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Based on review of policies and procedures, medical records, and interviews, it was determined the hospital failed to establish and implement an Inter Disciplinary Treatment Plan (IDTP) that ensured all disciplines involved with the treatment plan participated with the patient in the planning meetings as evidenced by Dietary not attending the meetings and nutritional goals established without the involvement of both Dietary and the patient in the goal setting in 4 of 4 patient records reviewed for nutritional planning. This has the risk for nutritional plans not being implemented and the patient not being involved in the decisions regarding the plan. (Patient #8; Patient #12; Patient #13; Patient #26; and Patient #24)

Findings include:

The hospital policy for the Individual Treatment and Discharge Plan (ITDP) dated January 14, 2015 revealed: "... Definitions ... 2. Individual Treatment and Discharge Plan: Is an individualized plan of care that contains measurable goals and specific steps to assist patients towards discharge. An ITDP meeting occurs when the treatment team and others involved in service provision to the patient , meet to discuss, coordinate, prepare and /or review a written plan outlining the patient's goals, the services, and the supports the patient will need to meet these goals and to document the patient's progress towards the goals...."

The Food and Nutrition policy dated January 2013 revealed the follow responsibly for the Dietician: "... Document all nutrition education provided to the patient in the Nutrition Progress Notes of the patient's health record...."

Patient #8's treatment plan under the Medical Issues dated 06/04/2015 revealed the patient was to follow her recommended dietary needs on a daily basis. The intervention identified was that nursing staff weighed the patient every Sunday, up to 5 minutes before breakfast, without shoes. The responsible staff was the registered nurse. The plan also documented the patient was to walk as much as 3 x per day for up to 10 minutes per session to assist with weight loss.

The patient was ordered on close observation. The close observation documentation was reviewed for July 8, 2015 through July 21, 2015. There was no documented evidence of walks recorded by the technicians of the patient taken on walks for these dates.

There was no documentation in the nursing notes of the staff ensuring daily walks three times per day.

Patient #8's Treatment Plan included the patient was to be weighed every Sunday. A review of two weeks July 8, 2015 through July 22, 2015 revealed no documented weights on the vital sign record for the dates of July 8, 2015 through July 22, 2015. The plan required weights to be documented on the 12 th and 19 th of July.

A review of the Dietary - Nutritional Plan/Addendum to Patient #8's treatment plan revealed short term goals to lose 5 pounds every month; consume snacks as ordered; consume appropriate amounts of fluids to prevent over/under hydration; and consume meal plan as ordered equal to or greater than 75% meals. This was documented in July 2014 with target dates each month to October 2014. The plan was signed by the dietician. There was no updated nutritional plan provided to the surveyor at the time of the survey. There was no documented evidence the patient achieved these goals.

A review of the nursing documentation revealed no documented reference to the implementation of the 2014 plan in the documentation revealed for the dates of July 8, 2015 through July 22, 2015.

There was no documented evidence of dietary notes included in the medical record provided to the surveyor.

Patient #12's medical record revealed a new Master Treatment Plan dated 05/14/2015. The nutrition Addendum under short term goals stated "See Nutrition Addendum". There was no documented evidence of a Nutrition Addendum within the paper medical record or the electronic record. There was no Documented evidence a dietician attended the ITDP meeting with the team.

Patient #13's medical record revealed the most recent Master Treatment Plan dated 06/15/2015. The plan included a note under Nutrition "See Nutritional Addendum." The Nutritional Addendum was reviewed and revealed dates within 2013 and 2014. there was no documented evidence the nutritional plan had been updated since June of 2014. The short term goals with a start date of June 2013 indicated Lose ---- (no value entered) pounds every: No further statements. There was no documented evidence the dietician attend the IDTP meeting on the 24 th of June 2015.

Patient #26's medical record revealed the Master Treatment Plan dated 06/09/2015. The patient has diabetes mellitus and a metabolic syndrome. The short term goals for the nutritional component related to the diseases documented on the plan revealed a nutritional addendum. The plan under the stabilize medical problems revealed the patient's plan was to reduce his overall weight by 5% monthly in reach of a weight within his ideal weight. The nutritional addendum revealed a start date of 04/10/2014 with target dates of 07/31/2014; 10/31/204/ and 01/31/2015. The patient was planned to loose 1-2 pounds each month. There was no update to the nutritional plan with the new treatment plan of 06/09/2015.

There was no documented evidence the previous goals were met and maintained.

Patient #24's medical record revealed the Master Treatment Plan dated 06/23/2015. The patient has Psychogenic Polydipsia (uncommon clinical disorder characterized by excessive water-drinking in the absence of a physiologic stimulus to drink). The treatment plan referenced the nutrition addendum for the goals of nutrition. The Nutrition Addendum found in the paper portion of the medical record revealed short term goals for 2013 through March of 2014. There was no further update to the addendum. There was no documented evidence the dietician attended the IDTP meeting.

The surveyor conducted an interview with the Dietician on July 28, 2015. The Dietician confirmed during the interview she does not attend all of the treatment planning meetings for the patients. She only attends the meetings for the patient with a BMI (Body Mass Index) concern.

