HospitalInspections.org

Based on review of hospital policies/procedures, internal documents, medical records, interviews, and direct observation, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A 122) failure to follow the Hospital's grievance process within policy time-frames;

(A 144) failure to ensure that patients received care in a safe setting;

(A 168) failure to require that the application of restraints be in accordance with the order of a physician or other licensed independent practitioner;

(A 174) failure to require that restraints were removed at the earliest possible time; and

(A 176) failure to require that physicians authorized to order restraints had documented working knowledge of the hospital's restraint policy.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.

Based on policy and procedure review, internal document review, record review, and interview, it was determined that the Hospital's grievance process was not followed within policy time-frames for response in two (2) of two (2) grievances reviewed (Patient #2, Patient #32).

Findings include:

The Oro Valley Hospital policy #9012 titled: "Service Recovery (Complaints and Grievances)" revealed: "I. PURPOSE: A. To provide a mechanism that identifies and addresses patient/visitor complaints in a timely and efficient manner. B. To provide guidelines for staff regarding the difference between complaints and grievances... III. DEFINITIONS: ... B. Complaint: A patient care concern that is identified and resolved at the time of the complaint by staff present... D: Grievance: A formal or informal written or verbal complaint that is made to the hospital by a patient or the patient's representative, when a patient issue cannot be resolved promptly by staff present... V. PROCEDURE: A. The person taking the complaint will obtain demographics, date of complaint, patient name, address, phone number and summary of complaint. Enter the information in the Event Reporting System (ERS) as a Complaint/Grievance event. B. The Risk Management Coordinator will screen all complaints and determine if they are a complaint or grievance using CMS (Centers for Medicare & Medicaid) guidelines... E. If it meets the definition of a grievance the director/manager will be informed of the date when the grievance resolution letter is due (within seven (7) days of receiving complaint)... G. Upon completion of the investigation of the grievance, the director/manager responsible for the complaint will contact the patient and explain the results of the grievance process and determine if the patient is satisfied within the actions taken on their behalf...."

Patient #2 presented to the Hospital Emergency Department (ED) on 04-30-14, with complaints of dizziness and abdominal pain. The patient disclosed that he had not taken his Adderall (psychostimulant) for one (1) week. The patient stated he had Cyclical Vomiting Syndrome (CVS), and was dehydrated. A 20 gauge (G) intravenous (IV) catheter was inserted in the right antecubital (before the elbow) area, and a normal saline bolus of 1000 milliliters (ml) was administered.

The patient presented to the ED again on 05-02-14, with generalized abdominal pain, and a 20 G intravenous catheter was inserted in the right wrist.

On 05-21-14, Patient #2 presented with "Limb Swelling" for a Doppler study as an outpatient. The "Imaging Report" revealed in the "Impression": "Superficial thrombosis of the right cephalic vein."

Internal Hospital documents revealed that on 05-27-14, Patient #2 called the Hospital, spoke with a Quality Improvement Analyst, and stated that he had a venous thrombosis as a result of an IV stated in the ED. The patient stated he returned to the ED and followed the recommendation of warm compresses, but the pain continued, and had affected his ability to work. The call was documented as a "complaint." The Quality Improvement Analyst notified the ED Director who spoke with the patient, and documented that the patient was requesting compensation, and referred the patient to the Quality Director.

The Quality Director acknowledged, during interview conducted on 11-17-14, that the patient's complaint met the definition of a grievance, and that the Hospital did not follow its grievance policy regarding Patient #2's concerns.

The Quality Director acknowledged, during interview conducted on 11-18-14, that Patient
#32 also had a grievance that was not addressed in a timely fashion, according to the Hospital's policy. Patient #32 wrote a letter to the Hospital that was received in Administration on 10-04-14, with multiple allegations regarding her care in the ED. The allegations included that her pain was not adequately addressed, requiring her to take one of her own Percocet (narcotic analgesic) for pain relief. The Director stated that the letter was just located on 11-14-14, which did not allow Hospital personnel to respond to the patient according to their policy.

Based on direct observation, review of hospital policies/procedures, census documents, and interviews, it was determined that the hospital failed to ensure that patients admitted to the Senior Behavioral Health Unit (SBHU) received care in a safe setting as evidenced by:

1. failing to equip the unit with beds that were free of visible and accessible surfaces for ligature attachment by a patient to be used for self-harm and/or suicide;

2. failing to secure beds and/or provide doors that opened to the outside of a patient's room, to prevent the use of a bed by a patient to block entrance of staff to the patient's bedroom; and

3. failing to develop a policy/procedure for supervision of patients who required calibrated medical equipment with tubing, due to the safety hazard of the use of tubing as a ligature by suicidal patients.

Findings include:

Review of the hospital policy/procedure titled "Patient Rights and Responsibilities" revealed: "...Rights: Definition: A patient's rights is(sic) defined as:...An environment that is safe, preserves dignity and contributes to a positive self-image...."

Review of the hospital policy/procedure titled "Patient Safety Plan" revealed: "...The purpose of the Patient Safety Plan is to provide a systematic, coordinated and continuous approach to the maintenance and improvement of patient safety through the establishment of mechanisms that support effective responses to actual occurrences; ongoing proactive reduction in medical/health care errors; and integration of patient safety priorities into the new design and redesign of all relevant organization processes, functions and services. The goal of the Patient Safety Plan is to provide a safe environment for patients and their families...The purpose includes creating an environment that encourages: recognition and acknowledgement of risks to patient safety and medical/health errors; The initiation of actions to reduce these risks...."

Review of SBHU policy/procedure titled "Admission/Exclusionary/Continued Stay/Discharge Criteria" revealed: "...Admission Criteria...Intensity of Service...1. The patient must require intensive, comprehensive, multimodal treatment with medical supervision and coordination 24 hours a day...The patient needs 24 hour nursing or medical supervision for safety to protect self or others...Severity of Illness...1. The patient poses a threat to self-requiring 24 hour professional observation: 1.1 Suicidal ideation or gesture within 72 hours prior to admission...1.2 Actual or threatened self-injury/mutilation within 72 hours prior to admission...1.3 Chronic and continuing self-destructive behavior that poses a significant and/or immediate threat to life, limb or bodily function...."

