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Based on interview and review of hospital documents, it was determined that the hospital's Governing Body failed to effectively carry out its responsibilities for the conduct of the hospital as evidenced by failing to assume responsibility for the hospital as a separately certified institution, ensuring focus on the hospital's individual issues as evidenced by:

Tag 0043: The governing authority failing to have a separate processes in place to identify the certified hospital's operations from the non-certified hospital's operations;

Tag 0049: The governing authority failed to ensure the medical staff provided quality care for 1 of 1 patient (Pt #2), as demonstrated by the medical staff failure to conduct and document a re-examination of the patient's physical status upon return from emergency department treatment as required by policy/procedure; and

Tag 0073: The Governing Body failed to have an overall institutional plan and budget for the Medicare Certified hospital separate from the hospital which is not Medicare Certified.

The cumulative effect and life endangering result of this problem resulted in the hospital's failure to meet the requirements of the Condition of Participation for Governing Body.

Findings include:

The hospital's administration team confirmed during the entrance conference conducted on 08/27/13, that the "Civil Hospital" is Medicare Certified and separate from the other non-certified facilities. The surveyor requested the most recent Governing Body minutes related to the Medicare Certified. The following were provided:

The "Arizona State Civil and Forensic Hospital Governing Body" Minutes dated July 30,2013 Meeting was called to order at 1:00 pm and adjourned at 2:30 pm. This 8 page report revealed the following:

"...Topics/Issues: Call to Order, Approval of minutes, Standing Business, Acting CEO Report, ASH Chief Medical Officer Report, Chief Operating Officer Report, Chief Nursing Officer Report,Chief Quality Officer Report, Patient Rights, Forensic Hospital Update, Human Rights Committee, Call to the Public, Call to Adjourn, and Date and Time of Next Meeting.

Additional similar meeting of the "Arizona State Civil and Forensic Hospital Governing Body" Minutes occurred April 30, 2013.

The meeting minutes contained documentation that the two hospitals (one certified and one not certified) were discussed at the same time, at the same meetings, and did not focus on the Civil Hospital's specific issues, as a separately certified hospital.

Quality reports and all other reports and discussion reflected combined data. There was no documented evidence that the Quality or operations of the Medicare Certified hospital were being addressed for the separate Medicare Certified entity by the Governing Body.

Interview with Acting CEO on 8/29/13, confirmed that the meetings and minutes do not address the individual hospitals separately. She also confirmed that the Forensic Hospital is separately licensed and not Medicare Certified.

Based on review of hospital documents, policies/procedures, medical record and interviews with staff, it was determined the governing authority failed to ensure that the medical staff provided quality care for 1 of 1 patient (Pt #2), as demonstrated by the medical staff failure to conduct and document a re-examination of the patient's physical status upon return from emergency department treatment as required by policy/procedure.

Findings Include:

The Medical Staff Rules and Regulations dated 2012-2014, required;..."Every member of the MEDICAL STAFF shall be subject to the Bylaws, Policies and rules of the HOSPITAL... Responsibility for Patient Care: Each member of the MEDICAL STAFF shall be responsible for the treatment of each patient assigned to his/her care in the HOSPITAL...."

The hospital policy titled Assessment of the Patient dated 11/01/12, required: "...3. Re-examination of the patient's physical status will be performed as follows: a. When patient exhibits signs of illness; b. When returning from inpatient or emergency department treatment provided by an outside medical facility...Responsible Person: Assigned Admitting Medical Physician and/or Assigned Physician's Assistant...."

Patient #2:

The patient was admitted on 06/08/11, with diagnoses of Mood Disorder not otherwise specified, impulse control disorder, borderline personality disorder, panhypopituitarism, ADD, Alcohol abuse, Cannabis Abuse, and was on the Ironwood East Unit. The patient had a history of self-injurious behaviors by swallowing items.

On 09/06/13, Pt #2 was sent to the ED of another acute care hospital, after obtaining and swallowing pieces of a broken CD. The patient returned from the ED on 09/07/13 (Saturday) at 0015 hours.

An interview with Physician #3 was conducted on 09/18/13 at 1430 hours. He confirmed he was the On-Call doctor for Saturday 09/07/13. He reported he received a call from an RN. The RN called to notify him that the patient had returned from the ED and the CT results.

Review of Pt # 2's medical record revealed a document titled Adult Emergency Department After Visit Summary; Encounter Date: 09/06/2013: "...Patient seen for ingested foreign body. CT (Computed Tomography) of abdomen and pelvis shows evidence of new foreign body when compared repeat CT on 9/3/2013...."

Pt #2's medical record did not contain documentation of re-examination of the patient's physical status by a Medical Physician or Assigned Physician's Assistant as required by hospital policy, when returning from emergency department treatment

On 09/08/13 (Sunday) the on-call physician saw the patient for behavioral problems that required an intramuscularly injection (IM) for the patient to calm down. No assessment of the patient's physical status was documented by this physician.

Progress notes written by PA-C #17 on 09/09/13 (Monday) revealed the following: "...The pt is up and about on the unit this AM. He was not seen today...."

During the interview with PA-C #17, he was asked to explain the following: "...He was not seen today...." He explained that meant he didn't do a physical examination.

Pt # 2 coded on 09/09/13 at 2210 hours, requiring transfer to an acute care hospital for emergency medical treatment.

Summary;

Pt # 2's medical record from the acute care hospital contained documentation that Pt #2 had required multiple transports for X-rays due to swallowing events, with a visit to the ED and X-rays on 9/6/13 due to abdominal pain and swallowing Compact Disc pieces. There was no evidence that a physician examined the patient for his medical concerns after return from the ED on 9/7/13. There was no evidence of re-evaluation by his Medical Physician or Physician's Assistant on 9/8/13 or 9/9/13, as required by hospital policy/procedure.

Based on review of meeting minutes, facility documentation and interviews, it was determined that the hospital failed to comply with the provisions that require the Governing Body to have an overall institutional plan and budget for the Medicare Certified hospital separate from the hospital which is not Medicare Certified.

Findings include:

The hospital's administration team confirmed during the entrance conference conducted on 08/27/13, that the "Civil Hospital" is Medicare Certified and that the other facilities are non-certified. The surveyor requested the hospital budget related to the Medicare Certified facility.The following were provided:

The "FY 2014 Appropriated Funds" Include: "...General Fund...Hospital Fund...Land Fund... Forensic Debt...Community Placement...EMR Start Up...."

There was no separate budget for the Medicare Certified hospital available for surveyor review.

Interview with Acting CEO on 8/29/13, confirmed that the budget is not broken down for the individual hospitals separately, but includes the Civil Hospital and the Forensic Hospital combined.

