HospitalInspections.org

Based on review of policies and procedures, job descriptions, internal hospital documents, medical record, review of assault video, and interview, it was determined:

Tag A 0144 1. that the Hospital failed to follow its policy and procedure for contraband, when 1 of 1 patient with contraband on the unit was able to hang herself from a shower handle with the contraband in a suicide attempt (Patient #4);

2. that the Hospital failed to provide care in a safe setting when 1 of 1 patients who used a pillow case as a noose was able to tear a pillow case into strips and use the strips to hang himself in a suicide attempt; four days later, the patient again tore a pillow case into strips and had a noose around his neck when found by a nurse (Patient #3);

3. that the Hospital failed to ensure that patients received care in a safe setting when 1 of 1 patient who eloped from the Hospital, was able to jump over a wall designed to keep patients secured on the Hospital grounds (Patient #9);

4. that patients received care in a safe setting when 1 of 1 psychotic patients with known assaultive behavior assaulted 3 other patients, a Social Worker, and a psychiatrist (Patient #18);

5. that the Hospital failed to identify and correct a defect in the concrete wall of a different courtyard designed to keep patients safe outdoors was found to have an approximately 1 inch (in) by 6 foot (ft) crack in the wall, creating the risk that contraband could be passed to patients from persons outside the Hospital;

6. that a Social Worker violated the patient's rights, when 1 of 1 voluntary patient had their purse entered without permission, which caused the patient emotional distress (anger), and the patient subsequently refused to be admitted to the Hospital. No medical record was kept to determine the risk of leaving without treatment to the patient (Patient #5);

7. that 1 of 1 pregnant patients, who was 10-12 days pregnant at admission received Klonopin (possibly teratogenic) as contraband from another patient, which could create the risk of adverse effects to the embryo (Patient #17).

The cumulative effect of these systemic problems resulted in the Hospital's failure to ensure the patients' right to mental and physical health and safety.

Based on review of policies and procedures, job descriptions, internal hospital documents, medical record, review of assault video, and interview, it was determined:

1. that the Hospital failed to follow its policy and procedure for contraband, when 1 of 1 patient with contraband on the unit was able to hang herself from a shower handle with the contraband, in a suicide attempt (Patient #4).

2. that the Hospital failed to provide care in a safe setting when 1 of 1 patient, who used a pillow case in a suicide attempt, was able to tear a pillow case into strips and use the strips to hang himself in a suicide attempt; four days later, the patient again tore a pillow case into strips and had a noose around his neck when found by a nurse (Patient #3).

3. that the Hospital failed to ensure that patients received care in a safe setting, when 1 of 1 patient who eloped from the Hospital, was able to jump over a courtyard wall designed to keep patients secured on the Hospital grounds was found by police in a busy intersection (Patient #9).

4. that patients received care in a safe setting when 1 of 1 psychotic patient, with known assaultive behavior, assaulted 3 other patients, a Social Worker, and a psychiatrist without provocation (Patient #18).

5. that the Hospital failed to identify and correct a defect in the concrete wall of a different courtyard, designed to keep patients safe outdoors, was found to have an approximately 1 inch (in) by 6 foot (ft) crack in the wall, which created the potential risk that contraband could be passed to patients from persons outside the Hospital.

6. that a Social Worker violated the patient's rights, when the voluntary patient's purse was entered without her permission, which caused the patient emotional distress (anger), and who subsequently refused to be admitted to the Hospital for treatment. No medical record was kept to determine the risk of the patient's refusal to be admitted for treatment. (Patient #5).

7. that a patient 10-12 days pregnant at admission received Klonopin (potentially teratogenic) as contraband from another patient, which could potentially create the risk of adverse effects to the embryo (Patient #17).

Findings include:

1. The Palo Verde Behavioral Health policy and procedure titled: "Patient Belongings, Valuable Storage and Contraband" revealed: "...Policy: It is the policy of Palo Verde Behavioral Health to maximize the health and safety of patients and staff on the unit by controlling access to certain objects known as 'contraband.' Items considered to be contraband will be locked in a secure area with controlled patient access or will not be allowed on the unit...Procedure:...3. Patient belongings are checked for the presence of contraband and valuables. Contraband is removed and either sent home with the family/friends placed in the secured area...CONTRABAND LIST 1. The following items will be restricted from the unit and placed in the contraband storage or sent home...j. Any belts, cloth sashes, cord-strung pants, drawstrings, suspenders, shoelaces are not allowed...."

The "High Risk Factors: Observations/Interventions" policy and procedure revealed: "...Suicide Risk: ...Monitor 'high risk' times: shower or bath times, room time...."

The Palo Verde Behavioral Health policy and procedure titled "Patient Rights and Responsibilities" revealed: "...I. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...."

The Palo Verde Behavioral Health BHT job description revealed: "JOB DESCRIPTION: The Behavioral Health Technician provides basic nursing care, aids with activities of daily living, and assists in the maintenance of a safe and clean environment...."

Patient #4, a young adult female, was admitted to the Hospital on 09-03-14. The PSYCHIATRIC EVALUATION, in the "HISTORY OF PRESENTING ILLNESS" revealed: "She reports that she has a history of mental illness and treatment, but has not been receiving any treatment recently. Before coming to the hospital, she had tried to jump out of a truck because of being very upset. The truck was going about 60 to 65 miles per hour...She said that she also uses methamphetamines...She also has a history of self-harm...PAST PSYCHIATRIC HISTORY: She has a long history of psychiatric treatment and has received treatment since age 13...MENTAL STATUS EXAM: ...She reported having suicidal thoughts and a recent suicide attempt...The ASSESSMENT revealed that Patient #4 had Axis I (Clinical Syndrome) findings which included: Mood Disorder, Anxious Disorder, Methamphetamine dependence, and Axis II (Developmental Disorders and Personality Disorders) findings of Borderline Personality Disorder.

The "Nursing Progress Notes" dated 09-10-14, (no time documented) revealed: "Pt (patient) signed a 24 hr (hour) notice (of intent to leave the Hospital) today...pt wants to go to a facility that is willing to help her. Pt will remain here per (Physician #1)...."

A Palo Verde Behavioral Health Therapy Group Documentation note dated 09-10-14 at 11-1230 PM, revealed: "Pt was upset that the dr (doctor) won't let her move to a facility closer to her home. She left the group after venting."

