HospitalInspections.org

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the governing body failed to require that Medical Staff Bylaws were implemented appropriately regarding the appointment of members to the medical staff. This deficient practice poses a risk to the health and safety of patients, when the qualifications of a provider have not been properly evaluated and approved by the governing body.

Findings include:

The Rules and Regulations of the Medical Staff require that " ...a patient may be admitted to the hospital only by a member of the Medical Staff in good standing with admitting privileges ...."

The Medical Staff Bylaws requires that " ...the only people who shall qualify for membership on the Medical Staff are those practitioners legally licensed in Arizona ...."

Review of the December 2020 On Call provider schedule revealed that Medical Staff #5 was on call from 12/01/20-12/04/20 and Medical Staff #6 was on call from 12/05/20-12/11/20. From 12/12/20-12/31/20, there was not a psychiatric provider listed as being on call. Medical Staff #2, an internal medicine physician, was listed as being on call every day in December.

The Medical Staff Bylaws require that " ...the Board shall be the final authority on granting, extending, terminating or reducing Medical Staff privileges and Medical Staff membership ...."

Review of the Medical Executive Committee Meeting Minutes from 10/20/20(the initial meeting), 02/01/21, and 05/05/21 failed to reveal documentation that Medical Staff #4 had ever been approved for provisional or full privileges.

Review of the Governing Body Meeting Minutes for 09/04/20, 10/22/20, 02/02/21, and 05/06/21 failed to reveal documentation that Medical Staff #4 had ever been approved for provisional or full privileges.

Employee #1 confirmed that these were the only Medical Executive Meeting Minutes and Governing Body Meeting Minutes available.

Review of the employment record for Medical Staff #4 revealed that temporary privileges were granted on 11/17/20. However, Medical Staff #4 did not obtain a license to practice in Arizona until 11/27/20.

Review of patient census records for December 2020 revealed that Medical Staff #4 is listed as the Admitting Physician for patients as early as 11/11/20.

Review of patient census records for December 2020 revealed that Medical Staff #3 is listed as the Admitting Physician for two (2) patients admitted on 11/23/20 and two (2) patients on 12/01/20. However, Medical Staff #3 was no longer employed as of 11/20/20.

Review of the employment record for Medical Staff #6 revealed that temporary privileges were granted on 11/01/20. However, review of the Medical Executive Committee Meeting Minutes from 10/20/20(the initial meeting), 02/01/21, and 05/05/21 failed to reveal documentation that Medical Staff #6 had ever been approved for provisional or full privileges. Review of the Governing Body Meeting Minutes for 09/04/20, 10/22/20, 02/02/21, and 05/06/21 failed to reveal documentation that Medical Staff #6 had ever been approved for provisional or full privileges.

The group (AIMS) providing services to the hospital at the time of the complaint is no longer delivering services as of 07/31/21. The CEO and Director of Nursing employed at the time of the complaint have since changed as well. The current CEO began employment in April of 2021.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the hospital failed to require that policies/procedures specific to monitoring patient weights and hygiene were established, implemented, and documented appropriately. This deficient practice poses a risk to the health and safety of patients, when significant changes in a patient's weight are not measured and documented and patient hygiene is not ensured.

Findings include:

Review of the "Patient Daily Care Forms" for Patient #5 revealed that a weekly weight was never documented. During an interview conducted on 08/04/21, Employee #3 confirmed that patient weights are to be obtained every Wednesday.

During an interview conducted on 08/05/21, Employee #1 confirmed that there was not a hospital policy that spoke directly to obtaining patient weights, but that they are ordered and obtained at least weekly.

Patient #5's stated weight on the Admission Orders form was 185 pounds. On 01/26/21, Employee #46 documented that Patient #5's weight was 159.4 pounds.

Review of the Provider Order forms failed to reveal an order to weight Patient #5 more frequently than once per week.

