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Based on review of hospital policies and procedures, documents, and staff interviews, the Department determined that the Administrator failed to require that policies and procedures specific to staffing and acuity were implemented to ensure safe staffing. This deficient practice poses a risk to the health and safety of patients, when there is not an appropriate skill mix to ensure patient safety.

Findings include:

The facility policy titled "Staffing/Acuity Plan" requires: "Staffing Mix: Consideration if given in the staffing plan to the utilization of registered nurses, behavioral health techs and nursing assistants (if applicable) according to identified patient requirements ...Acuity Tool: The acuity tool is based on five categories; Utilization, behaviors, medical complexity, mobility, toileting...." The scores are used to calculate a number that indicates the number of nursing and BHT staff needed for the shift. The bottom of the tool lists the average RN and average BHT staff needed. The tool includes a "key" to outline whether to decrease, maintain, or increase the number of staff needed. The tool includes a box labeled "plan" that should be completed to indicate whether to "drop staff", "add BHT", "add Nurse", or "Stay as is." This is to be indicated with a yes or no. Additionally, the tool is required to be completed for day shift, evening shift, and night shift by the registered nurse.

Document titled "Staffing/Acuity Plan Appendix" revealed "Score 4" for category "Behavior" is described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."
Lotus, Phoenix, Koi, Cicada, and Monarch Acuity sheets were reviewed for 07/11/2022 through 07/18/2022. The sheets were found to have staffing below the required based on unit acuity, conflicting information, and no actions noted for increasing or addressing acuity concerns in the documentation.

The acuity sheets for Lotus unit revealed:

Lotus Acuity Sheet dated 07/12/2022, "Night Shift" with an incomplete "Plan" noted a staffing mix total of 4.41 staff required for the shift. Staff assignments revealed 2 staff assigned to the unit with the unit being short 2.41 staff for the shift. This shift revealed 14 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

Lotus Acuity Sheet dated 07/13/2022, "Night Shift" noted a staffing mix total of 4.41 staff required for the shift. Staff assignments revealed 3 staff assigned to the unit with the unit being short 1.41 staff for the shift. This shift revealed 14 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

The acuity sheets for Monarch unit revealed:

Monarch Acuity Sheet dated 07/18/2022, "Night Shift" noted a staffing mix total of 4.38 staff required for the shift. Staff assignments revealed 3 staff assigned to the unit with the unit being short 1.38 staff for the shift. This shift revealed 5 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

Monarch Acuity Sheet dated 07/16/2022, "Night Shift" noted a staffing mix total of 4.43 staff required for the shift. Staff assignments revealed 2 staff assigned to the unit with the unit being short 2.43 staff for the shift. This shift revealed 4 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

Monarch Acuity Sheet dated 07/15/2022, "Night Shift" noted a staffing mix total of 4.23 staff required for the shift. Staff assignments revealed 2 staff assigned to the unit with the unit being short 2.23 staff for the shift. This shift revealed 4 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

The acuity sheets for Phoenix unit revealed:

Phoenix Acuity Sheet dated 07/14/2022, "Night Shift" noted a staffing mix total of 4.24 staff required for the shift. Staff assignments revealed 2 staff assigned to the unit with the unit being short 2.24 staff for the shift. This shift revealed 7 patients identified as level 4 for behavior described as " ...Frequent explosive behaviors, self-harm attempts, requires 1:1 care, requires restraint/seclusion, violence, major issues with staff splitting ...."

Interview with Employee #4 confirmed on 07/20/2022, that the staffing acuity requirements did not match actual staffing on the units, was frequently filled out inaccurately or was incomplete. Employee #4 further noted that the number of patients marked as "Behaviors" level 4 needing 1:1 attention were not accurate and did not have accurate documentation to provide.

Based on review of policy and procedure, medical records and interviews, it was determined that the hospital failed to ensure nursing notes were documented in patient's medical records accurately based on physician orders. This deficient practice poses the potential risk for the health and safety of patients that the medical record would not contain pertinent information needed to provide care to the patient and the wrong order may be followed.

Findings include:

Policy titled "Levels of Observation" reveals, " ...there are four types of observation used at the facility: Routine observation, Line of Sight (LOS) observation, One to one observation, Restricted to unit ...Definitions: Line of Sight: staff have visual observation of the patient at all times ...LOS may not be discontinued without a physician's order ...."