On "09/10" at 8:30 P.M., nursing documentation revealed: "Pt. found in bathroom c (with) string tied around her neck hanging from shower handle. Pt. was cut down c scissors & assisted to her bed. No LOC (Loss of Consciousness) but pt weakened. Very slight red mark on neck and slight bloodshot eyes. Feeling hopeless/helpless. Placed on 1:1 (1 staff member to 1 patient). VSS (vital signs stable). Neuro VS stable..." The physician was notified of the hanging.

The medical record revealed that the patient was in her room on the day of the hanging from 6:45 P.M. until 7:45 P.M., when she was found hanging in the bathroom.

On 09-11-14, nursing documentation revealed that the patient required medical care, and was transported to an acute care hospital in a cervical collar for a Computerized Axial Tomography (CT) scan and "neurology."

Emergency Department documention by an acute care hospital physician revealed: "This is a (young adult) female who presents for further evaluation after she attempted to hang herself with the drawstring of her scrub pants yesterday as an inpatient at Palo Verde mental health hospital. She complains of mild neck pain and points to the anterior neck. Plain films were obtained at PV (Palo Verde) and she was sent for further evaluation...."

The "Discharge Summary" revealed: "...The patient mostly had issues with personality disorder and also had a suicide attempt while she was at Palo Verde."

The Director of Risk Management stated, during interview conducted on 03-20-15 at 4:00 P.M., that the staff is supposed to cut both sides of drawstrings in pants, so that only a negligible amount of drawstring remains. The Director stated that the Behavioral Health Technician (BHT) who cut the drawstring by which the patient hanged herself, did not cut the string appropriately.

The Hospital's policy regarding contraband, dated "01/2014," in place at the time of the hanging, revealed that pants with drawstrings were considered contraband, and were not allowed on the unit.

2. The CNO job description revealed: "...This position directs the implementation and ensures compliance with the Standard of Nursing Practice that promotes optimum health care delivery...Provides leadership through assessment... and evaluation of nursing services provided in each clinical area...."

Patient #3 was admitted to the Hospital on 11-03-14, with Axis I diagnoses which included Mood Disorder, Rule Out Substance Induced Psychotic Disorder, and Schizoaffective Disorder. The patient had an Axis II diagnosis of Paranoid Disorder.

The Admission Nursing narrative "Admit Note" on 11-03-14 at 1:45 A.M., revealed: "...Pt being admitted to PVH (Palo Verde Health) Dual Dx (Diagnosis) Unit c (with) SI (Suicidal Ideation)/Detox (Detoxification) precautions. Pt found by (acute care hospital) security intoxicated + beligerent (sic) outside of (acute care hospital)...Hx (History) of SA (Suicide Attempt) by hanging 7/2014 at (name of another psychiatric hospital).

Documentation signed by BHT #1 on 11-03-14 at 10:05 A.M., revealed: "RN found pt in Bed (bed number) choking (sic) on a string from a pillow case. Pt was gasping for air. RN called for help. Tech (BHT #1) and RN #2 assisted in releving (sic) pressure. (BHT #1) cut the string from around his neck. Pt was evaluated by RN's and appears to be in stable condition."

Documentation signed by RN #8 revealed: "As above note, this writer entered into doorway of pt's room to call him up to med window for meds. While in the doorway, this writer observed that pt. was lying supine c (with) arms at sides. Color was pink and pt was staring up at the ceiling c constant rapid blinking of eyes. This writer came closer to pt + asked 'are you ok, sir?' + pt started to make short snorting noises as question was being asked. This writer looked closer at pt and seen (sic) a noose (made with pillow case strips) tied very tightly in a knot around his neck. This writer yelled for help: '(RN #2) come right now and bring a scissors'! (RN #2) and (BHT #1) both came within seconds. This writer (words illegible) had lifted the noose as well as could to relieve the pressure. Pt's color was changing from pink to purplish-blue...."

On 11-03-14 at 1:45 P.M., LPN #2 documented: "...When asked if he wants or plan (sic) to hang self, he replied 'Well (sic) see.'" Patient #3 was on 1:1 suicide precautions until 11-04-14 at 11:45 A.M.

On 11-04-14, Physician #2, a psychiatrist, documented in the "Justification for Continued Stay": + High risks DTS/DTO (Danger-to-Self/Danger-to-Others) if DC (Discharged).

On 11-06-14, nursing documentation revealed: "Pt remains entitled about 'housing' and stated if I am discharged 'I am going to the hood (neighborhood) and buy me a gun.'"

On 11-07-14 at 11:30 A.M., RN # 2 documented: "Pt very agitated states social worker told him he is going home pt states I will show them went to his room followed by this RN pt has torn pillow case attempting to put around his neck this RN called for help torn pillow case quickly removed...."

On 11-07-14, Physician #2 documented: "Pt. attempted suicide by sofocating (sic) c a noose he made with a pillow case...."

The "Discharge Summary: for Patient #3 revealed: "...The patient threatening to commit suicide. The patient, after he was told that he was going to be discharged, tried to hang himself again with a noose that he made again from a pillow case cover...."

The Director of Risk Management acknowledged, during interview conducted on 03-19-15 at 12:20 P.M., that the documention appears to reveal that the BHT was not watching the patient, as documentation revealed that the BHT had documented that the patient was "Awake/Alert" and in the "Patient room" on 11-03-14 from 9:00 A.M. until 10:45 A.M. The event in which the patient was found with a noose around his neck occurred, according to nursing documentation at 10:05 A.M. The Director acknowledged that the documentation appeared to reveal that the BHT documented ahead of the actual chronological time.

The CNO acknowledged, during interview conducted on 03-19-15 at 2:10 P.M., that she was not made aware of the second suicide gesture or attempt with another torn pillow case.

The Director of Risk Management also acknowledged that he was unaware of the second time the patient used a noose fashioned from a pillow case.

3. The policy titled "Observation Levels" revealed: "POLICY" Observation levels are levels of staff awareness and attention to patient safety/security needs...Reasons for these levels of awareness may include but are not limited to...Elopement Risk and Detox...It is the policy of Palo Verde Behavioral Health to provide a safe and secure environment for patients during their hospitalization. An increased precaution level can be initiated by physician or nursing staff...PROCEDURE: 1. The Registered Nurse (RN) in communication with the physician will determine the level of risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation, and current mental status....The "routine" observation level was "Every 15 minute patient visualization and documentation."