Review of the Patient Daily Care forms from 01/14/21-01/29/21 for Paitnet #5 revealed that nothing was documented under Hygiene on 01/14, 01/15, 01/16, 01/17, 01/18, 01/19, 01/20, 01/25, & 01/28. Pericare only was documented on 01/21, 01/22, 01/23, 01/24, 01/26, & 01/27. On 01/29, Patient #5 is documented as having received seven (7) showers. This is the only instance that a shower or bed bath are documented as being completed.

Review of the hygiene section of the "Patient Daily Care Forms" for Patient #1 revealed the following:
07/07-blank
07/08-"self"
07/09-form missing
07/10-blank
07/11-documentation is difficult to read, may indicate patient showered
07/12-form missing

Review of the "Daily Nursing Assessment" for Patient #1 revealed that the following documentation by the nursing staff:
07/09-disheveled
07/10-disheveled
07/11-well groomed

During an interview conducted on 08/05/21, Employee #1 confirmed that there was not a hospital policy that speaks specifically to patient showers, but that the expectation is for staff to either ensure a patient has showered or assist with showering a patient 2-3 times per week and as needed.






Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the Administrator failed to ensure that staff monitored patients as required by hospital policy. This deficient practice poses a serious risk to the health and safety of patients, when staff are not routinely ensuring that each patient is safe throughout the entire shift.

Findings include:

The policy titled "Patient Observation" requires that " ...documentation of all observations will be completed in the patient's record at least once per 15 minute increment ...."

On 08/12/21, while auditing charts on the 100 unit, it was observed that the nursing assistant had put the clip board with patient rounds forms down in the nurse's station and left to do something else. It was observed that 23 of 23 "Patient Safety Observation Rounds" forms were blank. This occurred at 0925. Employee #2, who was also on the unit, was notified immediately of the situation.

Review of open and closed medical records revealed that 31 of the "Patient Safety Observation Rounds" forms for ten (10) patients (#s 1, 4, 6, 7, 8, 9, 10, 12, 13, 14) had missing entries. This includes 23 "Patient Safety Observation Rounds" that were blank for the entire day shift (0700-1900).

Review of "NeuroPsychiatric Hospitals Clinical Orientation" revealed the following: " ...One person is assigned to 15 minute checks on the daily assignment sheet. 15 minute checks should be divided into 2 hour increments. Staff must rotate throughout their shift ...."

Review of the daily assignment sheets for both the 100 and 200 units revealed that the 15 minute checks were not assigned to anyone. There was not an area on the form to indicate the employee responsible for 15 minute safety checks at any given time.

During an interview conducted on 08/04/21, Employee #3 revealed that a nurse is supposed to review the rounds forms at least at the end of the shift to check for completeness. However, review of over 40 rounds forms failed to reveal documentation that a nurse had reviewed the rounds forms.





Based on review of medical records, policies and procedures, and staff interviews, the Department determined that the administrator failed to ensure that the "Patient Daily Care Form" were completed for 63 of 63 forms reviewed. This deficient practice poses a risk to the health and safety of patients when weight, vital signs, meal consumption, output, and hygiene are not tracked over time allowing providers to evaluate the patient's progress. Additionally, nursing signatures are missing that would indicate that the documentation had been reviewed by the nurse.

Findings include:

The NeuroPsychiatric Hospitals Clinical Orientation, NPH Aide Documentation indicates that " ...NPH Hospital system has specific documents that are required. Aides (NAs/CNAs) Patient Daily Care Form ...NURSES-Review and sign aide documentation!! Remember-They are documenting under YOUR license ...." Additionally, " ...Common Errors By Aides-No signature or date. Incomplete ADL documentation ...Fluid consumption not totaled, Missing weekly weights ...."