Policy titled "Physician Orders" notes " ...RNs (sic) may initiate a higher level of observation, such as 1:1, but must get a physician's order within four hours to support the intervention ...."

Patient #16 medical record revealed a provider order for: Line of Sight from 06/26/2022 to 07/08/2022. Nursing note dated 07/01/2022 10:52:59 PM notes "LOS while awake" and no corresponding physician order changing the LOS order at all times to LOS while awake.

Patient #16 medical record further contained an order dated 07/01/2022 for "One on one while awake" on 07/01/2022 from 2244 to 2300 with corresponding documentation in the chart revealing Nursing note dated 07/01/2022 at 9:40:55 PM revealed " ...Pt placed in seclusion room ...." The medical record contained no documentation of a seclusion order being obtained.

Employee #4 confirmed during an interview conducted on 07/20/2022 that Patient #16's medical record contained inconsistent documentation on provider orders and nursing notes and that the patient was placed in seclusion without an order obtained and the line of sight level of observation was changed to line of sight while awake without a provider order.

Based on review of policies and procedures, observation, and interviews,the Department determined that the Administrator failed to remove outdated medications from the emergency kit in the hospital kitchen. This deficient practice poses a risk to the health and safety of patients and staff if expired medications are administered to patients or staff during an emergency situation.

Findings include:

Policy titled "Drug Storage: Drug Storage and Preparation Area" revealed: "...Every thirty (30) days, the pharmacist and/or technician will check the stock for expired medications, removing the items that have expired...."

Observation on tour conducted on 07/18/2022 revealed an emergency kit in the hospital kitchen was found to have the following expired items:
1- 4 ounce bottle of Hibiclens solution, expiration date 06/2022
1- 6 ounce tube of Alocane Emergency Burn Gel, expiration date 11/2019
1- 4 ounce bottle of Physicians Care Eyewash solution, expiration date 11/2021
3- single dose packages of antibacterial ointment, expiration date 09/2021

Employee #19 confirmed during an interview on 07/18/2022 that the items found in the emergency kit were expired.

Based on review of hospital policies and procedures, documents, observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Condition of Participation for Physical Environment as evidenced by the following references to standard level deficiencies:

(A701) ensure that the condition of the physical plant and the overall hospital environment related to ligature risks (seclusion bathroom panels) were maintained in such a manner that the safety of the patients were protected from harm. Failure to prevent harm to patients from ligature points poses the high potential risk that patients will be subject to harm and does not provide for their safety and well-being.

(A724) ensure that facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality (restraint bed straps) left in an unsecured room accessible in such a manner that the patients were protected from potential harm.

The cumulative effect of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Physical Environment, which poses a potential risk to the health and safety of patients.

Based on review of hospital policies and procedures, documents, observations, and interviews, it was determined that the Hospital failed to ensure that the condition of the physical plant and the overall hospital environment related to ligature risks (seclusion bathroom panels) were maintained in such a manner that the safety of the patients were protected from harm. Failure to prevent harm to patients from ligature points poses the high potential risk that patients will be subject to harm and does not provide for their safety and well-being.

Findings include:

Facility tour on 07/18/2022, with Employee #4 revealed on Lotus Unit, the restraint and seclusion anterior door was unlocked, open and the two interior doors to the bathroom and restraint bed were also unlocked and open. The bathroom had a panel behind the toilet that had two holes large enough to be a ligature risk that were not properly sealed along the top of the panel.

Policy titled "Patient Rights" revealed " ...Patient rights according to federal and state guidelines include the following at a minimum:...The right to receive care in a safe setting..."

Interview with Employee #6 on 07/18/2022, confirmed the ligature risk in the restraint and seclusion bathroom on Lotus unit was not repaired prior to patients having access to the room.

Based on review of hospital policies and procedures, documents, observations, and interviews, it was determined that the Hospital failed to ensure that restraint straps were secured and not left in an unsecured room accessible to patients. The deficient practice poses a risk to the health and safety of patients by not providing a safe environment to patients.

