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Based on review of hospital documents, medical records, policies and procedures, observations on tour, and staff interviews, it was determined the facility failed to:

(A0144) ensure patients were observed and their safety maintained at all times in the dayroom, resulting in Patient #2 experiencing an adverse event.

(A0145 ) ensure that Patient #2 was not subject to sexual assault.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights; which poses a potential risk to the health and safety of patients if patients are not maintained free from potential harm.

Based on review of policies and procedures, documents, medical records, and interviews, it was determined that the facility failed to require hospital personnel observe patients and ensure their safety was maintained at all times in the dayroom, resulting in Patient #2 experiencing an adverse event.

Findings include:

Policy titled "Patient Rights and Responsibilities" revealed: "...8. Patients...have the right to: a. Be safe in their surroundings...H. Additional Patient Rights Under A.A.C. R9-10-212.2. Patients are not to be subjected to: a. Abuse...."

Policy titled "Census Management" revealed: "...GENERAL GUIDELINES 1. All staff are responsible for ensuring patient safety, including participation in the ongoing monitoring of location and condition of all patients. 2. All patients in the care and custody (while on hospital grounds)...will have their location identified and documented every 30 minutes to ensure their well-being and whereabouts...5. The Shift Charge Nurse is responsible for assigning coverage for visual observation in all patient care areas on the treatment unit. Staff must be present in all common areas occupied by patients...."

Facility document titled "Daily Staff Task Sheet" dated 10/21/2019, revealed that Employee #29 was assigned to the dayroom during the time of the event between 1100-1200 hours. At the same time, there is documented evidence that Employee #29 was off-site for an off campus appointment for Patient #19.

Video review confirmed no staff monitoring the day room, unit: Ironwood East on 10/21/2019, from 1049 until 1156.

Employee #1 confirmed during an interview conducted on 10/31/2019, that there was no staff monitoring the dayroom during the aforementioned date and time.

Based on review of policies and procedures, documents, medical records, video observations, and interviews, it was determined that the administrator failed to ensure that Patient #2 was not subject to sexual assault.

Findings include:

Facility document titled "Notice of Legal Rights for Persons with Serious Mental Illness (R9-21-211, Exhibit A)" revealed: "...You have the right to not be abused in any way, physically, verbally or sexually...."

Policy titled "Patient Rights and Responsibilities" revealed: "...6. Every staff person has the responsibility to support and protect patient rights by identifying a patient's need for Special Assistance regarding his/her rights, and either taking steps to protect the patient's rights or obtaining appropriate resources to ensure that the rights are protected...8. Patients...have the right to: a. Be safe in their surroundings...H. ADDITIONAL PATIENT RIGHTS UNDER A.A.C. R9-10-212...2. Patients are not to be subjected to: a. Abuse...f. Sexual abuse; g. Sexual assault...."

Medical record for Patient #2 dated 10/22/2019, revealed: "...On 10/21/2019, Pt was assaulted by a peer...."

Facility Risk document dated 10/22/2019, contained: "...Video review confirmed that a sexual assault occurred...."

Facility document titled "Daily Staff Task Sheet" dated 10/21/2019, revealed that Employee #29 was assigned to the dayroom during the time of the event between 1100-1200 hours. At the same time, there is documented evidence that Employee #29 was off-site for an off campus appointment for Patient #19.

Employees #1, #6, and #14, confirmed that there were no designated staff members monitoring the dayroom at the time of the sexual assault.

Based on review of policies and procedures, documents, medical records, tour, and interviews, it was determined that the nurse executive failed to ensure:

1. Patient #1 was monitored according to physician's 1:1 order and facility policy;

2. Staff were assigned and present to monitor the Ironwood East (IWE) unit dayroom on 10/21/2019, between 1100 - 1200, as required by policy; and

3. Palo Verde North (PVN) unit staff recorded a census for 16 patients on 10/23/2019 (between 1630 - 1700), and monitored patients every 30 minutes as required by the Census Management policy.

Findings include:

1. Policy titled "Close Observation," revealed: "...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. Close Observation (COS)/Line of Sight (LOS) requires continuous visual observation of the patient in the line of sight at ALL times...."