Review of the patient census on the SBHU on 11/5/14, 11/6/14 and 11/7/14, revealed:

on 11/5/14, 8 inpatients were residing on the SBHU. All patients were diagnosed with mood disorders. Three of the 8 patients were listed on the census as having "SI" (Suicidal Ideation); one specific patient was listed as "Drug OD (Overdose) SI Attempt";

on 11/6/14, 10 inpatients were residing on the SBHU; the previously listed 8 patients and 2 additional admissions, who each had "Depression"; and

on 11/7/14, two of the previous 10 inpatients had been discharged, and one patient had been admitted who was listed as having "Depression" with "suicide".

1. Direct observation of the 17-bed SBHU, conducted on 11/6/14, revealed that all of the patient beds were hospital beds. Each bed was constructed with a head board, approximately 18" in height, with 2 oval cut-outs, approximately 4-5" in diameter, midway up from the mattress and one to the right and one to the left; a foot board of similar height and with similar cut-outs; upper side rails with 2 larger oval cut-outs in the middle of each side rail; and lower side rails, each with one large cut-out, approximately 8" long and 3-4" wide in the center of the side rail.

The Director of the Unit confirmed, during interview conducted on 11/6/14, that the cut-out areas in the beds posed a safety hazard, since patients could wrap a sheet or other item through and around the cut-out areas and attempt suicide or self-harm by asphyxiation. She also confirmed that she had not identified these safety hazards, nor had anyone brought them to her attention.

Direct observation of the SBHU, conducted on 11/18/14, revealed that a "Low Boy" bed had been placed in a patient's room at his request. This bed had an arching foot board, constructed of material resembling Polyvinylchloride (PVC) pipe. The patient had a mood disorder: "Bipolar Disorder, Manic." The Director of the Unit confirmed that this bed was also a safety risk.

2. Direct observation, conducted on 11/13/14, of the patient beds described above revealed that they had wheels and were movable. The doors to all of the patient rooms on SBHU opened into the patient rooms and could not open to the outside, into the hallway. The Director of the Unit confirmed that the beds could be wheeled through the room, with potential to be placed against the door to the patient room, blocking entrance by staff.

3. Review of hospital policy titled "SBHU Admission/Exclusionary/Continued Stay/Discharge Criteria" revealed: "...Program Limitations (Exclusionary Criteria)...Individuals who present with one or more of the following criteria are to be reviewed by the Chief Executive Officer, or designee and the Medical Director. These include but are not limited to:...Medically unstable and/or requiring general hospital level of care. For example: Indwelling catheters/lines...calibrated equipment...."

Direct observation conducted on 11/18/14, revealed a patient with a fluid-filled bag and connective tubing providing intravenous (IV) fluid to the patient via an IV pump. The patient was seated inside a room with a visitor. Windows into the room provided visibility of the patient from the hallway.

The Chief Nursing Officer (CNO) stated, during interview conducted on 11-18-14, that the unit did not have a policy/procedure for use of IV's. The Director of the Unit stated that the patient had required 1:1 staffing during the night due to suicide precautions. The IV had been started during the night and was a time-limited IV. The physician had discontinued the 1:1 staff. The Director did not provide information regarding additional provisions for this patient's safety other than the routine rounds provided for all patients. The hospital did not provide evidence of review by the Chief Executive Officer or designee regarding accommodating the patient in the SBHU while she required IV intervention for her medical needs.

Based on review of hospital policy/procedure, medical record review, and interview, it was determined that the hospital failed to require that the application of restraints be in accordance with the order of a physician or other licensed independent practitioner for 1 of 1 patients restrained for the management of nonviolent behavior (Pt # 21), and 2 of 2 patients restrained for the management of violent behavior (Pts # 25 and 26).

Findings include:

Review of hospital policy/procedure titled "Restraint and Seclusion" revealed: "...In an emergency application situation, the nurse...may initiate the application of restraint...prior to obtaining an order from a Licensed Independent Practitioner (LIP). In this event, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint...has been applied...Violent/Self-Destructive Behavior...Initial Physician Order...The restraint order must be time limited and the duration of the order is written appropriate to the patient's age: 4 hours for adults...Complete order...Physician responsibility...Physician section is where the correct restraint type is to be marked...Confirm the time limitation...."

Review of Pt # 21's medical record revealed:

A Registered Nurse (RN) documented initiation of soft limb bilateral wrist restraints on 11/1/14, at 1000. A physician entered the order into the electronic record on 11/1/14, at 1529.

An RN documented initiation of restraints on 11/5/14 at 1300. An RN entered the physician's order for NonViolent Soft Bilateral Wrist Restraints on 11/5/14, at 1714.

Nursing personnel documented monitoring the patient in restraints every 2 hours on 11/2/14, from 0000 through 2200. The medical record did not contain a physician order for restraints on 11/2/14.

The Quality Coordinator confirmed, during interview conducted on 11/7/14, that nursing placed Pt # 21 in restraints and did not obtain a physician's order within a few minutes, as required by policy/procedure. She also confirmed that Pt # 21 was in restraints on 11/2/14, with no physician order for restraints.

Review of Pt # 25's medical record revealed:

A physician documented on 9/16/14, at 0139: "...very belligerent with our examination to the point...to be physically restrained. however after Geodon (atypical antipsychotic) he calms down quite a bit is able to be taken from his restraints...."

On 9/16/14 at 1040, an RN signed a Physician Restraint Order form and marked the section for Behavioral restraints: "...patient behavior is such that the patient poses a risk to themselves and/or others and the behavior is not related to an underlying medical condition..." The RN documented alternatives to restraints that were attempted. A physician signed the form on 9/16/14, at 1040. The section to be completed by the physician was blank. The form did not contain restraint type, site, time limitation or criteria for release.

Nursing documented initiation of restraints on 9/16/14, at 1040 and release of restraints at 1122. Nursing documentation did not include the type or placement of restraints.

The Quality Coordinator confirmed, during interview conducted on 11/14/14, that the physician had signed the restraint order form but did not order type of restraints, site for restraints, or time limitation for restraints as required.

Review of Pt # 26's medical record revealed:

A physician documented on 9/6/14, at 0704: "...held or supported for aggressive behavior and agitation alcohol abuse...been very aggressive...requiring multiple doses of medications and physical restraints...."

Nursing documented that Pt # 26 was in restraints from 9/5/14, at 1700 through 9/6/14 at 1400 and from 9/6/14, at 2145 through 9/7/14, at 0600 and from 9/7/14, at 1539, through 9/7/14, at 1945.

