chief Clinical Officer (COO).

-CuraHealth Policy, PolicyStat ID: 2944498, last approved 11/2016, included: "...Purpose...Focus on continuous improvement systems that foster a culture of safety. Provide a confidential mechanism of identification, tracking, trending and follow up of all incidences that pose an actual or potential safety risk...An incident report will be submitted for any circumstance not consistent with the standard routing operations or care of a patient...."

-Incident Reports require the following documentation: Type of incident (i:e: fall, acute care transfer, medication variance, equipment-related, patient death, miscellaneous, code blue) injury sustained, and medical treatment. The Report requires Description of Incident/Treatment Administered and Investigation Comments to include the investigator's signature, name and title.

Incident Reports for both campuses dated 10/01/16 to current revealed:

Phx. campus: 3 of 3 incidents were not investigated.
NW campus: 17 of 20 incidents were not investigated.

Patient #1's medical record revealed the following: "...03/13/17, 0945 (hours) Patient not in room, telemetry pack found on top of Med locker, nursing supervisor and security informed. Unable to find pt. (patient) inside building (hospital). Found to be off telemetry since 0840...03/13/17, 1130 Patient found by security outside of hospital property. Assisted back to the hospital/unit via wheelchair...."

The Director of Quality confirmed on 03/22/17, that the hospital does not have an inicident report for Pt. #1 eloping off the hospital's premises and confirmed the hospital has not investigated this incident.

The Director of Quality indicated that she had been employed for only two weeks (date of hire 03/06/17) since replacing the previous Director of Quality, and had not participated in any Quality Meetings as yet. The Director indicated that s/he would expect Quality to meet every 5 - 6 weeks but was unable to confirm that the committee met since 12/29/2016. S/he indicated that any information that may be available for Quality would be in the hospital's computer system but s/he has not have access since 03/19/17 due to technical issues. In addition, the Director stated that no Quality information was archived, and no measurable data was collected that s/he could locate.

The hospital's Quality committee had no meeting minutes or data to demonstrate if/what the hospital(s) have accomplished for Quality, and the Director of Quality could not articulate because she was newly employed and had no access to previous quality information.

Based on review of policy and procedures, medical records and interview with staff, it was determined the hospital failed to develop and keep current a nursing care plan for 3 of 3 patient records that were evaluated for nursing care plans. (Patient #'s 1, 2, and 3 ) This failure could jeopardize the colaboration of the patients' care team with the patients' goals and discharge needs.

Findings include:

The hospital policy titled CuraHealth Hospital Nursing Weekly Care Plan, PolicyStat ID: 2855765, last approved, 10/2016, required: "...The Plan of Care will be initiated by an RN after completion of the Admission Assessment...Once a week, prior to the team conference, a new weekly care plan form will be completed...."

Patient # 1

Patient #1 was admitted on 03/02/17 and discharged on 03/17/17. Review of the medical record on 03/17/17, revealed the following: one nursing care plan was initiated 4 days after the patient was admitted to the hospital and dated the week of 03/06/17 through 03/13/17. No other nursing care plans were in the medical record.

Staff #6 confirmed on 03/21/17, the findings that the care plan was not initiated after the nursing assessment on 03/02/17 and a second care plan was not initiated a week later.

Patient # 2

Patient #2 was admitted on 02/28/17 and discharged on 03/17/17. Review of the medical record on 03/21/17, revealed the following: one nursing care plan was initiated on 02/28/17, and no other care plans were in the medical record.

Staff #6 confirmed on 03/06/17, that the patient required 2 other care plans be initiated and nursing failed to initiate and update the care plan for the patient.

Patient # 3

Patient #3 was admitted on 02/22/17 and discharged on 03/17/17. Review of the medical record on 03/21/17, revealed the following: one care plan was initiated on 03/05/17, eleven days after the patient was admitted to the hospital's ICU.

Staff #6 confirmed on 03/06/17, that the patient's care plan was not initiated required 2 other care plans be initiated and nursing failed to initiate and update the care plan for the patient.

Based on review of hospital polices, documents, observation, and staff interviews, it was determined that the hospital failed to require the Registered Nurse assigned patient care according to the qualifications and skills of the staff, and patient acuities. This deficient practice posed the high potential risk for inadequate staff skills mix required to meet the needs of patients with varying acuities and co-morbidities.