Findings include:

Facility tour on 07/18/2022, with Employee #4 revealed on Lotus Unit, the restraint and seclusion anterior door was unlocked, open and the two interior doors to the bathroom and restraint bed were also unlocked and open. The restraint bed had the restraint straps attached to the bed and not in the secure box. The bathroom had a panel behind the toilet that had two holes large enough to be a ligature risk that were not properly sealed along the top of the panel.

Policy titled "Patient Rights" revealed " ...Patient rights according to federal and state guidelines include the following at a minimum:...The right to receive care in a safe setting..."

Interview with Employee #6 on 07/18/2022, confirmed the ligature risk in the restraint and seclusion bathroom on Lotus unit was not repaired prior to patients having access to the room. Interview with Employee #4 on 07/18/2022, confirmed that the three restraint and seclusion doors were left unlocked and open to patient entry and the straps were for restraint were not secured after use and were accessible to patients.

Based on CDC (Centers for Disease Control and Prevention) guidelines, review of policies and procedures, facility documents, video review, and interview, it was determined that the Hospital failed to ensure staff wear face masks when providing patient care. Failure to follow established infection control guidelines poses a patient risk for exposure to infectious diseases including exposure to COVID-19.

Findings include:

The CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic" Updated Feb. 2, 2022, requires: "...CDC ' s COVID-19 Community Levels recommendations do not apply in healthcare settings, such as hospitals and nursing homes. Instead, healthcare settings should continue to use community transmission rates and continue to follow CDC's infection prevention and control recommendations for healthcare settings...Source control and physical distancing (when physical distancing is feasible and will not interfere with the provision of care) are recommended for everyone in a healthcare setting...."

The facility policy titled "COVID-19 Plan Policy" revised 4/1/2022 requires: "...Personal Protective Equipment...Facemasks (Sic)...b. During all Status colors, facemasks (Sic) are to be worn at all times around patients and in patient care areas by ALL staff at Destiny Springs Healthcare...."

Observation on 07/18/2022, revealed a BHT in the intake area not wearing a face mask.

Employee #2 confirmed on 07/18/2022, that the staff member was not wearing a face mask as required.

Observation on 07/18/2022, revealed a BHT exiting the Lotus unit at 1214 escorting patients with their mask pulled down under their chin.

Employee #2 confirmed on 07/18/2022, that the staff member was not wearing their face mask as required.

Observation on 07/19/2022, revealed during a tour of the facility that (6) staff members were either not wearing a face mask while providing patient care or not wearing their mask over their nose and mouth in patient care areas and around patients.

Employee #1 confirmed on 07/19/2022, that six staff members were not properly wearing a face mask as required during a tour of the facility.

Based on policy and procedure, observation, and interview, it was determined that the facility failed to maintain a clean and safe environment in the patient exam room and the seclusion room on Koi unit which has the potential risk of cross contamination and increased infection.

Findings include:

The policy titled "Exposure Control Plan" requires: "...Equipment and work surfaces that have become contaminated with blood or other potentially infectious material must be cleaned and decontaminated as soon as feasible, as well as at the end of the work shift if the surfaces have become contaminated since the last cleaning...Sharp containers (small red) may be stored in the medical exam rooms until full (3/4) for permanent disposal. the sharp containers must remain upright at all times and disposed of when 3/4 full...."

Observation of Koi unit on 07/18/2022 revealed the patient exam room had a full, loose sharps container on the countertop next to the sink. The container was more than 3/4 full of used sharps. The sharps container attached to the wall was full with a used, bloody vacutainer attached to a butterfly needle and cannula hanging out of the top of the container. There was dried blood splatter on the wall immediately next to the sharps containers, and dried blood splatter on the oxygen concentrator immediately below.

Employee #4 confirmed on 07/18/2022 that the exam room sharps containers and dirty sharps were not discarded as required and that dried blood splatter on the wall and oxygen concentrator had not been cleaned and disinfected.

Observation of Koi unit on 07/18/2022 revealed the seclusion room bathroom sink was dirty. The sink had fuzzy, pink/brown clumps of debris in the sink and debris on the floor. Additionally, the soap dispenser for the sink had been removed from the wall and no soap was available.

Employee #4 confirmed on 07/18/2022 that the seclusion room bathroom and sink were not cleaned and disinfected and did not know when cleaning and disinfection had last occurred.

Observation on Monarch unit on 07/18/2022 revealed that the nursing medication room did not have a working soap dispenser at the handwashing sink.