A physician ordered restraints on 9/5/14, at 1645 with a time limit of 4 hours. S/he ordered restraints on 9/6/14, at 2145, with a time limit of 4 hours. A physician ordered restraints on 9/7/14, at 0545. The patient remained in restraints from 9/6/14, at 2145 through 9/7/14, at 0600. The medical record did not contain an order for restraints between 0145 until 0545, on 9/7/14.

The Quality Coordinator confirmed, during interview conducted on 11/14/14, that Pt # 26 was in restraints between 0145 and 0545, on 9/7/14 without a physician's order.

Based on review of hospital policy/procedure, direct observation, review of medical records and interview, it was determined that the hospital failed to require that restraints be removed at the earliest possible time for 1 of 1 patient restrained for the management of non-violent behavior (Pt # 21), and 1 of 2 patients restrained for the management of violent behavior (Pt # 26).

Findings include:

Review of hospital policy titled Restraint and Seclusion revealed: "...Staff is expected to assess and monitor the patient to ensure the patient is released from restraint or seclusion at the earliest possible time...."

Direct observation conducted on 11/6/14, revealed that Pt # 21, an ICU patient, was intubated, sedated, and appeared to be sleeping soundly with bilateral wrist restraints in place.

Review of Pt # 21's medical record revealed:

Nursing personnel documented monitoring of the patient in restraints every 2 hours from 11/1/14, at 1200, through 11/2/14 at 1800. The space designated for patient behavior was blank.

Pt # 21 was intubated on 11/5/14, at 1650. Nursing documented monitoring of the patient in restraints every 2 hours, from 11/5/14, at 2200, through 11/6/14, at 0800 and from 11/7/14 at 0200, through 0600, as "sleeping, restful." Nursing documented on the flow sheet designated for neurological assessment:
11/7/14 at 0000: sedated;
11/7/14, at 0400: sedated;
11/7/14, at 1000: No change;
11/714, at 1200: No change;
11/7/14, at 1400: No change;
11/7/14, at 1600: No change;
11/7/14, at 1800: No change;
11/7/14, at 1900; sedated;
11/7/14, at 2000: No change;
11/7/14, at 2200: No change.

The Quality Coordinator confirmed during interview conducted on 11/7/14, that nursing documentation did not reflect efforts to release the patient from restraints at the earliest possible time, as required by hospital policy.

Review of Pt # 26's medical record revealed:

The patient was in bilateral wrist and ankle restraints on 9/6/14 from 2145 through 9/7/14 at 0600. Nursing documented that the patient was sleeping from 0100 until 0500.

The Quality Coordinator confirmed during interview conducted on 11/14/14, that nursing documentation did not reflect efforts to release the patient from restraints at the earliest possible time, as required by hospital policy.

Based on review of hospital policy/procedure, medical records, physician credentialing files, and interview, it was determined that 3 of 3 physicians authorized to order restraints did not have documentation of a working knowledge of the hospital's restraint policy as required by hospital policy (MDs # 22, 23 and 24).

Findings include:

Review of hospital policy titled Restraint and Seclusion revealed: "...Physicians and LIPs authorized to order restraint...must have a working knowledge of hospital policy regarding restraint...as evidenced by documented review and education on the hospitals (sic) restraint policy...."

Review of Pt # 21's medical record revealed:

MD # 23 ordered Soft Limb Bilateral Wrist Restraints on 11/1/14, at 1529. Review of MD # 23's credentialing file revealed that it did not contain documentation of MD # 23's working knowledge of the hospital's restraint policy.

MD # 22 ordered Non-violent, Soft Wrist Bilateral Restraints on 11/5/14, at 1714.
Review of MD # 22's credentialing file revealed that it did not contain documentation of MD # 22's working knowledge of the hospital's restraint policy.

Review of Pt # 25's medical record revealed:

MD # 24 signed an order form for "Behavioral Restraints" and did not indicate the type, site/s or time limitation for restraints. Review of MD # 24's credentialing file revealed that it did not contain documentation of MD # 24's working knowledge of the hospital's restraint policy.

The Director of Medical Staff Credentials confirmed, during interview conducted on 11/17/14, that the hospital was unable to provide documented evidence that the physicians listed above were trained prior to the survey and had working knowledge of the hospital's restraint policy.

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

( A 386) failure to have a well-organized nursing service with delineation of responsibilities for patient care, as evidenced by failing to have a policy/procedure related to the Suicide Risk Assessment currently in use by nursing in the Senior Behavioral Health Unit (SBHU);

(A 395) failure to ensure that an RN supervise and evaluate the nursing care provided to each patient; and

(A 405) failure to require that an RN administer medication in accordance with a practitioner's order.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an adequate, organized nursing service.

Based on review of hospital document, hospital policies/procedures, medical records and interviews, it was determined that the hospital failed to have a well-organized nursing service with delineation of responsibilities for patient care as evidenced by failing to have a policy/procedure related to the Suicide Risk Assessment currently in use by nursing in the SBHU.

Findings include:

Review of the SBHU form titled BH Suicide Risk Assessment revealed: "Instructions: complete for all patients during the pre-admission &/or admission assessment process to behavioral health services. Check the level that applies to the patient's acuity, based on observed and/or reported risk factors and implement the corresponding interventions...Screening questions to ask all patients: Do you feel hopeless or helpless?...Yes...No...Have you had thoughts of suicide or self-harm?...Yes...No. If so, when_________and where________?...Are you having any now?...Yes...No...Do you have a plan to hurt yourself?...Yes...No...If so, explain how_____________....Is the patient currently under the influence of drugs or alcohol...Yes...No...If yes what ___________. If patient answers 'NO' to all questions above, check #4 and the appropriate 'protective factors' and sign below. If any 'YES' answers, complete the following Suicide Risk Assessment below...."

The remainder of the form contained sections for Observation/Precautions Levels 1: Imminent Risk of Harming self...1:1 constant observation; Level 2: Heightened Risk of Harming self...Line of Sight; Level 3: Low to Moderate Risk of Harming self...Every 15 minute observations; and Level 4: No danger to self...General/Routine Observations.

Beside each Level was a box for the RN to mark to designate the Level of Observation/Precaution indicated for the patient. Columns next to each Level contained headings: Observed Risk Factors; Reported Risk Factors; and Standard Intervention & Safety Plan.

The form also contained a section for the RN to document Protective Factors that Decrease Likelihood (Lethality) of Suicide Attempt.