Based on review of facility policies/procedures, job descriptions, personnel files, medical records, hospital documents and staff interviews it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure the patients' right to receive care in a safe setting.

The cumulative effect and life endangering result of this problem resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

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

1. failing to provide for safety of six of six patients (Patient # 2, 3, 4 ,5, 6 and 7) with a history of self- injurious behavior who harmed themselves while on Close Observation status; and

2. failing to provide an environment that would prevent patients from using items to harm themselves, when patients have physician orders and are known to use multiple objects for self-harm for three of three patients) Patient #'s 1, 3, 4, and 5).

Findings include:

Facility Policy and Procedure titled "Patient Rights and Responsibilities" dated November 1, 2012 revealed: "...Patients have the right to: 1. Be safe in their surroundings...Keep and use personal possessions, unless the person in charge of the agency determines that possession would pose a threat of bodily harm to the patient or others..."

Facility Policy and Procedure titled "Contraband / Controlled Items" dated June 6, 2012 revealed: "...Contraband- No contraband items are allowed on the treatment units. This includes but is not limited to, the following: NOTE: Even if not listed below, items that may be considered harmful to patients or staff may be removed at staff discretion...Caustic substances...Aerosol cans,combustible items, paint...Controlled items-items which may need to be temporarily removed from a patient due to the patient's individual condition or behaviors...If there is a need to temporarily restrict the use of personal items from a patient, the decision to implement the restriction must be based on a clinical assessment of the patient and documented...."

Facility Policy and Procedure titled "Close Observation" dated June 10, 2013 revealed: "...It is the policy of the Arizona State Hospital to provide close observation, when indicated, to assure the safety of the patients and other individuals at Arizona State Hospital...Close Observation/High Risk is a method of observation implemented when a patient's potential behavior poses an imminent threat to the patient's well being. Close Observation/ High Risk required continuous visual observation of the patient at ALL times and within 6 feet range of the patient. Unless otherwise indicated in the provider's order, a patient's face and hands must be visible at all times. An Environmental Risk Assessment will be completed at each initiation of close Observation/High Risk and documented on the Environment Risk Assessment Checklist...Close Observation/Line of Sight is a method of observation implemented when a patient's potential for an adverse event is high and warrants continuous visualization...requires continuous visual observation of the patient in the line of sight at ALL times. Unless otherwise indicated in the provider's order, a patient's face and hands must be visible at all times. The assigned staff member should be close enough to be able to intervene for patient safety...."

Facility Policy and Procedure titled "Code Gray" dated June 22, 2012 revealed: "...will be utilized to summon additional personnel to the site of an emergency behavioral situation whenever it is determined that additional personnel are needed at the site to help de-escalate or help effectively manage the situation...All Personnel...An alert sent to Code Gray Response Team Members to signify that additional personnel are requested to help manage a behavioral situation...A Code Gray shall be initiated in situations where a person is demonstrating escalating behaviors and may be likely to lose control and/or poses an immediate danger to self or others...."

The hospital has four levels of mental health program specialist (MHPS) I through IV; and included in each job description is the requirement to respond to psychiatric and medical emergencies.

The RN's job responsibility includes patient assignments, supervision of the provisions of care, and responding to psychiatric and medical emergencies.

1. Patient #2

Pt # 2's medical record contained documentation that he was admitted on 06/08/11, for mood disorder not otherwise specified (NOS), impulse control disorder, and borderline personality disorder. On 08/29/13, Pt #2 was on close observation/line of sight (COS/LOS), according to the staffing assignments.

RN #11 confirmed during an interview on 09/18/13, that Pt #2 was on COS/LOS.

Review of the physicians progress notes for 08/29/13 at 3:32 PM, written by Physician #9, revealed the following: "...(Pt # 2) told me at 2:30 this afternoon that at about 1 PM this afternoon he swallowed the plastic templates to sunglasses he found in a male peer's room next door to his room. He said he went through his bathroom into their room and the COS LOS staff didn't watch him and he stood at his sink and swallowed the frame parts...The patient remains on COS LOS and that staff was (sic) reminded to watch him when he goes to the bathroom...."

RN # 2 confirmed in an interview on 09/17/13, that Pt # 2 was able to obtain the glasses and swallow the broken pieces while on COS/LOS.

Review of a hospital document dated 09/06/13 at 1450 hours, identified that Pt # 2 was sitting on the floor in his room, and noticed a few CD plastic cases under a drawer. Pt # 2 grabbed the cases, and the staff assigned for COS/LOS called for help. By the time help arrived the patient had put pieces of the broken CD in his mouth, and swallowed them.

Review of physicians progress notes for 09/06/13, revealed the following: "...(Pt # 2) swallowed a sharp screw this morning and then this evening at about 1452h broke a CD hidden under a drawer he pulled out and broke and swallowed...Send (Pt # 2) to MMC (Maricopa Medical Center) Emergency Department...."

Pt # 2 was on COS/LOS on 08/29/13, and 09/06/13; was able to obtain items for self injury; and was successful in swallowing the items.

Patient #3

Pt. # 3 's medical record contained documentation that Patient # 3 was admitted to the facility on 4/20/12 for DTS (Danger to Self) and DTO (Danger to Others). MD #2 wrote orders on 6/13/13 at 3:05 pm for "...Close Observation/High Risk 24/7 to prevent biting himself, inserting foreign bodies...."

RN # 41 Nurse's documentation dated 6/25/13 at 1:39 pm revealed: "...remains on constant observation 1:1 high risk due to danger to self behavior...having his dressing to his self inflicted wound on his left arm changed. When his wound was opened and cleansed out, he pushed his way past the nurse and proceded (sic) to try and attempt to bit (sic) his hand when he was placed on a brief physical hold by two other staff members that was assisting the nurse during this procedure. When staff attempted verbal de-escalation without success...Dressing to left arm intact...."

RN # 15 Nurse's documentation dated 6/25/13 at 5:19 pm revealed: "...At about 1639 hour on the above date a staff called the nurse that the patient put foreign object in his left forearm, The patient inserted a shampoo cap into the old wound on the left arm. Patient commented 'the voices made me do it'. Patient asked the staff sitting on him if he can take a shower. He had not taken a shower for 3 days. He took his shampoo and washing things, walked into the shower and quickly inserted the shampoo cap in the left hand wound. Patient left hand was bleeding because of the insertion of the shampoo cap...Attending provider notified. Patient sent to...ER...."

Interview with RN # 15 conducted on 9/4/13 at 1530, confirmed that the patient was able to insert the shampoo cap into his existing wound while the 1:1 staff was observing the patient. He confirmed the patient had a known history of inserting items into his wounds which was the reason the patient was on a 1:1 Close Observation. RN # 15 also confirmed that the staff assigned to the patient was not familiar with the evening routine and the patient.