Findings include:

The hospital employs RNs, LPNs, and CNAs (Certified Nurse's Aid). The hospital cares for patients with multiple co-morbidities such as wound care, ventilators, isolation precautions, multiple medications, intravenous lines, dialysis, and varied activity levels.

The policy titled Nursing Acuity Tool and Guidelines #2900043 (last revised 10/2016) required: "...Nurse Assignment Criteria...Patients are allocated to nurses according to total acuity...."

The Nursing Acuity Tool requires the nurse to assess, determine, and assign each patient acuity according to four (4) Acuity Categories: Complicated procedures, Education, Psychosocial or therapeutic interventions, Medications (oral), and Complicated IV (intravenous) drugs and other meds. Each category is scored on a number value of 1 - 4, based on the number of interventions required which are weighted (interventions are weighted 1 - 4 depending on the complexity). The points for each category are added together for the "grand total" acuity score, as follows:

Acuity Category Scores:
Level 1: 1 - 15
Level 2: 16 - 30
Level 3: 31 - 45
Level 4: 45 or greater.

The highest possible total score is 60. The Grand Total score determines the patient's acuity level. The policy does not identify how staffing is determined based on the scores and does not differentiate for the staff mix: RN, LPN and CNA.

The Phoenix staffing/patient assignment forms revealed:

03/17/17: 4th Floor census: 13 patients (2) ventilator patients: Assignments (1) RN, (1) LPN, (1) CNA. No acuity was identified for the patients on the 4th floor. Interviews with the staff working revealed none of the staff knew if they were assigned to the code team for that day.

The Interim Chief Clinical Officer (CCO) confirmed on 03/17/17, they did not have acuity for the patients and none of the staff knew if they were assigned to the code team.

03/10/17: 3rd Floor Census 6: (1) RN assigned with no other staff on the unit. No acuities were identified for the patients on the staffing forms.

Staff #12 confirmed the staffing for this day, and the lack of the documentation of the patients' acuity level. S/he confirmed staffing was not appropriate.

03/13/17: 3rd Floor Census 6: (1) RN assigned with no other staff on the unit.

RN assigned to the 3rd floor on 3/17/17, confirmed during an interview on 03/23/17, that s/he was the only staff assigned to this unit, and s/he did not have a CNA.

The NW staffing/patient assignment forms revealed:

03/20/17: Census 15. Assignments: (1) RN to 5 patients with total acuity 13, (1) RN to 5 patients total acuity 12, (1) LPN to 5 patients total acuity 13, and (1) NA to 10 patients total acuities 28.

03/21/17: Census 13. Assignments: (1) RN to 5 patients with total acuity 13, (1) RN to 4 patients total acuity 9, (1) LPN to 5 patients total acuity 10.

03/22/17: Census 12. Assignments: (1) RN to 3 patients with total acuity 7, (1) RN to 3 patients total acuity 9, (1) RN to 3 patients total acuity 8, and (1) LPN to 3 patients total acuitiy 10.

NW campus RN #'s 31, 34, and 43, could not articulate during interviews conducted throughout the survey, how the acuity tool is used to determine the staff mix (of skill levels) for patients according to the the acuity assigned, nor how many of what acuity score the nursing personnel could be assigned. In addition, the staff could not articulate or identify a policy regarding how RNs provide oversight for LPNs.

Observation on 03/17/17, identified the following:

- 3rd Floor: Census 6 patients, of which (1) patient was on a ventilator .
- Assignments: (1) RN and (1) CNA for the 6 patients.

The RN (Staff #7) confirmed during an interview on 03/17/17, at 1500 hours, the following: that this was his/her first time working at this hospital; s/he is a registry nurse; s/he did not have any orientation prior to taking patients; s/he did not know if s/he was part of the code team; s/he did not have access to narcotics for her 6 patients; and s/he had no knowledge of the acuity system for the hospital. The CNA assigned to this floor also had 3 patient assignments on the 4th floor. No acuity was identified for the patients on the 3rd floor.

The Interim Chief Clinical Officer (CCO) confirmed the above findings on 03/17/17.

At approximately 1537 the only RN assigned to the 3rd floor, (RN # 7) left the unit, while the CNA also assigned to the third floor patients, was up on the 4th floor caring for her other 3 patients on the 4th floor. RN (Staff #7) left the unit and went to the ICU to have the RN obtain pain pills for a patient. This left the 3rd floor patients unattended without an RN or CNA on the floor. This observation was also observed by the interim CCO, who confirmed that the RN left the 3rd floor medical/surgical unit to obtain pain medications for her patient and the CNA was off the floor as well..