On 11/6/14, the Director of SBHU confirmed that the hospital does not have a policy/procedure or instructions related to the Suicide Risk Assessment form/tool described above.

RN # 28 completed the Suicide Risk Assessment for Pt # 13.

Cross reference Tag 0395 for information regarding Pt # 13 and the circumstances of her admission, on 11/6/14, for suicidal behavior which included possession of a gun and a "stand off" with the police.

RN # 28 stated during interview conducted on 11/7/14, that she had not received specific training regarding completion of the Suicide Risk Assessment, other than training to enter the information into the computer program. She stated that she had no experience working on an inpatient psychiatric unit prior to her hire date on 8/14/14. She stated that since Pt # 13 exhibited several factors of the Level 4 section, such as "Cooperative and communicative", "Able to discuss concerns". and "Compliant with instructions & interventions" that she had decided that those factors outweighed the factors that she had marked in the Level 2 and Level 3 sections which indicated higher levels of risk. She confirmed that she had not documented any Protective Factors that Decrease Likelihood (Lethality) of Suicide Attempt and had not completed the Suicide Risk Assessment.

Cross reference Tag 0395 for information regarding Pt # 11, the circumstances of her admission after a suicide attempt and the incomplete Suicide Risk Assessment documented by the RN.

The Director of SBHU, confirmed during interview conducted on 11/6/14, that she considered Pt #11 a high risk of suicide and that the RN had not completed the Suicide Risk Assessment and had marked Level 4 "No danger to self."

Review of hospital policy/procedure titled SBHU Level of Observation, Effective 9/2013, revealed: "...Patients will be assessed for suicide risk as part of pre-admission screening and admission assessments including the nursing assessment...Patients assessed to be at a heightened risk of suicide or self-injurious behaviors will be placed on suicide precautions commensurate with the assessed level of risk...The comprehensive admission suicide assessment will include the following risk factor elements:...History and lethality of previous suicide attempts or self-injurious behavior...Current suicidal thoughts with lethality and intent...Presence of concrete suicidal plan...Trauma or abuse history...Hopelessness/non future oriented...psychosis, agitation, or impulsivity...Family history of suicide...Recent significant loss...Recent severe, stressful life events...Unremitting pain...Alcohol or substance use or abuse...Access/means...determine the level of safety risk associated with each new admission and throughout their hospitalization on the basis of past behavior, present situation and current mental status...There are three levels of observation...Level One: Routine observation...Level Two: Line of Sight...Level Three: Constant One to One.

The above policy/procedure was provided to the surveyors as a current policy/procedure for SBHU. Comparison of this policy/procedure and the Suicide Risk Assessment tool, currently in use on SBHU, revealed several discrepancies: The current tool does not include lethality of recent or previous suicide attempts. The current tool does not include trauma or abuse history, family history of suicide, recent severe, stressful life events, unremitting pain or alcohol or substance use or abuse as reported risk factors. The policy contained three levels of observation, with Level Three considered the highest level. The current assessment tool contains four levels of observation, with Level One considered the highest level.

The Director of Quality confirmed, during interview conducted on 11/7/14, that the policy for SBHU Level of Observation does not correspond to the Suicide Risk Assessment tool currently in use to assess the patient's required level of observation.

The hospital was unable to provide a policy/procedure for nursing use of the current Suicide Risk Assessment tool and the policy/procedure that was provided is discrepant from the tool.

Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure that an RN supervise and evaluate the nursing care provided to each patient as evidenced by:

1. failure of an RN to evaluate patient safety needs for depressed/suicidal patients placed in the hospital beds located in the SBHU;

2. failure of an RN to complete the Suicide Risk Assessment and to assess patients' need for level of precautions above routine, for 2 of 2 patients admitted to the SBHU after suicide attempts;

3. failure of the RN to supervise the observation of a patient for 1 of 3 patients on the SBHU;

4. failure of an RN to obtain an order for restraint immediately after application of restraint, for 1 of 1 non-violent patient who was placed in restraints (Pt # 21);

5. failure of an RN to assess 1 of 1 ICU patients, as required by protocol, for withdrawal from alcohol (Pt # 21).

Findings include:

1. Cross reference Tag 0144 for information regarding the beds with visible and accessible
surfaces conducive to ligature placement located in the SBHU and the criteria for patient admission to the SBHU which includes "patients who pose a threat to self, requiring 24 hour professional observation."

The Director of the SBHU, an RN, confirmed, during interviews conducted on 11/6/14 and 11/18/14, that the beds on SBHU posed a safety hazard, since patients could wrap a sheet or other item through and around surfaces on the beds and attempt suicide or self-harm by asphyxiation. She also confirmed that she had not identified these safety hazards, nor had anyone from the nursing staff brought them to her attention.

2. Review of SBHU form titled BH Suicide Risk Assessment revealed: "Instructions: complete for all patients during the pre-admission &/or admission assessment process to behavioral health services. Check the level that applies to the patient's acuity, based on observed and/or reported risk factors and implement the corresponding interventions...Screening questions to ask all patients: Do you feel hopeless or helpless?...Yes...No...Have you had thoughts of suicide or self-harm?...Yes...No. If so, when_________and where________?...Are you having any now?...Yes...No...Do you have a plan to hurt yourself?...Yes...No...If so, explain how_____________....Is the patient currently under the influence of drugs or alcohol...Yes...No...If yes what ___________. If patient answers 'NO' to all questions above, check #4 and the appropriate 'protective factors' and sign below. If any 'YES' answers, complete the following Suicide Risk Assessment below...."

The remainder of the form contained sections for Observation/Precautions Levels 1: Imminent Risk of Harming self...1:1 constant observation; Level 2: Heightened Risk of Harming self...Line of Sight; Level 3: Low to Moderate Risk of Harming self...Every 15 minute observations; and Level 4: No danger to self...General/Routine Observations.

Beside each Level was a box for the RN to mark to designate the Level of Observation/Precaution indicated for the patient. Columns next to each Level contained headings: Observed Risk Factors; Reported Risk Factors; and Standard Intervention & Safety Plan.

The form also contained a section for the RN to document Protective Factors that Decrease Likelihood (Lethality) of Suicide Attempt.

The form contained a space for documentation of review with the physician and orders for precaution levels. Below this section was a statement: "...If a physician orders a different level than indicated on the assessment above, the nurse will verify the level of precaution...."