Employee #4 confirmed on 07/18/2022 that the soap dispenser in the nurses medication room hand washing sink did not work.

Based on review of policy and procedure, facility documents, and interviews, it was determined that the facility failed to ensure:

1. that the hospital policies for COVID-19 vaccination and response were comprehensive and included the required CMS components;

2. that 100% of staff without a medical or religious exemption were vaccinated as required; and

3. that the hospital implemented COVID-19 testing for unvaccinated staff as outlined in the facility policies.

Findings include:

1. The following policies and procedures were reviewed during the survey.

Infectious Disease Response and Containment, revised 04/05/2022
Mandatory COVID-19 Vaccination, revised 02/01/2022
Exposure Control Plan, revised 06/20/2022
COVID-19 testing and facemasks for exempted employees, revised 04/01/2022

The hospital policies for COVID-19 vaccination of staff revealed that processes were not developed and/or implemented for the following.

a. that policy and procedures did not include a process for ensuring all staff obtain any recommended COVID-19 vaccine booster doses or additional doses for individuals who are immunocompromised, in accordance with the recommended timing of such doses.

b. the policy and procedures did not include a process for tracking and securely documenting information confirming recognized clinical contraindications to COVID-19 vaccines provided by those staff who have requested and have been granted a medical exemption to vaccination.

c. the policy and procedures did not include a process for ensuring the tracking and secure documentation of the vaccinations status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, or individuals who received monoclonal antibodies or convalescent plasma for COVID-10 treatment.

d. there were no contingency plans for staff that are not yet vaccinated for COVID-19 (and without an exemption for medical contraindications or without a temporary delay in vaccination due to clinical considerations as recommended by the CDC and as specified in the State Operations Manual, including deadlines for staff to be vaccinated.

2. The facility policy titled "COVID-19 testing and facemasks" requires: "...All employees who are exempted from COVID-19 vaccination as of 03/15/2022 will be required to undergo regular COVID-19 testing and wear a facemask when in the workplace...COVID-19 Testing...All employees who are exempted from COVID 19 vaccination will be required...When the community level is LOW, COVID-19 testing will be based on symptoms and at the discretion of the Infection Control Preventionist or designee. N-95 Facemasks are required at medium risk. Regular face masks can be used a Low risk...When the community level is MEDIUM, COVID-19 testing will be; a. Tested for COVID-19 at least every thirty days and b. Must provide documentation of the most recent test result to the Infection Control Preventionist or designee no later than the 30th day of each month c. If an employee wishes to use a rapid home test, the test must by performed in the presence of a Nursing Supervisor or designee...When the community level is HIGH, exempted employees will be required to test weekly for COVID-19...Employees who report to the workplace...Must be tested for COVID-19 at least once every seven days; and Must provide documentation of the most recent COVID-19 test result to the House Supervisor no later than the seventh day following the date on which the employee last proved a test result...."

Review of Maricopa County's website revealed that community transmission levels for COVID-19 are currently HIGH and have been in the HIGH category since June 3, 2022.

Employee #3 confirmed on 07/19/2022, that the facility recognized that the community COVID-19 transmission rate transitioned to HIGH on June 8, 2022. Additionally, Employee #3 confirmed that the facility did not implement monthly and weekly COVID-19 testing for unvaccinated/exempted employees when the community transmission rate rose to medium and high as required in the facility's policy.

3. Two facility documents for staff COVID-19 vaccination status were reviewed. One document contained vaccination data for staff. The second document contained vaccination data for providers.

The staff list revealed that only 92% of staff are vaccinated, leaving 8% of staff who remain unvaccinated or incompletely vaccinated without an exemption.

The provider list revealed that only 96% of providers are vaccinated, leaving 4% who remain unvaccinated or incompletely vaccinated without an exemption.

Employee #23 provided the lists for review and confirmed on 07/19/2022, that 8% of staff without an exemption remain unvaccinated or incompletely vaccinated, and that 4% of providers without an exemption remain unvaccinated or incompletely vaccinated.

Based on review of policies and procedures, medical records and staff interviews, the Department determined that the administrator failed to require that the hospital's discharge planning process required regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan. This deficient practice poses a risk to the health and safety of patients, that upon discharge they may not have appropriate services in place.