The Assistant to the Chief Quality Officer confirmed in an interview conducted on 9/3/13 at 1000 am, that the documentation in the medical record reveals that the patient was on a 1:1 at the time of the incident to prevent him from inserting foreign bodies into his wound and he was still able to obtain a shampoo cap, and insert in existing wound.

Patient # 4

Pt. # 4's medical record contained documentation that Patient #4 was admitted to the facility on 9/22/08 for "...Schizoaffective Disorder...Borderline Personality Disorder with long term patterns of maladaptive thoughts, feelings and behaviors including self-harmful behaviors and assaultive behaviors...."

MD #2 's documentation written 5/6/13 at 11:01am revealed that Patient # 4: "...Close Observation Line of Site (sic), COS, Line of Site (sic) to Prevent Swallowing Foreign Bodies...."

Nursing documentation by RN # 15 dated 5/13/13 revealed: "...At about 2020 on 5/13/13 the above patient asked the staff sitting on her if she can wash up in the bathroom. The staff came to the charge nurse that patient handed him a bottle of Vaseline container and commented "i (sic) opened the bottle broke the tube in the container and swallowed it...."

Interview with RN # 15 conducted on 9/4/13 at 1530, confirmed that the patient was able to swallow a foot long plastic tube from a lotion bottle while the 1:1 staff was observing the patient.

Interview with RN # 39 conducted on 9/4/13 at 1400 confirmed Patient #4 was upset that she swallowed the tube and wanted to go to the Emergency Room to be seen, so she acted out on 5/14/13 by banging her head on the wall, attempting to eat paint, drywall and insulation. Patient complained of spitting up blood and thought that she would suffocate when the tube came back up. Patient continued to have emesis multiple times throughout the night of 5/14/13 through 5/15/13 with epigastric pain 8/10. Patient was transported to ER on 5/15/13.

The Assistant to the Chief Quality Officer confirmed in an interview conducted on 9/3/13 at 1000 am that the documentation in the medical record reveals that the patient was on a 1:1 at the time of the incident and was still able to obtain a plastic tube from a lotion bottle and swallow it.

Medical Staff Member # 7's documentation written 5/16/13 revealed: "...Return today from... admission. S/P EGD ( Status Post Esophagogastroduodenoscopy) for removal of FB from stomach. No description of FB in notes. Evidence of erosive esophagitis...."

Patient # 5

Pt. # 5's medical record contained documentation that Patient # 5 was admitted to the facility on 1/26/11 due to repeated self -injurious behaviors with suicidal ideation as well as aggressive behaviors towards others.

MD #10 's documentation written 7/2/13 at 4:43pm, for Patient # 5 revealed: "...Close Observation Line of Site (sic)...Impulsity...COS, LOS..."

Nursing documentation by RN # 23 dated 7/13/13 revealed: "...It was reported to this RN by the Lead MHPS that (patient) was in her bed and appeared to be doing something under her blankets. Lead MHPS is a male and explained that he did not feel comfortable entering the patient's room at this time. This RN went to Patient's room at which point I visualized a sock with blood on it next to (patient # 5's) bed...(patient) threw the shattered pieces of the compact disc toward staff. Blood was visualized on Patient's fingertips but patient refused assessment initially...(Patient) got out of her bed and continued to yell at staff...walked toward patio door and turned her back on staff...(patient) was observed pushing on the new wound on her left forearm, near wrist...(Patient) stated that she was pushing a piece of the disc further up into her arm. Patient's wound was dripping blood; small but deep wound assessed. Foreign body can be felt through skin...O.D (Officer of the Day) notified of incident...At 1630 wound cleansed and dressed...go to ...ED to have foreign body removed from forearm...."

Interview with RN # 23 conducted on 8/29/13 at 2:30 pm, confirmed that the patient was not to have hands covered under a blanket per hospital policy. She also confirmed MHPS #27 assigned to Patient # 5, at the time of the incident did not instruct the patient to remove her hands from under the blanket. RN #23 also confirmed that MHPS #27 left the patient to report the patient's behavior to RN # 23 instead of utilizing his radio to call for help and following the policy of calling a "Code Gray" to summon assistance.

The Assistant to the Chief Quality Officer confirmed in an interview conducted on 8/29/13 at 4:30 pm, that the documentation in the medical record reveals that the patient was on a 1:1 at the time of the incident and was still able to obtain a compact disc. She also confirmed that the patient's hands were concealed by the blanket which does not meet requirement of the policy.

MD #10 's documentation written 7/26/13 at 5:52 pm, for Patient # 5 revealed: "...Close Observation Line of Site (sic)...Suicidal Precautions...COS, LOS...."

Nursing documentation dated 7/27/13, revealed that Patient # 5 re-injured her left wrist by using a belt with a buckle while on COS/LOS.

Nursing documentation by RN # 23 dated 7/27/13 revealed: "...(patient) was laying in her bed with her hands under her blankets, 1:1 monitor directed ...to bring her hands out from under the blankets but she refused. While under the blankets...removed her belt and used the pointed metal part of the buckle to reopen the puncture wound on her left wrist. 1:1 monitor and Lead MHPS were able to retrieve the belt...(patient) came out to dayroom, and was yelling at staff...continued to escalate and was not responding to verbal redirection. Patient continued to be verbally assaultive to staff. (Patient) removed pieces of laminant (sic) from window sill and stuck her finger and pieces of laminant (sic) into her wound...Code Gray was called...OD (Officer of the Day) notified...Patient to (ED) for foreign body removal...."

Review of hospital written documentation of a video camera recording on 7/27/13, showed MHPS # 24 sitting in doorway of Pt #5's room; MHPS #24 went into room. Code Gray was called approximately 9-10 minutes after first self harming behavior.

The Assistant to the Chief Quality Officer confirmed in an interview conducted on 8/29/13 at 4:30 pm, that the time that the Code Gray was called was approximately 9 to 10 minutes after the first self harming behavior. She also confirmed that the documentation in the medical record reveals that the patient was able to harm herself with a belt buckle while covered with a blanket and observed by 1:1 staff.

There was no documented evidence that the 1:1 staff member called for assistance when Pt # 5 refused to remove her hands from under the blanket during the incident on 7/27/13.

The above events were confirmed by RN # 23 on 8/29/13 at 2:30 pm..

Patient # 5 had harmed herself with a compact disc on 7/13/13, and a belt buckle on 7/27/13. The patient harmed herself while observed by 1:1 staff. Both incidents occurred while the patient's hands were concealed under a blanket.

Patient # 6

Pt. # 6's medical record contained documentation that Patient #6 was admitted to the facility on 9/26/2007, due to Court Ordered Treatment for being Gravely Disabled with repeated self -injurious behaviors, auditory and visual hallucinations, and paranoid thoughts.