A review of medical records revealed that 63 of 63 "Patient Daily Care Form" reviewed were not fully completed for 6 of 6 patients. (Patients #6, 7, 8, 10, 12, and 13)

The following items were not documented in Patient #13's medical record on the following days:
08/10/21-hygeine, all meal %, output, nurse signature, day shift vitals
08/09/21-night shift vitals, nurses signature
08/08/21-hygeine, output, night shift vitals, nurse signature
08/07/21-hygeine, dinner %, nurse signature
08/06/21-night shift vitals, breakfast %, nurse signature
08/05/21-nurse signature
08/04/21-hygeine, output, weekly weight, nurse signature
08/03/21-day shift vitals, all meal %, intake, output, nurse signature
08/02/21-night shift vitals, nurse signature
08/01/21-hygeine, day shift vitals, nurse signatures
07/31/21-hygeine, output, nurse signature
07/30/21-nurse signature
07/29/21-hygeine, nurse signature
08/28/21-dinner %, weekly weight, nurse signature
07/27/21-night shift vitals, nurse signatures
07/26/21-hygeine, all meal %, input, output, nurse signatures
07/20/21-night shift vitals, nurse signatures

The following items were not documented in Patient #12's medical record on the following days:
08/09/21-nurse signature
08/08/21-night shift vitals, nurse signature
08/07/21-nurse signature
08/06/21-breakfast %, nurse signature
08/05/21-nurse signature
08/04/21-dinner %, weekly weight, nurse signature
08/03/21-hygeine, input, output
08/02/21-night shift vitals, nurse signature
08/01/21-hygeine, night shift vitals, nurse signatures
07/30/21-hygeine, nurse signature
07/27/21-entire form was blank with one signature
07/26/21-hygeine, day shift vitals, intake, output, all meal %, nurse signatures
07/21/21-hygeine, weekly weight, intake, nurse signature
07/20/21-hygeine, night shift vitals, dinner %

The following items were not documented in Patient #10's medical record on the following days:
08/11/21-hygeine, night shift vitals, intake, output, weekly weight, nurse signature
08/10/21-nurse signature
08/09/21-hygeine, day shift vitals, all meal %
08/08/21-hygeine, output, nurse signature
08/07/21-hygeine, output
08/06/21-hygeine, output
08/05/21-hygeine, output
08/03/21-hygeine, dinner %
08/02/21-dinner %, nurse signature
08/01/21-hygeine, output

The following items were not documented in Patient #8's medical record on the following days:
07/04/21-hygeine, output, day shift vitals, all meal %, nurse signature
07/06/21-nurse signature
07/10/21-hygeine, output, nurse signature
07/11/21-nurse signature
07/17/21-hygeine, day shift vitals, output, all meal %, nurse signature
07/18/21-all meal %, day shift vitals, nurse signature
07/21/21-hygeine, dinner %, output, weekly weight
07/22/21-hygeine, dinner %, output, nurse signature
07/26/21-hygeine, all meal %, day shift vitals, output
08/02/21-hygeine, dinner %, output

The following items were not documented in Patient #7's medical record on the following days:
08/04/21-hygeine
08/03/21-nurse signature
08/02/21-nurse signature
08/01/21-output, nurse signature
07/31/21-hygeine, output, nurse signature
07/30/21-hygeine, output, nurse signature
07/29/21-hygeine, output
07/27/21-hygeine, day and night shift vitals

The following items were not documented in Patient #6's medical record on the following days:
08/03/21-hygeine, output, nurse signature
08/02/21-nurse signatures
08/01/21-hygeine, output, nurse signature
07/31/21-nurse signature

Employee #1 confirmed during an interview conducted on 08/11/21, that the expectation for staff is to fully complete the "Patient Daily Care Form."

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the hospital failed to require that policies/procedures specific to the crash cart were implemented. This deficient practice poses a serious risk to the health and safety of patients, when routine maintenance and checks are not completed on emergency equipment.

Findings include:

The policy titled "Crash Cart and Emergency Medication Kit" indicates that " ...nursing is responsible for checking and documentation of the integrity of the crash cart and all equipment on top of the cart ...the daily check includes AED check, suction check, oxygen tank check and the check for integrity of the lock ...."