The "High Risk Factors: Observations/Interventions policy revealed: "POLICY: All patients will be assessed on admission for the presence of any High Risk Factors. These factors will be identified by the admitting clinician and the admitting physician. These high risk factors will be identified and ordered as a part of the admission orders...The nine (9) high risk factors are identified as: ...8. Elopement risk...Procedure: 1. Each patient will be assessed for potential high risk factors during the admission process. The admitting RN or clinician will confer with the physician, sharing the findings and the physician will order any necessary high risk factors he/she determines necessary...."

The Staff Nurse job description revealed: "...Knowledge/Skills:...Must be able to make sound, independent judgments based on scientific and/or ethical principles...."

The Behavioral Health Technician (BHT) job description revealed: " "...Knowledge/Skills:..Must be able to make sound, independent judgments based on scientific and/or ethical principles...."

Patient #9, a young adult homeless male, was admitted to the Hospital on 02-28-15, on an involuntary basis with Axis I diagnoses which included: Methamphetamine induced mood disorder, Amphetamine Dependence, Amphetamine Withdrawal. The Axis II Diagnosis was Antisocial Personality Disorder.

The "Comprehensive Assessment High Risk Notification Alert Form Inpatient" revealed that Patient #9 had "Psychotic Symptoms."

The "SHORT STAY SUMMARY" revealed that the Chief Complaint was: "I don't want to (expletive) be here. The police (expletive) brought me in here"...The patient was pacing the halls aggressively looking out the windows, scoping out the area...The "SUBSTANCE ABUSE HISTORY" revealed: "...He states his only drug of choice is methamphetamines. He states he used it every day...."

The "MENTAL STATUS EXAM " revealed: The patient was disheveled, pacing the halls, in casual clothes. Mildly agitated, uncooperative. Poor eye contact. Difficult to direct...Affect was agitated...Insight and judgment and impulsivity are poor..." The document was signed by Physician #3, an Addiction Psychiatrist.

The Palo Verde Comprehensive Assessment, Adult was completed on 02-28-15 at 7:25 A.M., and signed by Social Worker #2. The assessment revealed that the patient was a Danger-to-Self, and a Danger-to-Others, with a questionable "Acute onset of psychosis." The "Precipitating Events Leading to Assessment" revealed: "Unable to stop using meth (methamphetamine). Pt. is paranoid. Stated he will use physical harm if needed." The "History of Present Illness" revealed: "Cops found him naked running around street. Beneath the field titled "Elopement Risk" was written: "Pt attempted to escape intake area." The "Clinical Impressions (Emotional/Behavioral Functioning)-Completed at Intake" revealed that Patient #9 had "poor" insight, and was "Agitated."

The "Palo Verde Behavioral Health Physician Admission Orders" revealed a diagnosis of "Psychosis." The field titled "Precautions" had "Psychosis" handwritten in. The "Level of Observation was "Standard Observation."

RN #9 documented at 12:00 noon, that Patient #9 was "agitated," "pushing limits", and was on "Q 15" minute observation.

Patient #9 was permitted by RN #9, the nurse responsible for his care, to go outside at 2:15 P.M. BHT documentation revealed that Patient #9 was outside in the enclosed courtyard from 2:15 P.M. on 02-28-15, until 3:00 P.M., at which time the patient jumped over the enclosure wall and eloped.

The Palo Verde Behavioral Health Nursing Flow Sheet for Patient #9 on 02-28-15 at 3:00 P.M. revealed: "Pt went AWOL (Absent Without Leave)- pt was not cooperative-did not want to discuss events leading to his hospitalization with this writer or other staff-pt (word illegible) pt climbe (sic) over back wall-house super (supervisor) and phys (physician) notified-police notified and are searching for pt-Pt had denied S.I.-H.I. (suicidal ideation-homicidal ideation) prior to his departure from facility-No s/s (signs or symptoms) of active withdrawal."

There was no documentation that the admitting clinician or the admitting RN made the physician aware that the patient had attempted to elope during the intake phase of his admission.

Emergency Department documentation from the acute care Hospital to which Patient #9 was taken when the police found him, subsequent to his elopement, revealed that he arrived on 03-01-15 at 11:21 A.M. The "Arrival Complaint" revealed: "OD (overdose), Found on (name of busy intersection in city of acute care Hospital to which he was taken). The Diagnosis was Acute Psychosis and Substance Abuse. The "History of Present Illness" revealed: "Patient is a (young adult male) who was brought into the Emergency Department by (name of police department). Patient was found today dancing on (name of busy local intersection), disrupting traffic. He admits to meth use before coming into the hospital. Laboratory results at the hospital revealed that the patient was positive for amphetamines.

Observation of the courtyard and wall over which Patient # 9 eloped was conducted on 03-20-15 at 12:30 P.M. Observation revealed that there were two sides of the courtyard which abutted the Hospital building, not requiring a wall. The shorter wall at the far end of the courtyard, over which the patient eloped, was approximately 9 1/2 feet tall. A longer wall was approximately 10 feet 2 inches tall, with a segment that was approximately 9 1/2 feet tall.

When asked what the Hospital had done to prevent another elopement, the Director of Risk Management stated, during interview conducted on 03-20-15 at 12:30 P.M., that management had "discussed" the elopement. When asked if he had evaluated future risk, the Director stated that he had not, and stated that he was not aware that one part of the wall was lower (in actuality, two parts of the wall were lower at approximately 9 1/2 feet).

RN #5 stated, during interview conducted on 03-23-15 at 10:00 A.M., that she was on the unit the day that Patient #9 eloped. RN #5 stated that the patient was "pacing the floor-anxious." RN #5 stated that Patient #9 stated: "Man, I've got to get out of here." RN #5 stated: "They (BHTs) let them out for fresh air." RN #5 stated that patients are not supposed to be allowed to go out into the courtyard for the first 24 hours following admission. RN #5 stated: "Whoever wants to go out can go out; I didn't know he had just been admitted...."