MD #4 's documentation written 7/9/13 at 4:43 pm, for Patient # 6 revealed: "...Continuous Close Observation Line of Site (sic)......prevent throwing self off wheelchair and bed...."

Nursing documentation by RN # 26 dated 7/16/13 revealed:"... patient # 6 was in the wheelchair...wheeled self away from staff...unstrapped seatbelts and threw self to the ground...."

Interview with RN # 26 conducted on 8/29/13 at 9:30 am confirmed, Patient # 6 wheeled self away from staff, unstrapped seatbelts, and threw self to ground.

Review of hospital written documentation of a video camera recording on 7/16/13 at 0710 revealed: "...(contracted agency MHPS # 32) left (Pt #6) sitting in the hall several feet away as she stood at the nurses' station and talked to staff for quite a while, never even looking at (Pt #6) during this time...At no time did (Pt #6) wheel herself away from staff...the COS staff never even...look (sic) at (Pt #6) until after she threw self out of the chair...it looked like the housekeeper was the one that saw (Pt #6) on the ground first...."

MD #4 's documentation written 7/16/13 at 2:51 pm, for Patient # 6 revealed: "...Close Observation High Risk for safety reasons...."

Interview with Assistant to the Chief Quality Officer on 8/29/13 confirmed that patient # 6 required 1:1 Close Observation Line of Sight at the time of the incident. She confirmed that hospital documentation of the video recording of the incident revealed that the staff member assigned to maintain line of sight of the patient was not looking at the patient when the patient unstrapped her seatbelts and threw herself to the floor.

Patient # 7

Pt. # 7 's medical record contained documentation that Patient # 7 was involuntarily admitted to the facility on 1/25/2006, due to self harm, assaultive behavior, and impulsivity.

MD #5 's documentation written 7/9/13 at 10:26 am, for Patient # 7 revealed: "...Continuous Close Observation Line of Site (sic)...weekly renewal...."

Patient # 7 was placed on "... COS/LOS on7/9/13, at 10:26 am by MD # 5...."

Nursing documentation by RN # 29 dated 7/13/13 at 10:05 am revealed: "...pt began repeatedly strike his head against the towel dispenser in restroom sustaining multiple lacerations to forehead and scalp...verbal de-escalation/re-direction unsuccessful...pt was placed in physical restraint...."

Review of hospital document revealed: "...7/13/13 around 0804, (Pt # 7) was in room when staff heard a bang and a call for help...staff found (Pt # 7) with multiple lacerations to forehead and scalp and bleeding...indications are patient removed helmet and banged head on the paper towel dispenser in bathroom...."

Pt # 7 was able to remove his helmet and lacerate his head prior to the arrival of additional staff to assist the 1:1 staff assigned to the patient.

Interview with RN # 29 conducted on 8/30/13 at 2:15 pm confirmed, Patient # 7 required close observation for impulsivity and unpredictability. RN # 29 confirmed a registry staff was assigned to Close Observation Line of Sight for Patient # 7, and behavior cues were discussed with the registry staff. RN # 29 confirmed that while registry staff observed Patient #7, the patient removed his protective helmet, entered the bathroom and banged his head on the paper towel holder, causing multiple lacerations. Pt # 7 was subsequently placed in a physical hold and a "Medical alert" was called.

Interview with the Assistant to the Chief Quality Officer on 8/29/13 confirmed that Patient # 7 was on 1:1 observation at the time of the incident.

2. Review of facility policy titled Contraband/Controlled Items revealed: "...To identify patient contraband and controlled items which present a potential danger to patients, visitors, and staff...It is the policy of the (Name of Hospital) that patients will not be permitted to have items that might be a danger to themselves or others...Definitions...Contraband - No contraband items are allowed on the treatment units. This includes, but is not limited to, the following: NOTE: Even if not listed below, items that may be considered harmful to patients or staff may be removed at staff discretion...knives, razors, scissors, nail clippers, sharpeners, pins, tacks, and other sharp objects...Glass items...metal, soda cans...."

Patient #1

Patient #1 ' s physician orders on 2/20/13, at 0851 AM revealed: "...Please allow up to 20 min. per day for journaling w/pen and paper. Must check out and return pen. COS/LOS while journaling...."
On 2/21/13, an RN documented: "...At approximately 1600, it is reported patient was given a pen by float staff after patient requested a pen from her to journal. Patient was followed in her room by a regular staff member and was found she had been given a pen and was bent over it and she had swallowed the interior ink tube and the cone on the end that holds it in...."

Patient #3

Pt. # 3 's medical record contained documentation that patient # 3 was admitted to the facility on 4/20/12 for DTS (Danger to Self) and DTO (Danger to Others).

MD #2 wrote orders on 6/13/13 at 3:05 pm for "...Close Observation/High Risk 24/7 to prevent biting himself, inserting foreign bodies...."

Patient #3, on 6/25/13, inserted a shampoo cap into an open wound in his left forearm while on a 1:1.

The patient was allowed to have the shampoo cap during a shower.

Patient #4

Pt. # 4's medical record contained documentation that patient #4 was admitted to the facility on 9/22/08 for "...Schizoaffective Disorder...Borderline Personality Disorder with long term patterns of maladaptive thoughts, feelings and behaviors including self-harmful behaviors and assaultive behaviors...."

MD #2 's documentation written 5/6/13 at 11:01am for Patient # 4 revealed: "...Close Observation Line of Site (sic), COS, Line of Site (sic) to Prevent Swallowing Foreign Bodies...."

Patient # 4 on 5/13/13 swallowed a foot long plastic tube from a lotion bottle while on a 1:1 observation.

Patient # 4 was given the lotion bottle by staff knowing there was an order to prevent swallowing foreign bodies.

Patient #5

Pt. # 5's medical record contained documentation that patient #5 was admitted to the facility on 1/26/11, due to repeated self -injurious behaviors with suicidal ideation as well as aggressive behaviors towards others.

MD #10 's documentation written 7/2/13 at 4:43 pm, for Patient # 5 revealed: "...Close Observation Line of Site (sic)...Impulsity...COS, LOS..."

Patient # 5 had harmed herself with the sharp edge of a compact disc on 7/13/13, and then again on 7/27/13, with a metal belt buckle while she was on 1:1 observation.

Summary

Physicians had documented specific orders for prevention of patients' self-injury and patients were allowed to have objects that were used for self-harm.