During a tour of the 100 and 200 units on 08/05/21, it was discovered that the 100 unit was missing a "Daily Crash Cart Check Log" for the month of August. The form for July was blank for the 1st-16th, 20th-22nd, 24th, 26th-31st. The month of June had 15 days that were blank. The 200 unit did not have any sheets from previous months, nor did it have an August sheet.

During an interview conducted on 08/05/21, Employee #1 conformed that the "Daily Crash Cart Check Log" sheets present in the binders on the respective units were the only sheets there were.

During a tour of the 100 and 200 units on 08/12/21, it was discovered that the 100 unit had all sheets present and the August form was up to date. The 200 unit still had only an August sheet, and 08/10 was blank.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the Hospital failed to require that policies/procedures specific to discharge and transfer were implemented correctly. This deficient practice poses a risk to the health and safety of patients, when the patient and/or their representative do not have the opportunity to participate in the discharge process.

Findings include:

The policy titled "Transfer of Patient" requires that for a routine/non-emergent transfer- " ...social services or designee to communicate to the patient's family, if not present, the reason, date, and time of the transfer 24-48 hours prior to transfer ...and ...all decisions regarding the type of transportation require approval from patient/Power of attorney/Guardians prior to arrangement and the approval will be documented ...."

On 05/05/21 at 1710, Medical Staff #11 documented the following in a Progress Note " ...Patient was seen this morning for follow up in [her] room talking to self and laughing to self. [She] broke one of the peers glasses yesterday, [she] is still on 1:1 ...will continue to monitor for compliance and progress in [her] behavior ...will work with social services to plan safe discharge once considered stable from psychiatric standpoint ...."

Review of the medical record revealed that the "Interdisciplinary Discharge Plan" was completed by Employee #10 on 05/06/21. Medical Staff #11 signed the form on 05/06/21 at 1259. The "Interdisciplinary Discharge Plan" indicates that Patient #3 is being transferred to Banner Del Webb, but does not indicate why.

On 05/06/21 1030, Employee #41 documented the following: " ...DON informed this writer Patient to be transferred to Del Webb ...." At 1135, Employee #41 added the following: " ...transit here to take patient to Del Webb ER. All personal belongings and medical packet given to EMT. Patient placed on gurney and left by ambulance at this time ...."

On 04/13/21, Employee #26 documented the following: " ...I will be the point person for this family on a daily basis. Daily communication to include medical, psychiatric, current issues, OT, Behavioral Therapy and summary ...." There is no documentation by Employee #26 communicating with Patient #3's mother regarding discharge and there is no documentation of Employee #26 communicating at all with Patient #3's mother after 04/18/21.

Review of all electronic communication between the hospital and Patient #3's mother failed to reveal any mention of the patient being transferred to another facility for neurological testing. There is also no mention of Patient #3's mother requesting a transfer for this reason.

The box next to "Patient/POA/Guardian provided with education regarding discharge and medication" was checked.
Other than this, review of the medical record failed to reveal any further documentation that this discharge plan was discussed with or approved by Patient #3's mother.

Neither Employee #26, nor Medical Staff #11 remain employed by the hospital, and were therefore unavailable to interview.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the hospital failed to ensure that 12 of 12 "Interdisciplinary Treatment Plans" were completed and updated per hospital policy. This deficient practice poses a risk to the health and safety of patients, when the patient's progress toward discharge is not being evaluated and monitored by the entire interdisciplinary treatment team.

Findings include:

The policy titled "Treatment Interventions" requires that " ...the team will screen and assess; and will create individualized treatment plans and implement interventions to meet the needs of patient care ...and ...group intervention attendance and the patient's participation in the group is documented in the interdisciplinary progress notes. Weekly, on the multidisciplinary plan of care, summaries document social work and therapeutic recreation interventions and patient progress toward goals. Discharge planning is also documented. Education groups are documented in the attendance record upon completion of the group ...."