4. Patient #18, a young adult male, was re-admitted to the Hospital after having been an inpatient there from 12-31-14 to "February 2015." He was admitted on an involuntary basis on 03-21-15. The "Psychiatric Evaluation" revealed: "By the time of discharge, the patient was on Clozeril (anti-psychotic) 100 mg (milligrams) in the morning and 300 mg at night and he was much more stable and was no longer aggressive and hitting other patients and staff as he had been earlier in the hospitalization. The patient had a pattern of coming out of his room, pacing around the unit and spontaneously punching another patient in the face and then going back to his room...." The Axis I diagnosis was Schizophrenia.

The "Comprehensive Assessment, Adult," authored by a Social Worker, revealed that the reason for admission was: "Pt bought (sic) to ER (Emergency Room) after being in county jail for assaulting others @ his group home. Pt hit walls & required stitches." The "Precipitating Events Leading to Assessment" revealed: "Command hallucinations to punch others Denies SI/HI @ time 'saw demons & he saw a cop inside the cell. Could feel the fire of hell on his skin,' according to a jail RN. The "History of Present Illness" revealed: "'I don't even know what I'm doing anymore-I hit a window. I hit a girl I hear a lot of (expletive)." The suicide risk factors revealed that the patient was facing legal charges for "punch person in face." The suicide risk assessment revealed that Patient #18 had 8 "yes" answers. The form revealed that "High Risk Consideration" was: ">10 risk factors identified or any yes response to questions in the suicide inquiry section." The "Suicide Inquiry" revealed that Patient #18 had a "yes" answer to "Does the patient report having command hallucinations to harm or kill himself/herself? If yes, what are the voices saying"? The social worker hand wrote: "punch them or you will go to hell." The suicide risk circled was "High." Despite the patient being deemed a high suicide risk, the RN caring for the patient on 03-21-15 at 11:00 P.M., documented that the patient was placed on "Q 15" (every 15 minute level of observation).

The "Comprehensive Assessment High Risk Notification Alert Form Inpatient" revealed that, "Psychotic Symptoms" was checked, and "Assault/Homicidal" was checked. On the line for "Assault/Homicidal" was handwritten: "Punches pl (people). The form was signed by a clinician and an RN.

The "Palo Verde Behavioral Health Acute Psychiatric Progress Note" dated 03-22-15 at 3:15 P.M., revealed: "Psych (psychiatric) eval (evaluation) completed + (positive) psychosis + aggression."

The "Nursing Flow Sheet" dated 03-21-15 at 2100 or 2300 (mark through making exact time undetermined) that Patient #18 had "Homocidality" "threats," with "Grandiose" thought processes and "Hallucinations."

On 03-22-15 at 8:00 A.M., the RN documented that the patient was: "Paranoid, Irritable, Depressed, Guarded, and Anxious." The RN also documented that the patient was "Impulsive," and was on "Assault" precautions.

On 03-22-15 at 10:00 P.M., the RN documented that the patient was: "Paranoid," had hallucinations, and was impulsive.

Nursing narrative dated 03-22-15 at 12 noon (date is presumed due to chronological order of medical record, but date has been written over so to make the entry illegible): "Admits to AH (auditory hallucinations)...."

On 03-22-15 at 2:00 P.M., nursing narrative revealed: "(psychiatrist) on unit and evaluated pt due to assault (sic) behaviors..."

On 03-23-15 at 11:30 A.M., the "Nursing Progress Notes" revealed: "Hit another patient in the face. Placed in time out. Patient apologized for his behaviors."

On 03-23-15 at 12:25 P.M., the "Nursing Progress Notes" revealed: "Hit another patient in the head. He busted his stitches in his right fist...."

On 03-23-15 at 1:30 P.M., the "Nursing Progress Notes" revealed: "Hit Dr. (doctor) in the face. Placed in seclusion. Patient apologized for his behavior."

The Note revealed on 03-23-15: "Pt is very aggressive punching patient (sic) and staff (arrow up indicating increased) psychosis."

On 03-25-15 at 12:35 P.M., surveyor reviewed the Hospital's video of the assaults against patients and a Social Worker, and patients and a psychiatrist, respectively.

The video, without audio, revealed that on 03-22-15, Patient #18 was walking in the hall on the West (acute) unit. A female Social Worker walking toward the perpetrator (Patient #18), was observed to speak with the patient very briefly. The video depicted a few words spoken by the Social Worker to the patient, with no apparent response from the patient. The perpetrator continued walking, then changed course and swiftly, and without warning, violently sucker-punched the face of a female patient (Patient #14), standing in the hall. The patient fell backwards into the wall from the blow. Patient #18 then walked back down the hall, met the Social Worker in the hall, and without provocation, violently sucker-punched the Social Worker, knocking her backwards to the floor.

A video, without audio, revealed that on 03-23-15, Physician #1 entered the unit from a doorway, and stopped in the hall and appeared to inquire of Patient #18 the condition of his sutured hand, as the stitches in the hand had reportedly been torn from the assault on the previous day. The patient was observed to give the physician a gentle tap to the face as a "slap," and walk away. The patient entered a room, then came back into the hall, when the physician again appeared to inquire about the patient's hand. The patient then, unprovoked, punched the physician on the right side of his face.

An internal Hospital document, related to the 03-22-15 assaults, revealed that the "Pre-Incident Mental Status" was: "Confused, Agitated, Aggressive, Combative."

Subsequent to the 03-22-15 assaults, the restraint document for Patient #18 on 03-22-15 at 2:00 P.M. revealed: "...Pt attempted to punch this write (RN), pt did punch 2 staff members and one patient." The "Clinical Justification" was: "Danger to Others" and "Violent Behavior." "Patient responding to internal stim (stimulation)-delusional..."

The restraint record for Patient #18, dated 03-23-15 at 12:43 P.M., revealed that the clinical justification was "Danger to Others". The patient was administered Haldol 10 mg. intramuscularly (IM), Benadryl 50 mg IM, and Ativan 2 mg IM, and paced in seclusion. The "Specific Behavior Exhibited" was: "Punch (sic) 2 patients (Patient # 12, and #13) less than 1 hour apart then he punched the doctor."

The Palo Verde Behavioral Health Acute Psychiatric Progress Note dated 03-23-15 at 3:50 P.M., revealed: DC (Discharge) (name of police department) "(word illegible) (word illegible) aggressive (word illegible) assaultive (rest of sentence illegible.