Based on review of facility policies/procedures, job descriptions, medical records, hospital documents, interviews and direct observation, it was determined that the hospital failed to provide an organized nursing service 24-hours per day with an adequate number of registered nurses and competent nursing staff to assess patients' care needs and deliver, assign, supervise and evaluate the care required for each patient as evidenced by:

(A392) failure to ensure that the number of RN's and other personnel met the facility's pre-determined staffing requirements to provide for patients' safety and care needs for 9 of 9 patients who sustained self-inflicted injury, assaulted others or were assaulted by other patients (Pts # 7, 4, 9, 14, 5, 12, 10, 11 and 8);

(A395) failure to require that an RN supervise and evaluate the nursing care of each patient for Pts # 2, 1, 5, 4 and 9;

(A397) failure to require that the monitoring and supervising/close observation of patients who may be dangerous to themselves and/or others be assigned to staff according to documented competence and qualifications for 4 of 4 contracted agency MHPS's who were assigned to monitor and/or closely observe/supervise patients (contracted agency MHPS's # 33, 32, 42 and 41); and

(A398) failure to provide for the supervision and evaluation of the clinical activities of 4 of 4 contracted nursing personnel who were assigned to monitor and/or supervise/closely observe patients who were dangerous to themselves and/or others (contracted registry MHPS's # 33, 32, 42 and 41).

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the condition for nursing services.

Based on review of hospital policy/procedure, hospital documents and interviews, it was determined that the hospital failed to ensure that the number of RN's and other personnel were adequate to provide for patients' safety and care needs for 9 of 9 patients (Pts # 7, 5, 5, 10, 11, 4, 12, 8, 9 and 14) who sustained self inflicted injury, assaulted others or were assaulted by other patients as evidenced by:

1. failing to determine and provide the number and type of staff required to meet the patients' acuity/care needs according to the hospital's Staffing and Effectiveness Plan (Pts # 7, 5, 10 and 11);

2. failing to meet the facility's pre-determined Registered Nurse staffing requirements for 6 of 6 shifts;

3. failing to ensure that staff was assigned to provide COS/LOS according to physician orders and patient care needs (Pts # 4 and 12).

Findings include:

Review of hospital policy/procedure titled Staffing Acuity and Effectiveness Plan revealed: "...Purpose: To establish an acuity-based staffing plan for nursing services to meet patient care and organizational needs...It is the policy of...Nursing Department to maintain and provide an adequate number of competent staff to ensure quality patient care in a safe and therapeutic environment...The acuity system is a point-based measurement used to determine the final staffing for each unit and each shift...Staffing will be based on the shift acuity...Patient attributes and categories are based on the RN's professional assessment of the patients and their needs for the particular shift...."

Review of the hospital document titled Nursing Department, Patient Acuity System Unit Acuity Sheet, revealed that it contained patient acuity rating categories from 1 though 5, with 1 being the lowest patient acuity rating and 5 being the highest rating. The patient acuity rating corresponds with the patient's requirement for nursing care.

Review of the hospital document titled Staffing/Acuity Record revealed that it contained sections for each hospital unit, separated by specific sides, i.e., Ironwood East, Ironwood North, Desert Sage East, Desert Sage North, Palo Verde East and Palo Verde North. The total number of patients on each unit with each acuity rating is listed and a calculation completed which determines the number of staff required based on patient acuity. Further calculation determines the number of RN's, LPN's and MHPS's required. This "Adjusted Staffing" is listed next to the "Scheduled Staffing" and variance is noted by personnel marking a box to indicate that a variance was completed. The "Adjusted Staffing" is the required number and type of staff required to meet the patients' care needs/acuity.

1. Pt # 7; Ironwood North; 7/13/13

On 7/13/13, at approximately 0804, Pt # 7 sustained multiple lacerations to his forehead and scalp when he removed his helmet and banged his head on the paper towel dispenser in the bathroom. MHPS # 33 was assigned to Pt # 7 on 7/13/13 from 0645 until 0900. Pt # 7 was able to remove his helmet and lacerate his head prior to the arrival of additional staff to assist the 1:1 staff assigned to the patient.

Review of the Staffing/Acuity Record for Ironwood North day shift, on 7/13/13, revealed that it did not contain documentation of the required type of staff needed to meet patient acuity/care needs for the shift.

Pt # 5; Desert Sage East; 7/13/13

On 7/13/13, Pt # 5 sustained a self inflicted injury when she pushed a piece of a Compact Disc through her skin and into her arm. She required transport to and treatment in the ED at 1630.

Review of the Desert Sage East Staffing/Acuity Record for 7/13/13 evening shift revealed that the required staff based on patient acuity/care needs was not determined.
There was no documented evidence that staffing was based on shift acuity as required by hospital policy.

Pt # 5 Desert Sage East; 8/16/13

On 8/16/13, Pt #5 was a patient on Desert Sage East. At 09:28 PM an RN documented: "...At about 2010 on 8/16/13 staff reported that...patient walked to another peer (Pt #12) and hit him on the face. She stated 'He was making fun of other people.' Patient threw a bow (sic) of cereal...in the day room and it hit other peers and staffs (sic)...."

Review of the Desert Sage East Staffing/Acuity Record for 8/16/13 evening shift, revealed that a total of 7.8372 staff were required based on patient acuity/care needs. The type of staff required, based on patient acuity/care needs was not determined.

The hospital was unable to provide a Daily Task Sheet for Desert Sage East evening shift, 8/16/13, documenting staff assignments.

There was no documented evidence that staffing was based on shift acuity as required by hospital policy.

Pts # 10 and 11; Palo Verde East; 8/19/13

Pt #10 was a patient on Palo Verde East on 8/19/13. At 04:08 PM, an RN documented: "...(Pt # 10) was seen on the floor hitting another patient...."

On 8/19/13, at 04:50 PM, an RN documented: "...At 1645, (Pt #10) got up out of her chair, walked over to female peer (Pt # 11) and started hitting her with open hands about the arms and face and head...."

On 8/19/13, at 05:40 PM, an RN documented: "...(Pt #10) started kicking and hitting staff in the laundry room...."

Review of the Palo Verde East Staffing/Acuity Record for 8/19/13 evening shift revealed that a total of 7.5 staff were required based on patient acuity/care needs.

Review of the Daily Staff Task Sheet for Palo Verde East on 8/19/13 evening shift revealed that 2 RN's and 4 MHPs's were assigned. A variance report was not completed.

Documentation indicated that 1.5 fewer staff was provided than the patient acuity/care needs required and the type of staff required to meet patient acuity/care needs was not determined.

There was no documented evidence that staffing was based on shift acuity as required by hospital policy.

The hospital was unable to provide documented evidence that staffing for any of the units on any of the dates listed above was determined by patient acuity/care needs according to hospital policy.

The Assistant to the Chief Quality Officer confirmed the above, in interviews conducted on 8/30/13, 9/3/13 and 9/4/13.