The Director of the SBHU explained during interview conducted on 11/6/14, that the RN can determine the level of required observation/precaution for the patient, based on the risk factors. S/he is not required to obtain a physician's order for precaution level.

On 11/6/14, the Director of the SBHU stated that the BH Suicide Risk Assessment form has been incorporated into the electronic medical record with the same components as described above.

On 11/7/14, the CNO provided a copy of the computerized Suicide Risk Assessment which contained all of the elements described above.

Review of Pt #11's medical record revealed:

On 10/29/14, at 1803, an RN documented in the electronic record Intake Assessment BH Adult: "...Patient feels she can no longer deal with her chronic pain...and so she took intentional overdose of her prescribed pain pills as a suicide attempt. Patient denies current SI (Suicidal Ideation)...Patient has a history of depression and chronic pain...Patient is s/p SA (status post Suicide Attempt), worsening depression and hopelessness related to chronic pain...Attempted suicide...."

Review of Pt #11's medical record revealed that the spaces for all of the questions listed in the Screening questions of the Suicide Risk Assessment described above were blank.The section titled Level 4-No Danger to Self (General/Routine Observations) was completed: "...Observed Risk Ractors...Cooperative and communicative...Able to discuss concerns...Compliant with instructions & interventions...." The section titled Protective Factors that Decrease Likelihood (lethality) of Suicide attempt was blank.

The Director of SBHU, confirmed during interview conducted on 11/6/14, that she considered Pt #11 a high risk of suicide and that the RN had not completed the Suicide Risk Assessment and had marked Level 4 "No danger to self."

Review of Pt # 13's medical record revealed:

An ED Triage RN documented, on 11/6/14 at 1036: "...Suicidal Ideation: Constant...Suicide Hopeless or Helpless: Yes...Suicide Past Suicidal Thoughts: Yes...Suicide Current Suicidal Thoughts: Yes...Suicide Previous Attempts: Yes...Suicide Plan Includes Harm to Others: Yes...."

An ED Physician documented on 11/6/14, at 1051: "...The patient is brought to the emergency department from her home where she was apprehended by the SWAT team...reportedly depressed...recurrent episodes of Meniere's syndrome causing ear pain and vertigo...Last night she took 60 mg of diazepam in order to get comfortable...This morning when it reoccurred she pulled out her gun...Dr. (# 26) notified the emergency services. SWAT team was called to the patient's premises. There was a temporary standoff...hold gun to her chest...patient left her house without incident...The detective who accompany (sic) the patient to the hospital was very specific in stating that the patient should be treated as on a petition and not admitted again to the senior behavioral health center here...Subsequently Dr. (# 26) came and evaluated the patient here and spoke with...and has canceled the petition...."

The hospital was unable to provide documentation of the evaluation completed by MD # 26 in the ED.

On 11/6/14, at 1630, RN #28 recorded a telephone order from MD # 26 to admit Pt # 13 to the SBHU: "...Regular Diet...Q5 min obs (observation every 5 minutes)...."

At the time of Pt # 13's admission, routine observations were being conducted every 5 minutes due to the safety hazards of the hospital beds. The physician's orders for "Q 5 min obs" were not an individualized precaution for Pt # 13.

On 11/6/14, at 1738, RN # 28 completed Pt # 13's Suicide Risk Assessment: "...Do you feel hopeless or helpless?...Yes...Have you had thoughts of suicide or self-harm?...Yes...Are you having any now?...Yes...Do you have a plan to hurt yourself?...No...Is the patient under the influence of drugs or alcohol?...Yes...."

RN # 28 marked Observed Risk Factors and Reported Risk Factors in the Level 2 section (Heightened Risk of Harming Self...Line of Sight) of the Suicide Risk Assessment; she marked Observed Risk Factors and Reported Risk Factors in the Level 3 section (Low to Moderate Risk of Harming Self...Every 15 Minute Observations) of the Suicide Risk Assessment;and she marked Observed Risk Factors and Reported Risk Factors in the Level 4 section (No Danger to Self...General/Routine Observations) of the Suicide Risk Assessment. She did not mark any Protective Factors that Decrease Likelihood (Lethality) of Suicide Attempt.

RN # 28 stated during interview conducted on 11/7/14, that she had not received specific training regarding completion of the Suicide Risk Assessment, other than training to enter the information into the computer program. She stated that she had no experience working on an inpatient psychiatric unit prior to her hire date on 8/14/14. She stated that since Pt # 13 exhibited several factors of the Level 4 section, such as "Cooperative and communicative", "Able to discuss concerns". and "Compliant with instructions & interventions" that she had decided that those factors outweighed the factors that she had marked in the Level 2 and Level 3 sections which indicated higher levels of risk. She stated that she had not contacted the physician to review risk factors which may have required more than routine observations since the physician had seen the patient in the ED. She did not note the fact that the physician's evaluation was not documented and that it was conducted several hours before her assessment. She confirmed that she had not documented any Protective Factors that Decrease Likelihood (Lethality) of Suicide Attempt and had not completed the Suicide Risk Assessment.

3. Review of hospital policy/procedure titled SBHU Level of Observation, Effective 9/2013, revealed: "...Observation flow sheet entries should consistently reflect patient location, behavioral observations, adherence to level of observation and patient mental status every 15 minutes, regardless of level of observation, indicating the necessity for the level of observation ordered...."

Review of a letter written and signed by the hospital CEO on 11/7/14 revealed: "...In an effort to address potential patient safety issues related to the...hospital beds on the...Senior Behavioral Health Unit (SBHU), a plan to round on patients who are not attended by staff and are alone in their respective rooms every five minutes was implemented on November 6, 2014...."

Direct observation of Pt # 7's Patient Observation Flow Sheet conducted on 11/7/14, at 0950, revealed that it did not contain documentation of observation of the patient from 0725 through 0950. Employee # 29 confirmed that s/he had not been able to document observation of Pt # 7 due to other responsibilities.

4. Review of hospital policy/procedure titled Restraint and Seclusion revealed: "...In an emergency application situation, the nurse...may initiate the application of restraint...prior to obtaining an order from a LIP (Licensed Independent Practitioner). In this event, the order must be obtained either during the emergency application of the restraint or seclusion, or immediately (within a few minutes) after the restraint...has been applied...."

Review of Pt # 21's medical record revealed:

An RN documented initiation of soft limb bilateral wrist restraints on 11/1/14, at 1000. A physician entered the order into the electronic record on 11/1/14, at 1529.