The Director of Risk Management stated, during interview conducted on 03-25-15 at 1:00 P.M. that the patient was on "Assault" precautions. The Director stated that "Assault" precautions was a q (every) 15 minute observation level, with the staff to have heightened awareness. When asked what precautions the patient was placed on subsequent to the assaults, the Director stated that he remained on q 15 minute checks after the 03-22-15 assaults.

On 03-25-15 at 3:45 P.M., the Director of Risk Management acknowledged that the patient should have been placed on 1:1 to prevent subsequent assaults.

5. The Palo Verde Behavioral Health Hospital policy titled "Patient Rights and Responsibilities" revealed: "...I. Personal Safety: The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...."

The Palo Verde Behavioral Health policy titled: "Patient Belongings, Valuables Storage and Contraband" revealed: "...It is the policy of Palo Verde Behavioral Health to maximize the health and safety of patients and staff by controlling access to certain objects known as 'contraband."

Direct surveyor observation conducted on 03-24-15 at 2:40 P.M., of the courtyard on the East psychiatric unit, revealed a large bush, approximately 3 feet wide and 4 1/2 feet tall on the far side of the courtyard in which patients ambulated while outside. Behind the large bush, was the far wall of the courtyard, revealing an approximately 1 inch by 6 foot jagged diagonal crack, through which sunlight was observed. Further observation revealed that the wall which contained the large crack backed up to a dirt field, adjacent to a public street, with public access. Metal mesh at the top of the concrete wall also had a crack through which contraband could be passed through from the public access.

The Director of Risk Management acknowledged, during interview conducted on 03-24-15 at 2:20 P.M., that contraband, including small knives could be passed through the crack from the outside to patients in the courtyard, and that the Hospital had failed to identify the potential safety issue.

6. The Palo Verde Behavioral Health policy titled "Patient Rights and Responsibilities" revealed: "Palo Verde Behavioral Health's policy is to preserve the patient's basic human rights during hospitalization...Patient care is provided in accordance with the standards and ethics for licensed, certified, or registered health care practitioners...G. Respect and Dignity: The patient has the right to considerate, respectful care at all times and under all circumstances, with recognition of his/her dignity...."

The Job Description for an "Intake Evaluator," Licensed Social Worker (LMSW) #1, revealed: "...11. Maintains a positive and professional demeanor... Criteria IV: Customer Relation (sic) Skills and Professional Behavior 1. Represents the hospital in a manner which conveys a professionals, courteous, caring, and cooperative attitude...."

The patient's medical record could not be located by Hospital personnel. The patient reportedly presented to the Hospital on 03-09-15, and requested a mental health evaluation.

Registered Nurse #6 (RN) stated, during interview conducted on 03-23-15 at 11:40 A.M., that Social Worker #1 took the patient's purse into another room, and returned with the wallet out of the purse. The RN stated that the patient was angry at the time of the incident that the wallet had been removed without her permission.

The Chief Nursing Officer (CNO) acknowledged, during concurrent interview with RN #6, that the Social Worker should not have removed the wallet from the patient's purse without her permission. The CNO acknowledged, that while there was no written policy, it was considered a substantive policy.

7. Patient #17, was admitted to the Hospital at 10-12 days pregnant.

The "History of present Illness" revealed: "...She was seen in the emergency room where she was found to be pregnant...."

The "Physician's Order Sheet," dated 09-20-14, revealed: "... NO BENZODIAZAPINES. The entry was underlined. The physician or nurse practitioner signature is illegible.

The "Discharge Summary" revealed: "...COURSE OF HOSPITALIZATION:...The patient appeared to be getting better, however, on the day of her discharge, she had an episode where she became extremely angry and agitated. The patient had received Klonopin (benzodiazepine) from another patient because the patient had restrictions...."

On 03-23-15 at 3:45 P.M., the Director of Risk Management and the CNO stated that they were unaware of the patient getting Klonopin from another patient.

It is undetermined how much Klonopin the patient may have ingested.

Based on review of policies and procedures, medical record, internal document, and interview, it was determined that the Hospital failed to develop and maintain an effective quality program for the prevention and reduction of errors as evidenced by:

Tag A 286 1. failing to follow the Hospital's policy for a Sentinel Event with a Root Cause Analysis in 2 of 2 patients who attempted suicide by hanging; failing to follow the Hospital's policy for a Sentinel Event with a Root Cause Analysis when 1 of 1 patients who eloped was found by police dancing in the street at a busy intersection. The potential risk of not determining the root cause of these sentinel events is that similar incidents may occur at a future time.

2. failing to conduct analysis of incidents, in 5 of 7 documented incidents, which created a potential risk for being unable to prevent future similar incidents.

Tag A273 failing to analyze and trend "Falls, a key quality indicator. By failing to analyze and trend this key quality indicator, the potential risk is physical harm up to and including fractures.

The cumulative effect of these systemic problems resulted in the hospital's failure to assure that analysis of incidents and sentinel events were analyzed and trended to identify opportunities to improve the health ands safety of patients.

Based on review of medical record, facility document, job description, and interview, it was determined that the quality program failed to analyze and trend incident data and key quality indicator data by:

1. failing to analyze or trend incident reports, including suicide attempts, patient and staff assaults, and an elopement.

2. failing to analyze or trend patient falls data

Findings include:

1. Refer to Tag A 0286 for specific details related to suicide attempts, medication errors, patient and staff assaults, and an elopement. The Hospital had three suicide attempts. One on 09-10-14, 11-03-14, and 11-07-14. There was no documented evidence the Hospital reviewed in detail each of the events that occurred over a 2 month span. There was no documented evidence that the significant medication error of 10 times the dose was reviewed to analyze the pharmacist role in the administration of the wrong dose. There was no documented evidence of assaults being trend and evaluated. There was no documented evidence that the elopement of Patient #9 was evaluated to determine the adequacy of the height of the enclosure to prevent future elopements.

2. The Director of Risk Management/PI job description revealed: "...Responsibility I: Risk Identification and Evaluation... 3. Analyzes and trends data...."