2. On 8/27/13, at 1630, the CNO confirmed that the number of RN's required for a particular Unit is determined by a document posted in the staffing office titled Unit Base Staffing by Census. Review of this document revealed that a census of 16-20 patients on:

Palo Verde North Days/Eves required 2 RNs (or1 RN/1 LPN);

Palo Verde East Days/Eves required 3 RNs (or 2 RN/1 LPN);

Desert Sage North Days/Eves required 3 RNs (or 2 RN/1 LPN);

Desert Sage East required 3 RNs (or 2 RN/1 LPN);

Ironwood North Days/Eves required 3 RNs (or 2 RN/1LPN); and

Ironwood East Days/Eves required 3 RNs (or 2 RN/ 1 LPN).

Pt #7; Ironwood North Staffing; 7/13/13; day shift; Census 20;
Pt #4; Desert Sage North; 5/13/13; evening shift; Census 20;
Pt # 5; Desert Sage East; 7/13/13; evening shift; Census 20;
Pt # 5; Desert Sage East; 8/16/13; evening shift; Census 20;
Pt # 12; Desert Sage East; 8/16/13; evening shift; Census 20;
Pts # 10 and 11; Palo Verde East; 8/19/13; evening shift; Census 20;
Pt # 8; Ironwood East; 8/17/13; evening shift; Census 20;
Pts # 4 and 9; Desert Sage North; 8/22/12; evening shift; Census 20; and
Pt # 14; Desert Sage East; 8/22/13; evening shift; Census 20.

Each of the above patients were involved in events which included self-harm or assault and occurred on the above units, on the above dates and shifts when the hospital did not staff the required number of RN's on the unit based on the facility's pre-determined requirement based on census. Two RN's were assigned to provide nursing care to patients, rather than the required 3. The hospital did not provide documentation of rationale for adjusted numbers of RN's.

Summary for events on evening shift, 8/22/13, Desert Sage:

Pt # 4 assaulted Pt #9 at 1930 on Desert Sage North. At 2121, Pt #14 ran down the hall, charging at staff on Desert Sage East. Staffing by Census required 3 RN's on each side of the Unit; a total of 6 RN's for 40 patients. At the time of the assault, there were 3 RN's on Desert Sage for a total of 40 patients.

On 8/28/13, RN # 23 confirmed that at the time Pt # 4 assaulted Pt # 9, the Charge Nurse was off the North side on lunch break and the Charge Nurse from the East side "was covering." S/he also confirmed that neither RN's nor MHPS's are replaced when they are off the unit.

On 8/27/13, at 1500, the Assistant CNO confirmed that the units are staffed with 2 RN's, when the the hospital had determined that 3 were required.

3. Pt # 4: Desert Sage North; 5/13/13

On 5/13/13, at approximately 2020, Pt #4 swallowed the tube from a Vaseline lotion container, while she was in the bathroom and required Close Observation Line of Sight. On
5/14/13, Pt #4 banged her head on the wall and attempted to eat paint, drywall and insulation. On 5/15/13, she was transported to the ED due to emesis and epigastric pain.
Pt # 4's medical record contained a physician's order for the patient to be on COS/ Line of Sight, to prevent the patient from swallowing foreign bodies.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 9/4/13 at 1500, that the hospital was unable to provide the Daily Task Staff Sheets for the shifts when the patient engaged in behavior which was a danger to herself.

The hospital was unable to provide documented evidence that a staff member was assigned to Pt # 4 as required by physician order and patient acuity/care needs.

Pt # 12; Desert Sage East; 8/16/13

On 8/16/13 at 03:30 PM, an RN documented: "...Pt's acuity changed from 4 to 5. Pt placed on COS/LOS 2:1 due to behaviors. Pt has recently banged his head and has a wound. Pt has been confused. Pt has been laughing inappropriately...Pt has been undressing then redressing...."

A physician entered an order on 8/16/13 at 09:46 AM: "...2:1 LOS to prevent hurting self or others...."

On 8/16/13 at 09:28 PM, Pt #5 assaulted Pt #12 as described above ( section # 1, Pt # 5; Desert Sage East; 8/16/13).

The hospital was unable to provide a Daily Task Sheet for Desert Sage East evening shift, 8/16/13, documenting staff assignments.

The Assistant to the Chief Quality Officer confirmed that she was unable to provide documentation that 2 staff were assigned to Pt # 12, at the time that he was assaulted by Pt #5, as required by physician order and patient acuity/care needs

Based on review of job descriptions, medical records, interviews and review of policies/procedures, it was determined that the hospital failed to require that an RN supervise and evaluate the nursing care of patients as evidenced by:

1. nursing staff failed to inform providers of the follow up instructions after an emergency department visit on 09/06/13, which required a follow up with a primary care provider (PCP) within 1 day for an abdominal exam for 1 of 1 patient, (Pt # 2);

2. failing to require that staff follow physician orders for 1 of 1 patient who required COS/LOS while using a pen and ingested the ink insert and metal clip of a writing pen (Pt # 1);

3. failing to obtain a physician order for 1 of 2 patients, prior to the application of a Transport Safety Device for patient transport as required by policy (Pt # 1);

4. failing to prevent self-inflicted injury of 1 of 1 patient, who sustained self-inflicted injury while covered with a blanket (Pt #5);

5. failing to require change in patient room assignment to separate Pts # 4 and 9 after an assault of Pt # 9 by Pt # 4 on 8/22/13.

Findings include:

Review of the job description for Psychiatric Nurse II revealed: "...JOB DUTIES AND RESPONSIBILITIES ...Responsible and accountable for patient care during assigned shift...Assign nursing care of patients and supervise the provision of care...."

Review of the job description for Psychiatric Nursing Shift Supervisor revealed: "...JOB DUTIES AND RESPONSIBILITIES:..Responsible and accountable for patient care during assigned shift...Provides direct supervision to assigned staff and evaluates their work according to departmental policy...SUPERVISION ...Supervises nursing personnel for assigned shift and unit...."

RN # 40 explained, on 8/27/13, that the Psychiatric Nursing Shift Supervisor (PNSS) works as a charge nurse on the units if necessary.

1. Pt #2

Pt # 2 was admitted on 06/08/11, with diagnoses of Mood Disorder not otherwise specified, impulse control disorder, borderline personality disorder, panhypopitutarism, ADD, Alcohol abuse, Cannabis Abuse, and was on the Ironwood East Unit. The patient had a history of self-injurious behaviors by swallowing items.

On 09/06/13, Pt #2 was sent to the ED of another acute care hospital, after obtaining and swallowing pieces of a broken CD. The patient was evaluated in the ED and returned back to this facility on 09/07/13 (Saturday) at 0015 hours.