An RN documented initiation of restraints on 11/5/14 at 1300. An RN entered the physician's order for NonViolent Soft Bilateral Wrist Restaints on 11/5/14, at 1714.

The Quality Coordinator confirmed during interview conducted on 11/7/14, that nursing placed Pt # 21 in restraints and did not obtain a physician's order within a few minutes, as required by policy/procedure.

5. Review of Pt # 21's medical record revealed:

On 11/1/14, at 1115, a physician ordered: "...1 mg Soln-Inj IV hourly prn (as needed) for CIWA (Clinical Institute Withdrawal Assessment for Alcohol) 8-13...2 mg Soln-Inj IV hourly prn for CIWA 14-20...4 mg Soln-Inj IV hourly prn for CIWA 21 or greater...."

The physician also ordered: "...If score is (equal to or less than) 7, continue assessments and VS (Vital Signs) q4h (every four hours)...Notify provider for any score above 25...."

RNs recorded the following consecutive CIWA assessments for Pt # 21 and administered the following medication:

11/1/14, at 0900: CIWA score 21;
11/1/14, at 1000: CIWA score 26; an RN administered 4 mg Ativan at 1135;
11/1/14, at 1200: CIWA score 29; an RN administered 4 mg Ativan at 1357;
11/1/14, at 1400: CIWA score 29. Assessment was required at 1300;
11/1/14, at 1500: CIWA score 29; an RN administered 4 mg Ativan at 1552;
11/1/14, at 1600: CIWA score 25;
11/1/14, at 1800: CIWA score 29. Assessment was required at 1700; an RN administered 4 mg Ativan at 1800;
11/1/14, at 2000: CIWA score 28. Assessment was required at 1900; an RN administered 4 mg Ativan at 2000;
11/1/14, at 2100: CIWA score 28; an RN administered 4 mg Ativan at 2100;
11/1/14, at 2200: CIWA score 27; an RN administered 4 mg Ativan at 2230;
an RN administered 2 mg Ativan at 0134, with no recorded assessment;
11/2/14, at 0300: CIWA score 23. Assessment was required on 11/1/14, at 2300; an RN administered 2 mg Ativan at 0331. 4 mg was required for a score of 23; an RN administered 4 mg of Ativan at 0443, with no recorded assessment;
11/2/14, at 0800: CIWA score 4. Assessment was required at 0400; an RN administered 2 mg Ativan at 0825. No medication was required for a score of 4;
11/2/14, at 1000: CIWA score 22. Assessment was required at 0900; no medication was administered at 1000 and 4 mg Ativan was required for a score of 22; an RN administered 2 mg Ativan at 1137;
11/2/14, at 1200: CIWA score 29. Assessment was required at 1100; an RN administered 2 mg at 1211. 4 mg was required for a score of 29;
11/2/14, at 1400: CIWA score 26. Assessment was required at 1300; an RN administered 4 mg of Ativan at 1333;
11/2/14, at 1600: CIWA score 26. Assessment was required at 1500; an RN administered 4 mg Ativan at 1702 with no recorded assessment; an RN administered 2 mg Ativan at 1834 with no recorded assessment;
11/2/14, at 2000: CIWA score 5. Assessment was required at 1700;
11/2/14, at 2200: CIWA score 5;
11/3/14, at 0000: CIWA score 4.

RNs recorded the following consecutive CIWA assessments:

11/5/14, at 1000: CIWA score 4;
11/5/14, at 2000: CIWA score 4. Assessments were required at 1400 and 1800.

The Quality Coordinator and the Director of ICU confirmed, during interview conducted on 11/13/14, that RN assessments were required to be completed every hour, for CIWA scores above 8, per physician order. They confirmed that the RN's did not complete the assessments as required. They also confirmed that Ativan was required to be administered according to results of assessments in the amount ordered for the corresponding CIWA score. They confirmed that the RN's had not administered the Ativan according to CIWA scores.

Based on review of hospital policy/procedure, medical record and interviews, it was determined that the hospital failed to require that an RN administer medication to 1of 1 ICU patient, for withdrawal from alcohol, in accordance with a practitioner's order (Pt # 21).

Findings include:

Review of hospital policy/procedure titled Physician Orders revealed: "...Inpatient orders/power plans will be initiated by the appropriate licensed staff after review and verification...."

Review of Pt # 21's medical record revealed:

On 11/1/14, at 1115, a physician ordered: "...1 mg Soln-Inj IV hourly prn (as needed) for CIWA (Clinical Institute Withdrawal Assessment for Alcohol) 8-13...2 mg Soln-Inj IV hourly prn for CIWA 14-20...4 mg Soln-Inj EV hourly prn for CIWA 21 or greater...."

RNs recorded the following CIWA assessments for Pt # 21 and administered the following medication:

11/1/14, at 2200: CIWA score 27; an RN administered 4 mg Ativan at 2230;
an RN administered 2 mg Ativan at 0134, with no recorded assessment;
11/2/14, at 0300: CIWA score 23. Assessment was required on 11/1/14, at 2300;
an RN administered 2 mg Ativan at 0331. 4 mg was required for a score of 23;
an RN administered 4 mg of Ativan at 0443, with no recorded assessment;
11/2/14, at 0800: CIWA score 4. Assessment was required at 0400; an RN administered 2 mg Ativan at 0825. No medication was required for a score of 4;
11/2/14, at 1000: CIWA score 22. Assessment was required at 0900; no medication was administered at 1000 and 4 mg Ativan was required for a score of 22; an RN administered 2 mg Ativan at 1137;
11/2/14, at 1200: CIWA score 29. Assessment was required at 1100; an RN administered 2 mg at 1211. 4 mg was required for a score of 29;
11/2/14, at 1400: CIWA score 26. Assessment was required at 1300; an RN administered 4 mg of Ativan at 1333;
11/2/14, at 1600: CIWA score 26. Assessment was required at 1500; an RN administered 4 mg Ativan at 1702 with no recorded assessment; an RN administered 2 mg Ativan at 1834 with no recorded assessment;

The Quality Coordinator and the Director of ICU confirmed, during interview conducted on 11/13/14, that the CIWA protocol is part of a power plan. They confirmed that the RN was required to administer Ativan according to results of assessments in the amount ordered for the corresponding CIWA score. They confirmed that the RN's had not administered the Ativan according to CIWA scores and in accordance with the physician's order.