1. The Palo Verde Behavioral Health "2015 Quality Management Plan" revealed: "The Quality Management Plan supports Palo Verde Behavioral Health (PVBH) approach to plan, design, measure, assess and improve organizational performance...V. Strategic Objectives (Guiding Principles):...Monitor, improve and resolve areas of concern and noted trends...PIC (Performance Improvement Committee) uses the following areas of focus to identify needs for improvements: Incident Reports Sentinel Events...XI. Data Collection, Analysis, and Reporting: A. Evaluation of collected data will continue to be completed to monitor and identify levels of performance, trends or patterns that vary significantly from the norm, or that exceed threshold levels of acceptable performance...G. Aggregating and analyzing that allows the organization to draw conclusions about its performance specific to processes or outcomes. Analysis and comparison may include:Performance compared internally over time (patterns/trends)...."

During interview conduced on 03-31-15, the Director of Risk Management stated that "Falls" was a key quality indicator. The Director provided an internal document which revealed the following regarding "Falls" from the time of the ownership change of the Hospital, in March, 2014 to December, 2014.

March, 2014 0 Falls
April, 2014 3 Falls
May, 2014 1 Fall
June, 2014 0 Falls
July, 2014 1 Fall
August, 2014 3 Falls
September, 2014 5 Falls
October, 2014 5 Falls
November, 2014 3 Falls
December, 2014 1 Fall

During the interview, the Director acknowledged that the management team "discussed" the falls, but acknowledged that he had not analyzed or trended the falls.

Based on review of policies and procedures, medical record, internal document, and interview, it was determined that the quality program activities failed to analyze incidents and sentinel events according to the Hospital's policies and procedures as evidenced by:

1. failing to follow the Hospital's policy for a sentinel event in 2 of 2 patients who attempted suicide by hanging (Patients #3 and #4); Patient #3 subsequently "attempted" to hang himself in the same manner as the first attempt. Patient #4 required medical assessment at an acute care hospital Emergency Department.

failing to follow the Hospital's policy and procedure for a Sentinel Event when 1 of 1 patients who eloped was found by police dancing in the street at a busy intersection (Patient #9).

2. failing to conduct analysis of incidents in 5 of 7 documented incidents, which created a potential risk for being unable to prevent future similar incidents (Patients #1, 3, 4, 9, and 18) .

Findings include:

1.1 Refer to Tag A 0144 and A 0398 regarding the attempted suicide by hanging (Patient #4).

1.2 Refer to Tag A 0144 regarding a patient who hanged himself with a torn pillowcase, and subsequently made another "attempt" using a torn pillowcase (Patient #3).

1.3 Refer to Tag A 0395 regarding a patient who eloped from the Hospital (Patient # 9).

2.1. Refer to Tag A 0144 and A 0398 regarding the attempted suicide by hanging of Patient #4;

2.2. Refer to Tag A 0144 regarding a patient who was administered 5.0 milligrams of Alprazolam instead of 0.5 mg. of Alprazolam (Patient #1).

2.3. Refer to Tag A 0144 regarding a patient who hanged himself with a torn pillowcase, and subsequently made another "attempt" using a torn pillowcase (Patient #3).

2.4. Refer to Tag A 0144 regarding a patient who assaulted several patients and staff members; when the psychiatrist was assaulted, the police were called, and the patient taken to jail (Patient #18).

2.5. Refer to Tag A 0395 regarding a patient who stated: "Man I've got to get out of here," and was permitted to go onto the patio from which he subsequently escaped and went Absent Without Leave (AWOL) (Patient #9).

1. The Sentinel Event policy and procedure revealed: "PURPOSE: To provide guidelines for communicating, investigating and acting upon sentinel events. DEFINITIONS Sentinel Event: The Sentinel Event policy applies to events that meet the following criteria: The event has resulted in an unanticipated death or serious physical or psychological injury not related to the natural course of the patient's illness or underlying condition or had the potential to result in the patient's death or serious physical harm... An evaluative process structured to attempt to determine underlying causes of the sentinel event and whether there is a reasonable potential for process improvement to reduce the likelihood of such events in the future. The following are characteristics of a root cause analysis: Focus primarily of systems and processes The use of 'Why' repeatedly as each reason is determined; and Identification of changes, if any, that should be made in systems and processes, Analysis is thorough and credible...."

The Director of Risk Management acknowledged, during interview conducted on 03-20-15 at 4:00 P.M., that a root cause analysis of the suicide attempt of Patient #4 was not conducted because it did not meet the requirements of a sentinel event. The Director acknowledged, after review of the Hospital's policy regarding Sentinel Events, that the suicide attempt met the definition of a sentinel event.

There was not a complete analysis of potential causes or failures that may have prevented the event.

2. The Incident Report policy and procedure revealed: "Policy The Incident Report is a mechanism to inform Administration about circumstances surrounding individual problematic events. An 'Incident' or 'Occurrence' is defined as any happening that is not consistent with the normal or usual operation of the hospital and/or department... Procedure... 5. Instructions for completing the Incident report form: a. Complete each section of the Incident Report form... 7. Palo Verde Behavioral Health will conduct and document an investigation, including, but not limited to, interviewing clinical team members, family members and any other relevant individuals and reviewing pertinent medical record documentation... 9. For cases in which corrective action is necessary and recommended, the Director of Performance Improvement/Risk Management will ensure that all corrective actions have been implemented and are deemed effective at resolving all identified deficiencies. The Director of Performance Improvement/Risk Management will gather evidence that the corrective action plan was fully implemented...."

The Palo Verde Behavioral Health Director of Risk Management/PI job description revealed: "...JOB REQUIREMENTS: To perform this job successfully, an individual must be able to demonstrate competency in the criteria listed in this job description...JOB SPECIFICATIONS:...Responsibility I: Risk identification and Evaluation... 3. Analyzes and trends data 4. Identifies actual and potential risk situations and facilitates the determination of causative factors...."

The quality program had not identified that there was a contracted Registered Nurse (RN), and a Contracted Behavioral Health Technician (BHT) who did not have competency assessments by the Hospital on duty at the time of Patient #4's hanging; the program had not identified that the policy required that no drawstring pants were permitted on the unit, as the staff was cutting said drawstrings. The quality program had not identified that by continuing to provide Patient #3 with pillowcases, that he could again tear a pillowcase into strips and use the strips as a noose.