An interview with RN # 47 on 09/19/13 at 1430 hours, was conducted. He confirmed he was the RN assigned to Pt # 2, on 09/07/13 at 0015, after Pt # 2 returned from the ED. He confirmed he called Physician #18 and reported that the imaging was negative for signs of perforation. He confirmed he received the ED paperwork and put the paperwork in the chart so that it was offset and stuck out of the chart for the physicians to see. He explained that he did not see the "Follow Up Information" on page 1 of the Adult Emergency Department After Visit Summary which included: "...Follow up with Your (sic) primary care provider (PCP) In (sic) 1 day. (for abdominal exam)...."

An interview with Physician # 3 on 09/18/13 at 1430 hours, was conducted. He confirmed he was the On-Call doctor for Saturday 09/07/13. He reported he received a call from an RN. The RN called to notify him the patient returned from the ED and the CT results. The RN told him the CT was negative. He was not told about the follow up requirements to see a PCP in 1 day for an abdominal exam. He did not examine Pt # 2 on 09/07/13.

An interview with the PA-C (# 17) assigned for the medical care of Pt # 2 was interviewed on 09/18/13 at 1215 hours. He confirmed he was assigned to Pt # 2's medical management on 08/30/13. He was asked if he was aware of the follow up requirements from the ED visit on 09/06/13. The follow up instructions were shown to him and he explained he did not see those papers and added "they (ED) always say that."

Interviews with RN's # 11 and 49 were conducted on 09/18/13. Both RN's described the process for receiving documents from another hospital. They explained there is a basket by the Unit Secretary on Ironwood East for papers to be reviewed and signed by the providers. All documents, lab results, imaging results are placed in this basket.

The documents containing the follow-up instructions for examination of the patient by the patient's PCP the following day were not placed in the basket by the RN and the physician was not notified of the follow-up instructions.The RN did not ensure that the physician was notified of the follow-up directions.

Pt # 2 coded on 09/09/13 at 2210 hours, and was transferred to another acute care hospital for emergency medical care after the RN failed to inform the patient's PCP of the required follow-up assessment per ED instructions.

2. Pt #1

A physician entered an order on 2/20/13, at 0851 AM: "...Please allow up to 20 min. per day for journaling w/pen and paper. Must check out and return pen. COS/LOS while journaling...."

On 2/21/13, an RN documented: "...At approximately 1600, it is reported patient was given a pen by float staff after patient requested a pen from her to journal. Patient was followed in her room by a regular staff member and was found she had been given a pen and was bent over it and she had swallowed the interior ink tube and the cone on the end that holds it in...."

The Assistant to the Chief Quality Officer confirmed during interview conducted on 9/3/13, that the physician's order had not been discontinued and the nursing staff did not initiate COS/LOS when s/he gave the patient the pen to journal as required by physician order.

3. Review of hospital policy titled Transport Safety Devices revealed: "...Only appropriately privileged medical staff members may order the use of transport safety devices for civilly committed patients who meet the criteria for use of a transport safety device. The order must be initiated in Computerized Physician order entry (CPOE) for each episode of use and the rationale for use documented in the physician's progress notes...."

Pt #1

An RN assessed the patient prior to application and after removal of a Transport Safety Device on 1/31/13, 2/4/13, 2/11/13, 2/21/13, 3/12/13, 3/15/13, 4/10/13 and 4/17/13. Pt #1's medical record did not contain physician orders for the Transport Safety Device to be applied to the patient on 2/4/13, 2/11/13, 2/21/13, 3/12/13 and 3/15/13.

The RN assessed the patient prior to application and allowed the restraint to be applied without an order.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 8/29/13, that the patient was placed in the Transport Safety Device on the above dates without a physician's order as required.

4. Pt #5

Review of hospital policy titled Close Observation revealed: "...Close Observation/Line of Sight...Unless otherwise indicated in the provider's order, a patient's face and hands must be visible at all times...."

Pt #5 sustained a self inflicted injury on 7/13/13 while she was covered with a blanket and cut herself with a Compact Disc. She also injured herself on 7/26/13, when she used the buckle of a belt to re-open a puncture wound. Her hands and the belt were concealed under a blanket at the time. The patient was assigned to an individual staff member and was on Close Observation Line of Sight at the time of both injuries.

The Assistant to the Director of Quality confirmed in an interview conducted on 8/29/13 at 4:30 pm, that the documentation in the medical record reveals that the patient was on a 1:1 at the time of the incident on 7/13/13, and was still able to obtain a compact disc. She also confirmed that the patient's hands were concealed by the blanket which does not meet requirement of the policy.

Nursing failed to supervise staff to follow the hospital policy related to Close Observation Line of Sight which includes the requirement that the patient's hands are visible.The patient's medical record contains documentation of the patient's extensive history of self inflicted injuries by cutting and use of ligatures. Nursing failed to evaluate the patient's ability to safely utilize specific items and limit the patient's access to harmful items accordingly.

5. Pt #4

On 8/22/13 evening shift, Pt # 4 became angry that the door to the bathroom located between her room and Pt # 9's room was locked, causing Pt #4 to be locked out of the bathroom. Pt #4 pushed past staff and entered Pt #9's room and jumped on Pt #9, punching her repeatedly. Pt #9 was in bed, asleep at the time.

RN # 23 confirmed, during interview conducted on 8/28/13, that Pts # 9 and 4 remained in their respective rooms until 8/28/13, when a room change was made. During the six days after the assault, these patients had direct access to each other via the bathroom connecting their rooms. S/he confirmed that Pt # 9 was given the choice of sleeping in the Observation Room to feel safe between 8/22/13 and 8/28/13.

Nursing did not evaluate and supervise the care of Pt # 9 or # 4 by allowing these two patients to continue to reside in rooms connected by a bathroom. Each patient has access to the other via the bathroom and Pt # 4 had already assaulted Pt # 9.

Based on review of medical records, hospital documents, personnel files, interviews and direct observation, it was determined that the hospital failed to require that the monitoring and supervising/close observation of patients who may be dangerous to themselves and/or others be assigned to staff according to documented competence and qualifications for 4 of 4 contracted agency MHPS's who were assigned to monitor and/or closely observe/supervise patients (contracted agency MHPS's # 33, 32, 42 and 41).

Findings include:

Pt #7 (MHPS # 33)

Pt # 7 was a patient on Ironwood North.

Physician # 5 entered an order for "...Close Observation Line of Sight...." with a Start Date of 7/9/13 and Stop Date of 7/15/13.

Review of hospital document revealed: "...7/13/13 around 0804, (Pt # 7) was in room when staff heard a bang and a call for help...staff found (Pt # 7) with multiple lacerations to forehead and scalp and bleeding...indications are patient removed helmet and banged head on the paper towel dispenser in bathroom...."