The following items were not documented in Patient #1's Interdisciplinary Treatment Plan:
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update
Goals/Interventions related to provider, social services, psychology, or behavior programming

The following items were not documented in Patient #2's Interdisciplinary Treatment Plan:
"Date Closed" for any goals
Target date for goals
Goals/Interventions related to provider, social services, psychology, or behavior programming

The following items were not documented in Patient #3's Interdisciplinary Treatment Plan:
"Date Closed" for any goals
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update

The following items were not documented in Patient #4's Interdisciplinary Treatment Plan:
Substantiated diagnosis Axis 1 or 3
"Date Closed" for any goals
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update

The following items were not documented in Patient #5's Interdisciplinary Treatment Plan:
Substantiated diagnosis Axis 1 & 3
"Date Closed" for any goals
Goals/Interventions related to provider, social services, psychology, or behavior programming
Follow up/update

The following items were not documented in Patient #6's Interdisciplinary Treatment Plan:
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Identified Goals or Interventions

The following items were not documented in Patient #7's Interdisciplinary Treatment Plan:
Substantiated diagnosis Axis 3
Goals/Interventions related to provider, social services, psychology, or behavior programming
Follow up/update

The following items were not documented in Patient #8's Interdisciplinary Treatment Plan:
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Goals/Interventions related to provider, social services, psychology, or behavior programming
Follow up/update

The following items were not documented in Patient #9's Interdisciplinary Treatment Plan:
Substantiated diagnosis Axis 1 & 3
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update
Goals/Interventions related to provider, social services, psychology, or behavior programming

The following items were not documented in Patient #10's Interdisciplinary Treatment Plan:
Substantiated diagnosis Axis 1 & 3
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update
Goals/Interventions related to provider, social services, psychology, or behavior programming

The following items were not documented in Patient #11's Interdisciplinary Treatment Plan:
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update
Identified Goals or Interventions
Goals/Interventions related to provider, social services, psychology, or behavior programming

The following items were not documented in Patient #13's Interdisciplinary Treatment Plan:
Signatures indicating that the patient or POA participated in the creation of the treatment plan
Follow up/update
Identified Goals or Interventions
Goals/Interventions related to provider, social services, psychology, or behavior programming

During an interview conducted on 08/12/21, Employee #1 acknowledged the incomplete Interdisciplinary Treatment Plans.

Based on review of hospital policies/procedures, documents, and staff interviews, it was determined that the Administrator failed to ensure that Patient #4 received interventions by psychology staff as documented in the Interdisciplinary Treatment Plan. This deficient practice poses a risk to the health and safety of patients, when integral members of the treatment team are not available to provide services.

Findings include:

The Interdisciplinary Treatment Plan for Patient #4 indicates that the patient should have Process Group seven (7) times per week and 1:1's five (5) times per week "to encourage patient to verbalize feelings and issues ...." related to the identified problem of anxiety. The staff responsible for this is listed as Psychology. Review of Patient #4' group notes failed to reveal any 1:1 sessions or Process groups. Additionally, there was no group documentation on February 21, 22, 23, 25 or March 2, 7, 11, 16. During interviews conducted on 08/04/21, Employee #1, 3, and 18 all revealed that Process Groups are not conducted. Review of the current employees revealed that there are not currently any licensed therapists on staff. There are two employees with Masters of Social Work degrees, but they do not facilitate groups. Employee #1 confirmed that there are no licensed therapists on staff, but they are currently recruiting to fill the positions.

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

Findings include:

The policy titled "Nursing Staffing Plan requires that " ...unit schedules will be saved for a period of three (3) years ...."
" ...daily staffing schedules should include documentation of: facility name, date, shift hours, employee's name, illness or absence reason ...."

The policy titled "Nursing Acuity Plan" requires that " ...staffing for patient care is based on acuity and level of care needed for the medical/psychiatric patient ...."