The patient treatment plans identified medical and psychological problems related to nutrition and identified plans that were not documented as implemented by any discipline within the patient care team.

Based on a tour, video review, interviews, review of hospital policy/procedure and hospital documents, it was determined the hospital failed to ensure patients received care in a safe environment as evidenced by the Director of Nursing failed to ensure the patient was safe as evidenced by:

1. staff making rounds every 30 minutes during the night shift and staff were able to determine the patient was safe and respirations present according to the hospital procedure; and
2. staff observing the patient from the doorway was able to see the patient to determine the patient was safe and not in any medical or psychological distress.

Findings include:

The hospital policy for Census Management dated April 25, 2012 revealed the nursing staff assigned to monitor census throughout each shift will record on the Patient Census sheets the location of every patient. During the night, when patients are in bed, the Census Monitor will ensure each patient is in their assigned bed and will verify their well-being. The procedure states this means "Respiration are visible and the patient is in NO medical or psychological distress...."

On July 23, 2015 the surveyor reviewed video tapes of all three units (Desert Sage; Ironwood; and Palo Verde). The timeframe for the review was focused on the late evening and night shifts. The surveyor identified rounds were made every 30 minutes. The quality of the rounds varied as it related to the ability of the technician making the rounds to be able to visualize the patient to the extent the technician could determine if the patient was safe and in no medical or psychological distress.

The various videos were viewed in the presence of the Director of Quality who confirmed the quality of the rounds did not meet the expectations of the faciliy were not adequate to determine the patients were safe.

2. The hospital policy for Close Observation/Line of Sight revealed this is a method of observation implemented when a patient's potential for an adverse event is high and warrants continuous visualization. Close Observation/Line of Sight 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.

On July 24, 2015 the surveyor toured the patient units. The surveyor identified on Ironwood Unit at approximately 2:30 P.M. a technician sitting in a chair in front of a closed door with the patient in the room on his bed. The passageway out of the patient's room was blocked by the technician and the chair the technician was sitting in. There was a window in the door of the patient's room however the technician could not view the patient's upper body through the window in the door.

This was observed by the Director of Nursing and the Psychiatric Nurse Manager. Both confirmed the technician could not visualize the patient, and the technician was blocking the door of the patient's room.

Based on a review of documentation, meeting minutes and interview, it was determined the Governing Body approved a Quality Plan for the process that involved the hospital departments and services, however was not able to demonstrate implementation of the quality program as evidenced by:

1. the failure to implement the quality reporting structure identified to demonstrate the flow of quality data, action, and evaluation transmitted from the hospital wide committees to the Governing Board: and
2. the failure to integrate contract review into the quality program.

Findings include:

1. A review of the hospital's Quality plan revealed the plan was approved by the Governing Board in July.

A review of the meeting minutes for June, July, and August of 2015 for the Governing Board, Hospital Wide committee and Executive team revealed no discussion related to the quality indicators, results, action or evaluation.

The quality plan revealed the reporting structure. This structure included a Quality Management Committee where the quality indicators, action, and evaluation of the monitoring of those indicators from the Hospital wide committee and the aggregate of the peer review activities would be reported. This committee had not been implemented at the time of the survey. The committee is planning to meet in August of 2015. This committee would then report to the Executive Committee and then the final report will be provided to the Governing Body for review and evaluation.

In an interview with the management team on July 22, 2015 the CEO confirmed the implementation had not been finalized and in the interim the CEO (Chief Executive Officer) implemented a reporting process via email in July to seek out input from the governing board members prior to the meeting in September. This reporting process included within the document the hospital indicator findings. These were sent to each of the Governing Board members. These included code arrest response; close observation monitoring by unit; healthcare acquired infections; physical hold; mechanical restraints; grievances and appeals. The CEO requested within this notification each of the board members provide feedback on what types of information the board would like to see within the quality reports; what recommendations would the board members have regarding the presentation of the material; area in the data that raises concern; and recommendations for action. This would then prepare the board members for an active discussion at the September meeting. This process was initiated on July 23, 2015.

The CEO revealed this was a process implemented to keep the Governing Board members actively involved throughout the implementation process as an interim step while the hospital continued to finalize the reporting structure for all quality activity.



The CEO and the Quality Director confirmed in an interview on July 23, 2015 the Governing Body had approved the Quality Plan; however the implementation and confirmation of indicators for all hospital departments and services had not been completed at the time of this survey.

2. A review of two contracts related to patient services were reviewed. These contracts include a contact with the acute care hospital that provides inpatient and emergency services for patients that is not available at the hospital and the second contract was for environmental services. Each of these contracts require implementation of a quality review. There was no evidence of implementation of a quality review for either of these contracts provided to the surveyor.

The Director of Quality confirmed in an interview on July 24, 2015 there had not been an implementation of quality review for contracted services at this time. There were plans moving forward for this to occur; in the following month. The CEO in an interview on July 24, 2015 revealed the contracts were under review and the quality portion of the contract would be enhanced with the contract review.