Policy titled "Close Observation," revealed: "...A. Close Observation - All Levels...4. The unit charge nurse will assign a staff member to monitor the patient on Close Observation and enter the assigned staff member's name on the Assignment of Care Form...5. The assigned staff member will carry out the following care directives: a. Provide line-of-sight continuous observation of the patient, as appropriate/ordered;...6. The assigned staff member shall document a description of the patient's behavior/condition and the interventions provided on the Close Observation Documentation Form...."

Medical records for Patient #1 contained an order for 10/22/2019, at 1430, that required: "...Close Observation 1:1 Line of sight...."

Facility document titled "Acuity Tool" for unit Ironwood North (IWN), dated 10/22/2019, PM, revealed that Patient #1 was not indicated/documented as COS/LOS.

Facility document titled "Patient Census/Wellness Monitoring Form" dated 10/22/2019, for unit IWN revealed no documentation of monitoring Patient #1 at 1500, 1530, 1600, and 1630.

Employee #1 confirmed on 10/31/2019 and 11/7/2019, there was no documentation that Patient #1 was monitored as a 1:1 according to the doctor's order between the hours of 1430 - 1730.

2. Facility document titled "Daily Staff Task Sheet" dated 10/21/2019, for unit IWE revealed that Employee #29 had been assigned to the dayroom during the time of the event between 1100 - 1200. The document further revealed that there was no correction to the task sheet by the Charge Nurse, and no staff member was reassigned to the task of monitoring the dayroom during the time frame of 1100 - 1200.

Video observation of the dayroom on 10/21/2019, revealed the dayroom was not monitored by staff from 1100 until 1156.

Tour of the facility on 11/15/2019, revealed the corner of the dayroom where Patient #1 sat, and where the incident occurred, could not be visualized from the nurses' station.

Employees #1 and #6, confirmed in separate interviews that the task sheet for 10/21/2019, was never updated to reflect the schedule change to cover Employee #29's reassignment from the dayroom during 1100 - 1200.

Employees #6, #16, #17, #18, and #19, confirmed during separate interviews conducted on 11/13/2019, that the expectation for a BHT is that they will stay at their assigned post during their assignment. If the BHT is to monitor the dayroom, they are expected to be in the dayroom with eyes on the patients through the entire time of their assignment.

3. Policy titled "Census Management" revealed: "...PURPOSE To establish guidelines to ensure patient safety through ongoing monitoring of the location and condition of all patients...Census Monitor: Nursing staff assigned to monitor census throughout each shift...1. All staff are responsible for ensuring patient safety, including participation in the ongoing monitoring of location and condition of all patients. 2. All Patients...will have their location identified and documented every 30 minutes to ensure their well-being and whereabouts. 3. All hospital staff will be provided the expectations on patient census management in New Employee Orientation...PROCEDURE A. CENSUS MONITOR 1. The shift Charge Nurse will ensure that a nursing staff member is assigned as Census Monitor throughout each shift...b. Staff will not be assigned conflicting activities during the time they are assigned to the Census Monitor role...4. The Shift Charge Nurse will ...b. Ensure the assigned Census Monitor for the entire shift is clearly designated on the standardized Nursing Staff Assignment Sheet. c. Revise and reflect any changes that occur during the shift on the assignment sheet...."

Facility document titled "Patient Census and Wellness Monitoring Form" dated 10/23/2019, unit PVN, revealed for the time of 1630-1700, there were initials signed, which did not belong to any staff assigned on that unit. The initials present appeared to match those of Employee #25, who was assigned and present on a different unit. There is no documentation that a staff member monitored all 16 patients on unit PVN from 1630 - 1700 on 10/23/2019.

Additionally, review of the facility document titled "Patient Census and Wellness Monitoring Form," dates between 10/15-10/31/2019, there were 10 documented instances of monitoring timeframes between 40 min-1 hour, when the policy requires 30 minutes monitoring.

Employee #25 confirmed during an interview conducted on 11/19/2019, that s/he did not initial the Patient Census and Wellness Monitoring Form dated 10/23/2019, unit PVN, as s/he could not have been assigned to 2 different units simultaneously.