Based on direct observation, review of the Director of Nutritional Services job description, and interview, it was determined that the Director of Nutritional Services failed to appropriately manage dietetic services by failing to maintain a sanitary environment in the dietary department.

Findings include:

The job description for the Director of Nutritional Services revealed in the "Position Purpose": "Provides overall management and strategic leadership for Nutritional Services programs and services. This position assures the Mission, Vision, and Values of Oro Valley Hospital (OVH) are represented in all decisions for the delivery of services..." The field titled "Standards for general Duties and Leadership Skills" revealed: "...Displays the principle that actions speak louder than words, leads by example. Behavior consistently reflects values of the organization and serves as an effective role model...."

An environmental tour was conducted on 11-07-14 at 4:10 P.M. Direct observation revealed a metal dietary cart for used dietary trays in the soiled utility room in the Intensive Care Unit (ICU). Direct observation revealed that the dietary cart contained one (1) tray in which the food had been consumed, on a shelf of the cart. Observation revealed dried food and liquids clinging to the walls and bottom inside the cart. The Facilities Director, present during the tour, acknowledged that the dietary cart should have been clean, and that it may require power water washing to effectively clean the cart.

On 11-12-14 at 2:05 P.M., a tour was conducted of the dietary department with the Chief Quality Officer and the Dietary Director in attendance. A trash container in the dietary department was observed to have dried food and dried liquids visible on the trash container lid. There was a black-brown substance covering the floor in an approximately three (3) foot by one (1) foot area of the dietary floor, behind CO2 tanks. The substance was raised, and dried. A (brand name) bread rack containing loaves of bread contained a visible black substance stuck to various aspects of the bread rack. The Dietary Director was observed during tour to touch various aspects of unsanitary surfaces in the dietary kitchen. When prompted, the Dietary Director conducted hand hygiene, and subsequently put his hand down in a trash receptacle, touching the inside of the plastic liner without subsequently performing hand hygiene.

The Dietary Director acknowleded, during interview conducted in 11-12-14 at 2:30 P.M., that the bread racks were dirty and need to be cleaned.

The Chief Quality Officer acknowledged, during interview conducted on 11-12-14 at 2:40 P.M., that areas of the dietary kitchen which were identified as unsanitary were an infection control issue.

Based on direct observation, review of Environmental Services Manager job description , Dietary Director job description, review of policy and procedure, and interview, it was determined that the hospital did not maintain the condition of the physical plant in a manner that assured the health and safety of patients as evidenced by:

(A0701) failure to equip the Senior Behavioral Health Unit (SBHU) with beds that were free of visible and accessible surfaces for ligature attachment by a patient to be used for self-harm and/or suicide; and

failure to secure beds and/or provide doors that open to the outside of a patient's room, to prevent the use of a bed by a patient on the SBHU to block entrance of staff to the patient's bedroom; and

failure to assure that multiple areas of the Hospital maintained a sanitary environment to ensure the safety of patients.

The cumulative effect of these systemic problems resulted in the hospital's failure to provide an overall environment that ensured the safety of patients.

Based direct observation, review of Environmental Services Manager job description, Dietary Director job description, review of policy and procedure, and interview, it was determined that the hospital did not maintain the condition of the physical plant in a manner that assured the health and safety of patients as evidenced by:

1. failing to equip the Senior Behavioral Health Unit (SBHU) with beds that were free of visible and accessible surfaces for ligature attachment by a patient to be used for self-harm and/or suicide;

2. failing to secure beds and/or provide doors that opened to the outside of a patient's room, to prevent the use of a bed by a patient on the SBHU to block entrance of staff to the patient's bedroom;

3. failing to maintain sanitary conditions in the dietary kitchen;

4. failing to maintain sanitary conditions in a metal meal delivery cart;

5. failing to maintain sanitary conditions in the receiving dock, to which clean and sterile medical supplies and equipment were delivered;

6. failing to maintain sanitary conditions in an ice machine in the ICU, a juice machine in the Telemetry unit, and coffee-makers in the ICU and Telemetry units, respectively;

7. failing to maintain sanitary conditions in 4th Floor elevator lobby;

8. failing to maintain sanitary conditions in the radiology department when security straps on a Computerized Tomography (CT) machine were soiled; and

9. failing to maintain a sanitary environment when the floor of a radiology department storage room contained dried liquids and a black substance on the floor.

Findings include:

1. Cross reference Tag 0144 for information regarding the beds, located in the SBHU, with visible and accessible surfaces conducive to ligature placement and the criteria for patient admission to the SBHU, which included"patients who pose a threat to self, requiring 24 hour professional observation."

The Director of the SBHU, an RN, confirmed, during interviews conducted on 11/6/14 and 11/18/14, that the beds on SBHU posed a safety hazard, since patients could wrap a sheet or other item through and around surfaces on the beds and attempt suicide or self-harm by asphyxiation. She also confirmed that she had not identified these safety hazards, nor had anyone from the nursing staff brought them to her attention.

2. Direct observation, conducted on 11/13/14, of the patient beds located on the SBHU, revealed that they have wheels and are movable. The doors to all of the patient rooms on SBHU open into the patient rooms and cannot open to the outside, into the hallway.

The Director of the Unit confirmed that the beds can be wheeled through the room, with potential to be placed against the door to the patient room, blocking entrance by staff.

3. Refer to Tag 0620 for information regarding the unsanitary conditions in the dietary kitchen.

4. Refer to Tag 0620 for information regarding the unsanitary conditions related to a dietary kitchen metal meal cart.

5. The job description for the Environmental Services Manager revealed: "...Continuously evaluates the effectiveness of department programs and services to assess the need for new, revised or expanded services...Manages Environmental Services (EVS) staff, ensuring quality and timeliness of duties...."

Tour was conducted on 11-12-14 at 9:45 A.M., at the receiving dock, in the presence of the Chief Quality Officer and the Facilities Director. Direct observation revealed a black substance on the floor near the door opening of the receiving dock. A metal cabinet in the receiving area had a black substance on the cabinet top.

During interview conducted on 11-12-14 at 9:50 A.M., the Chief Quality Officer acknowledged that the receiving dock floor and cabinet top were not clean.