RN # 7 failed to ensure that there was a minimum of one staff member on the unit at all times to respond to patient needs, when she left the unit.

Based on review of hospital documents, observations and interview with staff, it was determined the hospital failed to ensure non-employee nurses had supervision and evaluation of their clinical skills for 1 of 1 registry, non-employee nurses (Staff #7) observed working on 03/17/17. This failure has the potential risk of unskilled nurses providing unsafe care to patients risking their health and safety.

Findings include:

Observation on 03/17/17, revealed the following:

03/17/17

- 3rd Floor census was 6 patients, one (1) of which was a ventilator patient.

Assignments (1) RN and (1) CNA for the 6 patients.

The RN (Staff #7) confirmed during an interview on 03/17/17, at 1500 hours, the following: that this was his/her first time working at this hospital; s/he is a registry nurse; s/he did not have any orientation prior to taking patients; s/he did not know if s/he was part of the code team; s/he did not have access to narcotics for the 6 patients; s/he had no knowledge of the acuity system for the hospital and s/he was not oriented to the hospital policy's and procedures.

The Interim Chief Clinical Officer (CCO) confirmed the above findings on 03/17/17.

At approximately 1537 the only RN assigned to the 3rd floor, (RN # 7) left the unit, while the CNA also assigned to the third floor patients, was up on the 4th floor caring for her other 3 patients on the 4th floor. RN (Staff #7) left the unit and went to the ICU to have the RN obtain pain pills for a patient. This left the 3rd floor patients unattended without an RN or CNA on the floor. This observation was also observed by the interim CCO, who confirmed that the RN left the 3rd floor medical/surgical unit to obtain pain medications for her patient and the CNA was off the floor as well..

The DON failed to ensure that RN # 7 was oriented and trained to the requirements/expectations of her role as a registry non-employee RN to ensure that patients were provided safe care.

Based on review of policies, procedures, medical record for Patient #3, and interview with staff, it was determined nursing failed to ensure medication orders were complete to include, the symptom or indication for use, the frequency, the minimum and maximum dosages, incremental dosing changes allowed and nursing did not follow a physician's order for a sedation vacation for 1 of 1 patient (Patient #3) receiving medications in the ICU. This failure poses the high potential risk of harm to a patient if a medication was improperly administered, or if orders were not followed.

Findings include:

The hospital policy titled Kindred Healthcare Ordering of Medications, H-MM 03-001, release date 06/2016, required: "...All medication orders...must include: drug name, strength, form, route, dosage, frequency, date, time of order, and name of prescribing licensed practitioner...'PRN' medication orders must include a frequency and symptom or indication for use...Titrate orders are allowed with the following provisions. Minimum and maximum dosage range...Clinical indication for titration...incremental dosing changes...."

The hospital policy titled Kindred Healthcare Propofol (Diprovan) Continuous Infusion (Outside the Procedure/Surgery Area), required: "...Patients requiring more than 24 hours of continuous propofol infusion are awakened daily...Respiratory and neurological function should be assessed during the awakened period...."

Patient #3's medical record revealed the following:

An order written on 3/17/17, revealed: "...(triangle symbol meaning change) Fentanyl IVP to prn...."
The order is not complete to include the frequency or indication for use.

Staff #6 confirmed the missing order elements on 03/21/17.

An order written on 3/8/17 at 08:59 revealed: "...Start Versed drip, titrate to keep breathing rate less than 24...."
The order is not complete to include the maximum and minimum dosage and the amount of the incremental dosing changes allowed. Nor does it indicate the minimum respiratory rate allowed.

Staff #6 confirmed the missing order elements on 03/21/17.

An order written on 3/4/17 at 0655 revealed: "...Give Vercuromium IV now. Start Vercuromium drip. Call pharmacy for preparation...."
The order is not complete to include the maximum and minimum dosages, the clinical indication for titration, the incremental dosing changes.

Staff #6 confirmed the missing order elements on 03/21/17.

An order written on 02/27/17, at 1640 revealed: "...daily sedation vacation...."

Staff #6 confirmed during an interview, the patient was on Propofol from 02/27/17 through 03/01/17 and no sedation vacation was documented by any of the RN's caring for the patient for those 3 days. Staff did not follow the physician's order for a sedation vacation.