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Based on review of hospital documents, policies/procedures, medical records, observation, and interview, it was determined the hospital failed to protect and promote each patient's rights as evidenced by:

Tag A123; 482.13(a)(2)(iii) Patient Rights: Notice of Grievance Decision: the hospital failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 patient whose complaints were considered violations of rights and referred to the Division of Behavioral Health Services, Office of Grievances and Appeals (Pt #4); and

Tag A 144; 482.13 (c) (2) Patient Rights: Care in Safe Setting: failing to require that staff members have the skills and knowledge necessary to intervene effectively in an AWOL crisis situation for 1 of 1 patient (Pt #1);

2. failing to provide for safety of 1 of 1 patient with a history of self-injurious behavior who had full grounds privileges (Pt #2 );

3. failing to provide effective immediate intervention to prevent overdose of medication by 1 of 1 patient who informed staff she had "cheeked" her medication (Pt #3); and

4. failing to provide a patient care environment that is free of fixtures, surfaces, and/or equipment conducive to patient self-injury or suicide for all patients admitted to the Civil Units.

The cumulative effect of these systemic problems resulted in the hospital's failure to protect and promote each patient's rights.

Based on review of hospital policies/procedures, hospital documents, and interviews, it was determined that the hospital failed to provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion for 1 of 1 patient whose complaints were considered violations of rights and referred to the Division of Behavioral Health Services, Office of Grievances and Appeals (Pt #4).

Findings include:

Review of hospital policy/procedure titled Patient Grievance, Appeal, Complaint Process revealed: "...Complaint...An expression of dissatisfaction with any aspect of care other than the appeal of an action. Complaints include, but are not limited to:...Concerns about the quality of care or services provided; Aspects of interpersonal relationships with behavioral service providers; lack of respect for patients' rights; and Allegations of abuse or neglect...This also includes requirements cited under CFR 482.13 (a) (2) which references a complaint as a 'grievance' if the patient complaint:...Is submitted in writing; Cannot be resolved at the time of the complaint by staff present; Is postponed for later resolution; Is referred to other staff for later resolution; Requires investigation; and/or Requires further actions for resolution...The Executive Risk Management Team (ERMT) shall serve as the entity with delegated responsibility for the review and resolution of patient grievances/complaints...Address Complaints as follows:...Provide written notice of the disposition of the complaint to the patient within seven (7) working days of resolution, but no later than ninety (90) days following receipt of the complaint. The notice shall include the following: Steps taken to resolve the complaint; Results of the process; Date the complaint process concluded; Sufficient detail to demonstrate that the issue(s) have been adequately reviewed and the patient's needs are being met; A Hospital contact name and phone number to call for additional assistance or to express unresolved concerns; and Contact information for the State Licensing Agency...."

Review of a document titled Arizona Department of Health Services Division of Behavioral Health Services Policy and Procedures Manual...Policy...Conduct of Investigations Concerning Persons with Serious Mental Illness revealed: "...ADHS/DBHS conducts investigations into allegations of physical abuse...violations of rights, and conditions that are dangerous...Within five days of receipt of the investigator's report, ...shall review the investigation case record, and the report, and issue a written, dated decision which shall either: Accept the report and state a summary of findings and conclusions and any action or corrective action required of AzSH (Arizona State Hospital)...to the investigator, AzSH...the person who filed the grievance...The decision sent to the grievant and the person who is the subject of the grievance...shall include a notice of the right to request an administrative appeal of the decision within 30 days from the date of receipt of the decision...."

Review of a hospital document containing information regarding Pt #4's complaints and grievances revealed that 3 written complaints from the patient were referred to the hospital investigator, since the complaints contained an allegation of verbal abuse (received 2/28/11), allegation of intimidation and harassment by a security guard (received 4/6/11), and allegation of physical abuse by a MHPS(Mental Health Program Specialist) (received 7/7/11).

The hospital Ombudsman confirmed during interview conducted on 11/9/11 from 0830 to 1040, that the 3 complaints were considered grievances and were referred to the hospital investigator. She confirmed that the patient received a letter informing him when the investigation had been started and the patient received a letter informing in that the investigation has been completed. The investigation results were sent to OGA (Office of Grievance and Appeals). (The patient has a "Serious Mental Illness.") However, the hospital was unable to provide documentation that the patient was informed, as required by policy, of the resolution of the grievances, including the steps taken, results of the process, or date that the process was concluded.