Based on review of medical record, job description, policies and procedures, facility documents, personnel file, Depakote manufacturer's website, internal document, and interview, it was determined that the organized nursing service failed to:

A 395 1. assure that a Registered Nurse (RN) competent to supervise and evaluate the care of a patient admitted for a recent suicide attempt, was assigned to a patient who hung herself in the milieu;

2. assure the safety of a patient who tore a pillow case into strips, and used the strips as a noose to hang himself; the patient subsequently tore another pillow case into strips which he used as a noose; and

3. supervise and evaluate the care of a newly admitted psychotic patient who told a Registered Nurse (RN) that he needed to leave the Hospital and was permitted to go outside, subsequently went Absent Without Leave (AWOL); the patient was subsequently found by police in the middle of a busy city intersection.

A 397 1. ensure that a newly licensed Registered Nurse (RN #1) correctly transcribed an order for Alprazolam (anti-anxiety agent), when an order for 10 times the intended dose was administered on four (4) occasions; and

2. ensure that an RN and BHT who were caring for a patient who hung herself while in their care had documented psychiatric competencies.

A 398 1. ensure that a contracted RN had documented psychiatric competencies, when a patient entrusted to her care hung herself with a cord from her clothing; and

A 405 1. ensure that a patient 10-12 days pregnant, was protected from being administered a teratogenic (harmful to fetus) drug, when the patient was administered Depakote (psychotropic drug used in Seizure Disorder and Bipolar Disorder) was administered to the patient with no order; and

2. ensure that Alprazolam (Anti-anxiety agent) was not administered at a dose ten (10) times greater than the intended dose. The potential risk was overdosage of a psychotropic drug.

The cumulative effect of these systemic problems resulted in the Organized Nursing Service's failure to ensure the health and safety of patients by the organized nursing service.

Based on review of medical record, job descriptions, facility document, and interview it was determined that a Registered Nurse failed to supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to assure that a Registered Nurse (RN) competent to supervise and evaluate the care of a patient admitted for a recent suicide attempt, was assigned to a patient who hung herself in the milieu with a drawstring that was considered by policy to be contraband (Patient #4).

2. failing to assure the safety of a patient who tore a pillow case into strips, and used the strips as a noose to hang himself; several days later, the patient subsequently tore a pillow case into strips again and used them as a noose (Patient #3).

3. failing to supervise and evaluate the care of a newly admitted psychotic patient, when an RN overheard the patient talking about elopement, then subsequently allowed the patient to be taken outdoors into a courtyard from which he eloped (Patient #9).

Findings include:

1. Refer to Tag A 144 regarding suicidal patient who hung herself at the Hospital. Refer to Tag A 0398 regarding no competency assessment for a contracted RN.

The Palo Verde Behavioral Health job description for the CNO revealed: "The CNO develops... standards of performance... The position directs the implementation and ensures compliance with the Standard of Nursing Practice that promotes optimum health care delivery... KNOWLEDGE/SKILLS:...3) Must stay current with federal, state, and local healthcare standards, policies and procedures for workplace health and safety... PRIMARY CRITERIA/RESPONSIBILITIES: 1. Provides leadership through assessment, planning, implementing and evaluation of nursing service provided in each clinical area... 4. Defines and maintains the quality standards of nursing practice within the Hospital...6. Assesses the quality of care rendered by the nursing department through quality assurance monitoring,..."

The Palo Verde job description for a Staff Nurse (Registered Nurse) revealed: "The Staff Nurse and the Charge Nurse provide safe and effective nursing care in the assigned area(s) in a manner consistent with the philosophy and objectives of the Hospital and within the framework of established policies and procedures of the Department of Nursing Services... Knowledge/Skills: ...must be able to perform concentrated and/or complex mental activity with frequent involvement in complex and/or highly technical situations... Must be able to make sound, independent judgments based on scientific and/or ethical principles... PRIMARY CRITERIA/RESPONSIBILITIES: 1. Completes an assessment for each patient by performing a thorough mental, physical, nutritional and functional assessment on admission, and as needed, based upon patient's condition... 6. Organizes and directs care of patients... 8. Provides care for patients with Depression/Suicidal impulses...."

The Behavioral Health Technician (BHT) job description revealed: "The Behavioral Health technician provides basic nursing care, aids with activities of daily living, and assists in the maintenance of a safe and clean environment...."

The Palo Verde "Patient Belongings, Valuable Storage and Contraband" policy and procedure revealed: "...Policy: It is the policy of Palo Verde Behavioral Health to maximize the health and safety of patients and staff on the unit by controlling access to certain objects known as 'contraband.' Items considered to be contraband will be locked in a secure area with controlled patient access or will not be allowed on the unit... Procedure: ...3. Patient belongings are checked for the presence of contraband and valuables. Contraband is removed and either sent home with the family/friends or placed in a secure area... CONTRABAND LIST: 1. The following items will be restricted from the unit and placed in the contraband storage or sent home... j. Any belts, cloth sashes, cord-strung pants, drawstrings, suspenders, shoelaces are not allowed...."

On 09-10-14, time undocumented by 7:00 A.M.-7:00 P.M. nurse, RN #7 documented: "Pt (patient) signed a 24 hr (hour) notice today. Pt main complaint is wanting to be closer to family in (distant city in northern Arizona) that is willing to help her... Pt will remain here per (psychiatrist). he feels that she is not ready to go yet. Will encourage pt to get the help she needs here... There was no documentation that indicated that the RN evaluated why the patient felt the Hospital was not willing to help her.

On 09-10-14, another un-timed entry by RN #7 on the 7:00 A.M.-7:00 P.M. shift revealed: "Pt needs to be monitored after dinner for vomiting food up. Pt does participate in all activities but pt is wanting to go home. Pt did contact patient advocate Mrs. (name) for help." There was no documentation of communication between the RN and the Patient Advocate regarding the patient's desire to leave the Hospital.

The Palo Verde Behavioral Health Nursing Flow Sheet dated 09-10-14, revealed that the patient did not have a shift assessment for the 7:00 A.M.-7:00 P.M. shift until "1700" (5:00 P.M.) by the RN responsible for her care. The narrative entries contained no time to determine how to place the narrative into a time context.