On 7/13/13 at 0830, Physician #13 documented: "...Pain to his scalp after tearing off his protective helmet and banging it with force on the paper towel holder in the bathroom...Pt is well known to myself...has a long history of self injury including head banging, biting, eye gouging, swallowing FBs (foreign bodies)...Without cueing he responded to delusional thinking today with severe head banging...."

Review of the Daily Staff Task Sheet for Ironwood 1 North, dated 7/13/13 revealed that contracted agency MHPS # 33 was assigned to Pt #7 on 7/13/13 from 0645 until 0900.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 8/30/13, that the hospital did not have documentation of contracted registry MHPS # 33's competence or qualifications to provide COS/LOS supervision to an acutely self-destructive patient at the time that s/he was assigned to Pt # 7.

Pt #6 (MHPS #32)

Physician # 5 documented on 7/16/13, at 0727: "...(Pt # 6) was on a 1:1 in her wheelchair and at 0710 threw herself out of her wheelchair hard face foreward (sic) onto the floor (Linoleum concrete) and hit with her forehead splitting open the hairline and forehead. She was reluctant or unable to speak and then was unable to explain what she did or her condition...will be sent to (name of hospital) Emergency Department...."

Review of the Daily Staff Task Sheet for Palo Verde North, dated 7/15/2013, for the night shift 2315-0715, revealed that contracted agency MHPS # 32 was assigned to patient # 6 during the hours 0600-0715.

Review of hospital written documentation of a video camera recording on 7/16/13 at 0710 revealed: "...(contracted agency MHPS # 32) left (Pt # 6) sitting in the hall several feet away as she stood at the nurses' station and talked to staff for quite a while, never even looking at (Pt # 6) during this time...At no time did (Pt # 6) wheel herself away from staff...the COS staff never even...look (sic) at (Pt # 6) until after she threw self out of the chair...it looked like the housekeeper was the one that saw (Pt # 6) on the ground first...."

The Assistant to the Chief Quality Officer confirmed during interview conducted on 8/28/13, that the hospital did not have documentation of contracted agency MHPS # 32's competence or qualifications to provide COS/LOS supervision to a potentially self-destructive patient at the time that s/he was assigned to Pt #6. The hospital did not have the last name of contracted agency MHPS # 32 readily available.

Pt # 4 (MHPS # 42)

On 8/22/13 at 0945 PM, RN #23 documented: "...At about 1930, (Pt # 4) was upset about shared bathroom door being locked in her room. (Pt #4) ended up coming out of her room and after yelling at, and chasing temporary staff, she pushed past male MHPS into female peer's room (Pt #9). Once in peer's room, (Pt #4) jumped on female peer, who was asleep on her bed, and began punching her repeatedly...."

Review of Desert Sage North Daily Staff Task Sheet for evening shift on 8/22/13 revealed that contracted agency MHPS # 42 was assigned to monitor the Hall from 1600 until 2000.

Lead MHPS # 43 confirmed during interview conducted on 8/28/13, that on 8/22/13, Pt #4 "charged" contracted agency MHPS #42 down the hall. Lead MHPS #43 confirmed that contracted agency MHPS #42 was assigned to monitor the Hall at the time.

The hospital provided the completed form titled Competency Self-Assessment and Skills Checklist for Agency Behavioral Health Technicians for contracted agency MHPS # 42. Self-assessment and validation of skills for supervising patients in the milieu, recognizing escalating behavior and reporting to the Charge Nurse and reporting changes in pt conditions to Charge RN and all other skills listed were documented on 8/28/13.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 8/30/13, that the hospital did not have documentation of contracted agency MHPS # 42's competence or qualifications at the time that s/he was assigned to monitor the Hall on 8/22/13.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 9/3/13, that the form used to document competence and skills for the agency MHPS was developed on 8/23/13. The hospital was unable to provide documentation of competence of agency MHPS prior to that time. On 9/4/13, the Acting CEO confirmed that the hospital has been using MHPS's from the contracted agency since May, 2013.

MHPS #41

Direct observation conducted on Ironwood East, on 8/27/13, revealed a contracted agency MHPS, # 41, who was monitoring the patients in the Dayroom. On 8/28/13, the hospital provided a form titled Competency Self-Assessment and Skills Checklist for Agency Behavioral Health Technicians which contained documentation of validation of contracted agency MHPS # 41's ability to supervise patients in the milieu completed on 8/27/13. His competency had not been determined or validated prior to his assignment.

The Assistant to the Chief Quality Officer confirmed on 9/3/13 that MHPS #41's check list was completed while surveyors were on site and after he had been assigned and was working at the facility.

Direct observation conducted on 8/27/13, revealed that Lead MHPS # 31 assigned a contracted agency MHPS to Pt A.O. who required COS/LOS. This MHPS was assigned to Pt. A.O. for the following time intervals: 1600-1700, 1800-1900, 1900-2000, 2000-2100, 2100-2200 and 2200-2300.

Lead MHPS #31 confirmed that s/he was completing the assignments for the 8/27/13 evening shift.

The Assistant to the Chief Quality Officer stated during interview conducted on 8/28/13, that the facility discontinued assigning contracted agency MHPS's to patients who require COS/LOS after Pt # 6's incident on 7/16/13. She was unable to provide documentation of that directive.

Based on review of hospital documents and interview, it was determined that the Chief Nursing Officer (CNO) failed to provide for the supervision and evaluation of the clinical activities of 4 of 4 contracted non-employee nursing personnel who were assigned to monitor and/or supervise/closely observe patients who were dangerous to themselves and/or others (contracted registry MHPS's # 33, 32, 42 and 41).

Findings include:

Contracted Registry MHPS # 33 was assigned to Pt # 7, on 7/13/13, when the patient sustained a self inflicted injury by banging his head against the paper towel dispenser in his bathroom.

Contracted Registry MHPS # 32 was assigned to Pt #6, on 7/16/13, when the patient threw herself out of her wheelchair onto the floow, splitting open her hairline and forehead.

Contracted Registry MHPS # 42 was assigned to monitor the hall, on 8/22/13, when Pt #4 chased the MHPS down the hall and then assaulted a female peer.

Contracted Registry MHPS # 41 was directly observed monitoring patients in the Ironwood East Dayroom, on 8/27/13.

The hospital was unable to provide any documented evidence of the supervision and evaluation of the contracted registry MHPS's listed above.

The Assistant to the Chief Quality Officer confirmed during interview conducted on 9/3/13, that the hospital did not have documentation of the supervision or evaluation of MHP's # 33, 32. 42 or 41. She confirmed that the hospital did not have a current process to document supervision and evaluation of contracted registry MHPS.

The Acting CEO confirmed, on 9/4/13, that the hospital has been using MHPS's from the contracted agency since May, 2013.