The hospital COO confirmed during interview conducted on 11/9/11, that the hospital did not have documentation that the patient received notification of the resolution of the grievances, including the steps taken, results of the process, or date that the process was concluded.

Based on review of facility policies and procedures, job descriptions, medical records, hospital documents, staff interviews, and direct observation, it was determined that the hospital failed to ensure the patients' right to receive care in a safe setting as evidenced by:

1. failing to require that staff members have the skills and knowledge necessary to intervene effectively in an AWOL crisis situation for 1 of 1 patient (Pt #1);

2. failing to provide for safety of 1 of 1 patient with a history of self-injurious behavior who had full grounds privileges; (Pt #2 )

3. failing to provide effective immediate intervention to prevent overdose of medication by 1 of 1 patient who informed staff she had "cheeked" her medication (Pt #3);

4. failing to provide a patient care environment that is free of fixtures, surfaces, and/or equipment conducive to patient self-injury or suicide for all patients admitted to the Civil Units.

Findings include:

Facility Policy and Procedure titled "Patient Rights and Responsibilities" dated October 12, 2010 revealed: "...All patients have the right to: 1. Be safe in their surroundings...."

Review of the job description for Mental Health Program Specialist (MHPS) revealed: "...JOB DUTIES AND RESPONSIBILITIES:... objective observation...patient rights...maintain safety, and security for patients...."

Review of the job description for Psychiatric Nurse II revealed: "... Knowledge, Skills and abilities : ...Hospital policies and procedures...Assessment of patient's physical and mental status... Provide direction for patients and staff...Maintain a safe and therapeutic environment... Responsible and accountable for patient care...."

1. Pt #1's medical record contained nursing documentation entered into the electronic medical record 5/18/11: "...Date Service Provided: 5/17/2011...Time Service Provided 11:25 AM (sic)...At 2325 (MHPS #29) informed PNSS (Psychiatric Nursing Shift Supervisor) that patient AWLO (sic) (Absent Without Leave) status...PNSS questioned how patient was able to leave the unit...patient ran and jumped on the desk...and grabbed (MHPS #29's) ID off his person then patient exit door off north hall and exit side door off unit by north nursinf (sic) desk...."

Review of hospital document revealed: ..."(MHPS #29) stated...not familiar with the hospital policy on escapes...not familiar with any instructions for immediate responses to escapes or crisis situations...didn't believe that training and education really went over policies regarding escapes...Unit staff failed to act according to policy and procedure during an escape when: Unit staff did not use critical thinking during a crisis situation on their unit... failed to implement a structure of order during a crisis situation...was unfamiliar with proper radio or telephone commands to be utilized during a crisis situation...."

The COO (Chief Operating Officer) confirmed during an interview conducted on 11/2/11 that findings of the hospital's review of Pt #1's escape indicated a need for staff education regarding how to handle an AWOL situation and awareness of surroundings. However, she was unable to provide documentation that education had been provided to staff.

RN #34, a nurse who works on Ironwood #1 North, confirmed during interview conducted on 11/2/11 at 1436 that she provided nursing care for Pt #1 while he was hospitalized. She confirmed that she has received no education regarding the AWOL or radio/telephone "codes" following the patient's escape.

2. Pt #2's medical record contained documentation recorded by a physician on 6/25/11 at 7:56 PM: "...Patient was in the mall and cut him self (sic) with a piece glass (sic)...." On 6/25/11, at 8:27 PM, a nurse documented: "...(Pt #2) cut...his left forearm ventral aspect...at around 1930...bleeding at site...accepted treatment...Sent out to (name of hospital) ER (Emergency Room...."

RN #21 confirmed during an interview conducted on 11/3/11, that Pt #2 had a recent and long-standing history of engaging in self-injurious behavior and had full grounds privileges on 6/25/11. She confirmed that Pt #2 had expressed the need for increased supervision during the evening shift on 6/24/11, due to a desire to cut himself. She also confirmed that she had documented in the medical record, Pt #2's desire to cut himself but did not notify the physician.

RN #19 confirmed during an interview conducted on 11/8/11 at 1540, that she had not read RN #21's documentation from the evening of 6/24/11, and she had not received verbal report regarding Pt #2's desire to cut himself expressed on the evening shift of 6/24/11. She also confirmed that Pt #2 lacerated his forearm while on the grounds on 6/25/11.

3. Pt #3's medical record contained nursing documentation entered into the electronic medical record on 7/29/11 at 8:10 PM: "...Pt stated to MHPS...'I have been cheeking my seraquel (sic) and I am going to OD tonight'...This RN went into pt's room and saw 5-7 white colored, oblong pills in pt's hand which she immediately swollowed (sic). approx 20 min later pt told staff she took '3 more Seraquels.' (sic) This was not witnessed...."