Nursing narrative by RN #3, the contracted nurse, revealed on "09/10" at 8:30 P.M.: "Pt. found in bathroom c (with) string tied around her neck hanging from shower handle. Pt. was cut down c (with) scissors & assisted to her bed. No LOC (Loss of Consciousness) but pt weakened. Very slight red mark on neck and slight bloodshot eyes. Feeling hopeless/helpless. Placed on 1:1 (1 staff member to 1 patient). VSS (vital signs stable). Neuro VS stable...." The physician was notified of the hanging. There was no nursing documention that the patient was placed in a cervical collar in the event of a spinal cord injury from the hanging.

The 7:00 P.M.-7:00 A.M. shift assessment was documented at "2100" (9:00 P.M.), after the patient attempted suicide.

RN #3, a contracted nurse, had no documented psychiatric competencies assessed and documented by the Hospital prior to providing nursing care to Patient #4.

The BHT job description revealed: "SUPERVISION RECEIVED: Chief Nursing Officer...,House and Charge Nurse/Staff Nurse... PRIMARY CRITERIA/RESPONSIBILITIES: ...5. Ensures safety of patient at all times.

On 09-11-14 at 6:20 P.M., nursing narrative revealed: "...orders received from NP (Nurse Practitioner) (name) to send pt to ED (Emergency Department) for CT (Computerized Tomography) scan + neurology c/s (consult); pt. advised of recommendation, agreeable; C-collar (cervical collar) on for precautions...."

The Director of Risk Management stated, during interview conducted on 03-20-15 at 4:00 P.M., that staff are to cut both sides of string in pants with a drawstring, so that only a small amount of string remains concealed in the hem containing the drawstring. The Director stated that a BHT cut only a small portion of the drawstring, allowing enough remaining string to form a ligature and hang herself.

2. Refer to Tag A 0144 regarding patient who tore a pillow case into strips and hung himself; the patient subsequently again tore a pillow case into strips, using the strips as a noose. A Registered Nurse failed to supervise the patient, when on the day of the second suicide attempt, the patient was having auditory hallucinations and suicidal ideation; the RN failed to inquire what the auditory hallucinations were telling the patient to do, and failed to quantify and assess the suicidal ideation.

3. Refer to Tag A 144 regarding a newly-admitted psychotic patient with a history of methamphetamine use, overheard by the RN who provided his care on the day of his elopement to state that he wanted to leave the hospital. The RN had documentation from the Intake Clinician that the patient had attempted to escape the Intake area prior to admission. The RN assigned to the patient failed to supervise the care of the patient, when she permitted the patient to go outside in an enclosed area from which he eloped. The patient's health and safety were compromised when he was found one day later dancing in a busy city intersection, disrupting traffic.

Based on review of clinical record, job description, policies and procedures, personnel file, and interview, it was determined that the Hospital:

1. failed to ensure that a newly licensed Registered Nurse (RN #1) correctly transcribed an order for Alprazolam (anti-anxiety agent), when an order for 10 times the intended dose was administered on four (4) occasions, and the RN did not have demonstrated competencies for psychiatric medication dosing. The potential risk was an overdosage of a psychoactive drug (Patient #1).

2. failed to ensure that an RN and Behavioral Health Technician (BHT) had documented competencies when a patient entrusted to their care hung herself with a cord from her clothing (Patient # 4)

Findings include:

1. Refer to Tag A 049 with reference to Patient #1, and a verbal order for ten (10) times the intended dose of Alprazolam, which was subsequently administered four times by Registered Nurses.

The "Staff Nurse" job description revealed: "The Staff Nurse and the Charge Nurse provide safe and effective nursing care in the assigned area(s) in a manner consistent with the philosophy and objectives of the Hospital and within the framework of established policies and procedures of the Department of Nursing Services... Knowledge/Skills:... Must be able to make sound, independent judgments based on scientific and/or ethical Principles...Must be able to comprehend and perform oral and written instructions and procedures...."

The "Order Verification" policy and procedure revealed: "...All medication orders will be clarified prior to being processed or administered to the patient... 1. All medication orders will be reviewed by a pharmacist prior to administration...."

The policy and procedure titled: "Physician Orders" revealed: "Policy The communication of medical orders must be executed in a manner designed to ensure patient safety and eliminate misunderstanding...."

Review was conducted of the personnel file of RN #1. Review revealed that the nurse was initially licensed on 01-17-14, and transcribed the incorrect dose of Alazopram for Patient #1 on 03-23-14. The personnel file contained no documented competencies in dosing of psychotropic drugs.

The RN Educator stated, during interview conducted on 03-18-15 at 2:50 P.M., that RN #1 did not have demonstrated competencies regarding knowledge of commonly used psychotropic drugs.

2. Refer to Tag A 398 regarding a patient who hung herself with a cord from her clothing, and the RN and BHT on the unit were both contracted staff with no documented competencies.

Based on review of personnel file, policy and procedure, medical record, and interview, it was determined that the Director of Nursing Services failed to ensure that a contracted licensed nurse and a contracted Behavioral Health Technician (BHT), caring for a patient at the time the patient attempted suicide by hanging, had hospital-documented competencies to care for 1 of 2 psychiatric patients who attempted suicide by hanging (Patient #4).

Findings include:

Refer to Tag A 144 regarding Patient #4, and an attempted suicide by hanging while an inpatient.

The "Staff Orientation, Competency and Qualifications" policy and procedure revealed: "...This policy establishes guidelines and requirements related to Palo Verde Behavioral Health's New Employee Orientation and Training program. Supervisors will conduct a competency review at the time of hire, time of 90-day evaluation by observation, and at least annually thereafter... C. 1) Palo Verde Behavioral Health provides comprehensive orientation and training to meet all applicable federal and state regulations and accreditation requirements. Palo Verde Behavioral Health's new hire orientation is designed to welcome new team members, orient individuals regarding the patients served, and ensure new team members have the knowledge and skills necessary to support the behavioral health delivery system and operating policies required to successfully fulfill their roles...."

Review of the personnel file of Registered Nurse (RN) #3, the contracted RN caring for Patient #4 at the time of the suicide attempt, revealed no documented competencies by the Hospital to care for psychiatric patients.

Review of the personnel file of BHT #3, the BHT caring for Patient #4 at the time of the suicide attempt, revealed no documented competencies by the Hospital to care for psychiatric patients.

The Director of Human Resources, acknowledged, during interview conducted on 03-20-15 at 2:20 P.M., that the Hospital had not assessed the competencies of RN #3 or BHT #3, prior to caring for patients at the Hospital.