Findings include:

Policy titled "Discharge Planning" revealed " ...Discharge planning begins at the time of admission ...Discharge criteria and expected length of stay are discussed upon admission ...All Discharges ...At a minimum, the Patient's assigned social worker shall make an entry in the record every three days giving indication as to the status of the discharge plan until it is complete ...."

Patient #21 record revealed an initial treatment plan dated 07/08/2022, with no expected length of stay and no discussion of discharge planning. Discharge planning discussed in "Social Worker Note" dated "07/12/2022," and Patient #21 was discharged on 07/14/2022.

Patient #22 record revealed an initial treatment plan dated 06/10/2022, with no expected length of stay and no discussion of discharge planning. Discharge planning discussed in "Social Worker Note" dated "06/13/2022," noting follow up would occur " ...at next treatment plan ...." Treatment plan dated 06/14/2022, and 06/21/2022, revealed no discharge planning and Patient #21 was discharged on 06/22/2022.

Patient #23 record revealed an initial treatment plan dated 06/23/2022, with a noted expected length of stay of 06/29/2022 and no further discussion of discharge planning. Discharge planning notes were requested. None were provided. Patient #23 was discharged on 06/29/2022 with no recorded discharge planning.

Interview with Employee #12 on 07/19/2022, confirmed Patient #21, #22 and #23 did not have discharge planning with regular re-evaluation of the patient's condition to identify changes that require modification of the discharge plan.

Based on review of the facility documentation, medical records and interviews, it was determined that the hospital failed to assess the discharge planning process with regard to patients who were admitted within 30 days of a previous admission, to ensure that the plans are responsive to the patient post-discharge needs. This deficient practice poses a risk to the health and safety of patients, when proper discharge planning is not coordinated for the needs of the patient post-discharge.

Findings include:

Policy titled "Discharge Planning" revealed no documentation on reviewing patients who were admitted within 30 days of a previous admission.


Patient #10, #11, #12, and #13 were readmitted to the hospital under 30 days. Documentation assessing the discharge planning process with regard these four patients who were admitted within 30 days of a previous admission was requested. None was provided.

Employee #12 revealed during an interview conducted on 07/20/2022, confirmed that patients who return to the hospital under 30 days are not being assessed or tracked, to ensure that the plans are responsive to the patient post-discharge needs.

Based on review of policy and procedure, medical records and staff interview, it was determined that the facility failed to ensure Interdisciplinary Treatment Plans were developed within 72 hours, and reviewed, signed and updated at least every seven (7) days, with each treatment plan review, or within twenty-four (24) hours following any qualifying event. This deficient practice poses a potential risk to the patient's health when the treatment plan is not current and/or does not support the patient's recovery.

Findings include:

The policy titled "Interdisciplinary Treatment Plan Team Meetings" revealed: "...Per the interdisciplinary Treatment Planning (ITP) Policy, all patients shall have an ITP initiated and reviewed by the team within 72 hours of admission. Although every patient shall be reviewed every day in the treatment team meeting, all patients shall have a formal Treatment Team Review every seven (7) days and/or within twenty-four (24) hours of any qualifying event, whichever is sooner...."

The policy titled "Interdisciplinary Treatment Planning (ITP) Documentation" revealed: "...ITP Review...Treatment plan reviews occur whenever there is a significant change in the individual ' s condition or at a minimum of every seven (7) days. Treatment plan reviews ensure that the individual's goals and objectives are regularly reviewed and revised based on the individual's clinical condition. Treatment plan reviews are discussed and documented in the treatment team meetings...."

The treatment plan for each patient included a signature page for members of the treatment team, the "patient/client", the "parent/guardian". Below the signature lines is another signature line that reads "A copy of this treatment plan was: ____ given to the patient/client/family OR ____ declined by the patient/client/family: Date: ____ Clinician: ___________ Title: ________. This was left blank for all treatment plans reviewed.

Patient #20's initial treatment plan was initiated on 05/25/022 and completed on 06/09/2022 which included long-term and short-term goals all with the target date of 06/02/2022.

Patient #25's initial treatment plan was initiated on 04/21/2022. The treatment plan was signed by the ITP team and patient on 04/28/2022.

Employees #4 confirmed on 07/20/2022, that Patient #20, #25 treatment plans were not reviewed by the team within 72 hours of admission.