Employee # 9 confirmed during an interview conducted on 11/3/11 at 1545 that Patient #3 was found with pills in her hand by the MHPS (Mental Health Program Specialist ). The MHPS left Patient #3 and went to find the nurse. The RN and the MHPS then went into the room and witnessed Patient #3 with pills in her hand and swallowing them.

Documentation in the record revealed an outcome of Pt #3's transfer to an Emergency room and subsequent admission to a telemetry unit.

4. The survey team directly observed the following environmental safety hazards while on site from 11/1/11 through 11/9/11:

Ironwood #1 North Unit:

Exposed hinges on all patient bathroom doors (two doors in each bathroom) with space above and below hinges to permit wrapping of cloth around the hinge;

Lever style door handles on all bedroom doors (inside and outside of the room) and on all bathroom doors (inside and outside of the bathroom). Each door handle has a straight section, approximately 1 and 1/4 inches wide which extends from the door and which is sufficient to wrap a cloth around; and

Exposed plumbing fixtures on each toilet and pipes under each bathroom sink. (Pipes under sinks are incased with a protective covering which can be removed).

Palo Verde North Unit:

All patient bathrooms and bedrooms have the same hazards as described above.

In addition, the bathrooms, located between the patient rooms each have two doors, each with a metal fixture at the top which forms a V-shape. This fixture provides a surface for looping cloth and is also the height of the door.

During tour conducted on 11/9/11, the Ironwood #1 North Unit Nurse Manager and the ACNO confirmed that all patient bathrooms and bedrooms throughout the Civil hospital are equipped with the same fixtures and hardware as described above for Ironwood #1 North Unit. The Civil hospital includes Ironwood #1 North, Ironwood #1 East, Desert Sage North, Desert Sage East, Palo Verde North and Palo Verde East.

Based on review of medical records, hospital document, hospital policy/procedure and interviews with staff, it was determined that the hospital failed to require that the quality assessment and performance improvement program activities analyze the cause of adverse patient events and implement preventive actions that include feedback and learning throughout the hospital as evidenced by:

1. failing to take needed action identified in the hospital's analysis of a patient's escape from hospital grounds for 1 of 1 patient (Pt#1); and

2. failing to evaluate, per hospital policy, the medication overdose of 1 of 1 patient who reported "cheeking" her medication (Pt #3).

Findings include:

1. Review of Pt #1's medical record revealed that the patient escaped from the Ironwood #1 North on 5/17/11 at 2325 by grabbing an employee's ID badge and using it to pass through electronically secure doors and walk out the front Civil lobby door to the parking lot.

Review of hospital documentation of follow-up items identified regarding the event revealed: "...7/14/11...5. Educate staff on how to handle AWOL situations and awareness of surroundings: ACNO 8/31/11...."

The COO confirmed during an interview conducted on 11/2/11 that findings of the hosptal's review of Pt #1's escape indicated a need for staff education regarding how to handle an AWOL situation and awareness of surroundings. However, she was unable to provide documentation that the action was taken to provide the education to the staff.

2. Review of hospital policy/procedure titled "Incident Reports" dated July 22,2011 revealed: "...Incident Reports requiring clinical follow-up will be assigned to the appropriate discipline as determined by the ERMT (Executive Risk Management Team) and will be completed utilizing the 'Clinical Review Supplemental Page' (attachment #2)...."

Facility Document titled "Clinical Review Supplemental Page" revealed: "...Clinical Follow-up Information
(to be completed for all incidents that require reporting...and as per request of the ERMT)...."

(Cross reference Tag #C293 for information regarding Pt #3.)

The hospital was unable to provide documentation of a clinical follow up to the incident related to Pt #3's overdose of medication on 07/29/11.

RN # 12 confirmed on 11/9/11 at 9:45 AM, that no further corrective actions were taken after the overdose and no clinical review form was filled out.

The Chief Nursing Officer (CNO) and Interim Chief Quality Officer confirmed on 11/9/11 at 1220 that no Clinical Follow-up was completed. She confirmed the facility did not follow policy and procedure for further follow-up and review.