Core Staffing Matrix per unit:
Inpatient Programs for Days (7am-7pm)-Includes weekends and holidays
1-8 patients: 1 Nurse & 1 Aide/Tech
9-18 patients: 2 Nurses & 2 Aides/Techs
19-24 patients: 3 Nurses & 3 Aides/Techs
Inpatient Programs for Nights (7pm-7am)-Includes weekends and holidays
1-9 patients: 1 Nurse & 1 Aide/Tech
10-20 patients: 2 Nurses & 2 Aides/Techs
21-24 patients: 3 Nurses & 3 Aides/Techs

" ...the Registered Nurse on the patient unit completes the acuity classification for the patient prior to the final determination of the next shift. It is the responsibility of the Registered Nurse on the nursing unit to make the nurse staff/patient shift assignments ...."

Patients are split evenly between the nurses on shift, which may include both registered nurses and licensed practical nurses. The licensed practical nurse completes the Acuity Sheet for their assigned patients. During an interview conducted on 08/04/21, Employee #17 and Employee #18 both confirmed that they complete Acuity Forms for their assigned patients.

The policy titled "Nursing Acuity Plan" requires that " ...the Registered Nurses will give the completed Acuity Tool to the Director of Nursing ...and staffing levels will be reconciled according to acuity for the next shift ...and ...completed Acuity Sheets are maintained in a binder at the Nurses Station for review and retention. When the Acuity binder is purged the acuity sheets are to be stored on site in the Director of Nursing's Office and/or designated area ...."

During an interview conducted on 08/04/21, Employee #3 revealed that the completed Acuity Sheets are put in a binder by the CEO's office. Employee #1 confirmed that the forms are kept in a binder outside his/her office, and they are kept for as long as required. Employee #3, the current acting Director of Nursing, revealed that s/he does not do anything with the Acuity Sheets after completing the ones for his/her assigned patients. Employee #1 confirmed that staffing is not based on patient acuity, but rather the "Core Staffing Matrix."
Employee #3 revealed that patient assignments are based on continuity of care (which nurse had the patient the day before) and the number of patients split evenly between the nurses.

Employee #3 revealed that if the nurses feel that there is not enough staff, they contact Employee #1 to obtain more staff. Employee #1 indicated that registry staff and travelers have been utilized.

The policy titled "Nursing Staffing Plan" requires that " ...the appropriate number of qualified staffs should be on duty at all times according to staffing guidelines based on census and acuity ...."

The daily staffing sheets for October 2020 through August 2021 were requested. The staffing sheets from October, November, December, and January were the only ones provided. The master schedule for 01/31/21-08/07/21 was also provided, but it only indicated who was originally scheduled, but not who ultimately worked the shift.

The staffing for 08/01/21-08/12/21 was reviewed. Based on Core Staffing Matrix requirements, the following shifts did not have the required staff:

100 Unit-The forms for 08/01, 08/02, 08/04, 08/06, 08/09, 08/10, and 08/10 were not provided.
08/03-Days: missing 1 nurse & 1 aide Nights: blank
08/05-Days: missing 1 nurse & 1 aide Nights: blank
08/07-Days: blank Nights: missing 2 aides
08/08-Days: missing 1 aide Nights: missing 1 aide
08/11-Days: missing 2 aides Nights: blank

200 Unit-The forms for 08/01, 08/02, 08/09, and 08/10 were not provided.
08/03-Days: missing 1 aide Nights: blank
08/04-Nights: missing 1 aide
08/05-Nights: blank
08/06-Nights: missing 1 nurse & 1 aide
08/07-Nights: blank
08/08-Nights: missing 1 aide
08/11-Days- missing 1 aide Nights: blank
08/12-Days: missing 1 aide Nights: blank

During an interview conducted on 08/04/21, Employee #1 revealed that they do not document or track staffing discrepancies.