Based on review of policies/procedures, medical records, job descriptions staff interview with staff and direct observation, it was determined that the nurse executive failed to supervise and evaluate the nursing care for each patient as evidenced by:

1. failing to assess a patient upon his return from an outside medical facility emergency department as required by policy for 1 of 1 patient (Pt #2); and

2. failing to ensure that a patient swallow medications administered for 1 of 1 patient who "cheeked" medications and then overdosed (Patient #3); and failing to ensure that patients swallow medications as required by policy for thirteen out of seventeen patients observed during routine medication administration on Palo Verde East Unit at 0800 on 11/2/11.. (Patients # 10 through 13; 15 through 22, and #26);

Findings include:

1. Review of the hospital policy titled Assessment of the Patient revealed: "...10. An RN will document a completed patient assessment utilizing the Nursing Symptom Review and Physical Assessment form upon any patient's return from:...an outside medical facility emergency department...."

Review of the hospital policy titled Continuity of Care for patients Receiving Services at Outside Clinics/Medical Facilities revealed: "...Treatment Unit Charge Nurse...Conduct a patient assessment utilizing the Nursing Physical Assessment form upon any patient's return from the emergency room. Include in the documentation on the back of the Assessment form the following:...the outcome in regards to the reason the patient was treated from the outside medical facility emergency room...any special instructions regarding treatment or care...any medication changes...the patient's Mental Status...."

Pt #2's medical record contained documentation recorded by a physician on 6/25/11 at 7:56 PM: "...Patient was in the mall and cut him self (sic) with a piece glass (sic)...." On 6/25/11, at 8:27 PM, a nurse documented: "...(Pt #2) cut...his left forearm ventral aspect...at around 1930...bleeding at site...accepted treatment...Sent out to (name of hospital) ER (Emergency Room...."

On 6/26/11 at 0631 AM, an RN documented: "...Pt returned to unit from (name of hospital) ER, in company of staff and security, at 2315. Pts breathing was unlabored, no acute distress noted. L (Left) forearm dressing in splint for comfort intact, no bleeding or drainage noted...V/S (vital signs) done...Pt denies pain. pt went to bed, and slept all night...."

The medical record did not contain a completed patient assessment recorded on the Nursing Symptom Review and Physical Assessment form or an assessment of the patient's Mental Status as required upon the patient's return from the ER.

RN #10 confirmed during interview conducted on 11/3/11 at 1100, that the RN did not complete and record the required patient assessment.

2. Review of facility policy and procedure titled Administering Medications, dated November 17, 2010, revealed: "...Do observe the patient to ensure the medication has been swallowed...." RN # 12, the Unit Nurse Manager, verified on 11/9/11 at 9:45 AM that this facility policy/procedure was the current policy used on the Nursing Unit.

Review of the job description for Licensed Practical Nurse revealed: "... pharmacology...the hospital's policies, procedures, protocols...Administration of medications...make necessary modifications as necessary to increase safety and active treatment...Monitors the milieu and reports to the RN any safety concerns, medications and changes in patient condition...."

Review of the job description for Psychiatric Nurse II revealed: "...Pharmacology...Hospital policies and procedures...Administer medications in a safe manner...Maintain a safe and therapeutic environment... Responsible and accountable for patient care...administer medication and treatments...."

RN# 12, a Unit Manager, confirmed during an interview on 11/9/11 at 9:45 AM, that it is not routine for all patients to be checked to ensure that medications are swallowed.

LPN # 6 confirmed during an interview conducted on 11/2/11 at 0750, that she only checks patients for "cheeking" if the patients have a history of "cheeking" medications. LPN # 6 stated that it is not routine to check every patient to determine if they swallowed the medication.

Medical record review:

Pt #3 was admitted on 7/13/11 and had a history of impulsive behavior, including overdose of medication.

Documentation on Pt #3's Medication Administration Record revealed LPN # 5 's administration of Quetiapine Fumarate (Seroquel) 1200 mg at 2000 on 07/26/11 through 07/28/11. This was confirmed by the ACNO on 11/3/11 at 1500.

RN # 13 documented administration of Quetiapine Fumarate (Seroquel) 1200 mg at 2000 on 07/29/11. This was confirmed by the Unit Manager on 11/8/11 at 1150 am.

On 07/29/11, at approximately 8:10 PM, Pt #3 ingested an overdose of Seroquel that she admitted "cheeking." The patient was transferred to an Emergency Room and was subsequently admitted to a telemetry unit.

Direct observation of a medication pass by LPN# 6 on 11/2/11 at 0745, revealed that thirteen out of seventeen patients who received medications were not checked to see if they swallowed the medication, as required by policy. Only four of the seventeen patients were asked to open their mouths so that the nurse could see if the patients swallowed the pills.