6. Tour conducted on the ICU unit on 11-07-14 at 4:10 P.M., revealed a "Symphony" ice machine with significant scale build-up in the reservoir. Water with approximately 1/2 inches of a brown substance was in the reservoir of the coffee maker in an ICU galley. The Facilities Director termed the liquid as "scum."

Tour of the Telemetry unit on 11-07-14 at 4:20 P.M., revealed a coffee maker with brown liquid in the reservoir. A "Royal Grove" juicemaker revealed a reservoir containing orange juice solids combined with liquid.

During interview conducted on 11-07-14 at 4:20 P.M., the Facilities Director acknowledged that the respective ice machine, juice machine, and coffee makers needed to be cleaned.

7. Observation during a tour conducted on 11-12-14 at 9:55 A.M. revealed the baseboard in the elevator lobby contained a dark substance adhered to the surface. The baseboard area also contained multiple visible dust bunnies.

During interview conducted on 11-12-14 at 9:55 A.M., the Facilities Director acknowledged the area needed to be cleaned.

8. Tour of the radiology department was conducted on 11-12-14 at 10:45 A.M. Multiple darkened spots of unknown origin were visible on the security straps on the Cat Scan (CT) machine.

During interview conducted on 11-12-14 at 10:45 A.M., the Department Director acknowleded that the straps needed to be cleaned.

9. During the tour of the radiology department conducted on 11-12-14 at 10:43 A.M., the surveyors observed that the floor of the storage room contained liquid splashes of unknown origin, and a dark substance adhered to the floor.

The Facilities Director acknowledged, during interview conducted on 11-12-14 at 10:44 A.M., that the floor needed to be cleaned.

Based on direct observation, review of policy and procedure, review of Environmental Services Manager job description review, and interview, it was determined that the infection control officer failed to assure a system was in place for identifying infection control issues when multiple areas of the Hospital were observed to be unsanitary.

Findings include:

Refer to Tag A0620 regarding Dietary Services and an unsanitary environment.

Refer to Tag 0701 regarding an unsanitary environment in various aspects of the physical plant.

Based on review of hospital policy/procedure, medical record and interviews, it was determined that the hospital failed to have an effective discharge planning process that applies to all patients as evidenced by:

(A 806) failure to evaluate the patient's capacity for self-care prior to discharge;

(A 810) failure to conduct a timely discharge planning evaluation; and

(A 821) failure to reassess the patient's discharge plan when factors affected the patient's care needs and appropriateness of the discharge plan.

The cumulative effect of these systemic problems resulted in the hospital's failure to have a discharge planning process in effect that applies to all patients.

Based on review of hospital policy/procedure, medical records, and interviews, it was determined that the hospital failed to evaluate the patient's capacity for self-care at the time of his discharge and formulate a plan to meet his self-care deficits for 1 of 1 patient who was discharged to his apartment from the Senior Behavioral Health Unit (SBHU) with an active court order for inpatient evaluation due to persistent or acute disability (Pt # 1).

Findings include:

Review of hospital policy/procedure titled "SBHU Discharge Process/Plan" revealed: "...Patient discharged (sic) from the Senior Behavioral Health program occur as planned events at the conclusion of inpatient treatment...The Social Worker/Therapist will review the following with patient and family prior to discharge...Discharge/Aftercare plan and safety plan...In developing discharge aftercare plans, the following is assessed:...Family relationships...Physical and psychiatric needs...Financial needs...Housing needs and/or placement issues...Home environment safety...Transportation problems related to aftercare treatment...Potential for relapse...The discharge/aftercare plan should define the following:...A listing of all medications that the patient is to continue taking after discharge and patient's method for obtaining medications...All professionals who will follow-up with the patient, including medical follow-up to monitor medications...Specific efforts to educate the family regarding the patient's treatment interventions, medication and prognosis...Development of a crisis/safety plan...The discharge plan is communicated to the patient and family, as appropriate, and documented in the medical record. The discharge plan is signed by the patient and the patient is given a copy...."

Review of Pt # 1's medical record revealed:

On 4/25/14, at 1510, an ED physician documented: "...he has been walking since last night. ..was found unconscious on the side of...Boulevard and sent in for evaluation...he was found by the police and the medics brought him in...he states he is not taking any medications for weeks because he lost his job and has no money or insurance and so was going to leave Tucson...heat exposure, dehydration and now rhabdomyolysis and some renal insufficiency...has not had his insulin in a couple of weeks...."

MD # 23 documented, on 4/25/14, at 2019 in the History Physical: "...easily agitated...does demonstrate an explosive anger...has history of...diabetes, hypertension...Assessment:...Acute rhabdomyolysis...Acute renal failure...Acute dehydration...Agitation...History of diabetes...Social problems...."

Pt # 1 was discharged from the acute medical units of the hospital to the SBHU, on 4/30/14.

The Psychiatric Evaluation completed by MD # 26, on 4/30/14 at 1409, contained documentation that Pt # 1 was unable to manage his financial matters; that his sisters were finding it increasingly difficult to look after him, due to his noncompliance with his prescribed psychiatric medications, his anger, paranoia and his inability to attend to his medical regimen for his diabetes and hypertension. He is noncompliant regarding his dietary requirements and his insulin administration. He has Type 2 diabetes, but his sugars were uncontrolled and he now requires insulin.

A psychiatrist documented on 5/1/14, at 0730: "...Discharge Planning...:Compliance Risk with Medications/Aftercare with potential for relapse...Noncompliant with Medical Regimens-Potential hazard to the health or life of a patient who, due to concurrent psychiatric illness, is unable to comply with prescribed medical health regimen...Delay in discharge due to placement concerns...."

On 5/2/14, at 1328, Registered Occupational Therapist (OTR) # 35 documented, in the Occupational Therapy Assessment that Pt # 1's "Instrumental Activities of Daily Living" were "Unreliable/Questionable" with regard to Medication Management, Meal Preparation and Money Management and that he is unable to drive.

On 5/2/14, at 1713, MSW # 36 documented a telephone conversation with Pt # 1's sister that contained the sister's concerns that the Pt # 1 is no longer able to safely live independently. The sister had found Pt # 1's apartment with open cans of food sitting around the house and an overturned television.

On 5/7/14, after a meeting between Pt # 1, his sister and her husband, MSW # 36 documented the sister's concerns regarding the patient's inability to manage his medications and his diet and her concerns that he might be discharged. The MSW encouraged the sister to explore filing a petition for involuntary evaluation/treatment via Southern Arizona Mental health Corporation (SAMHC) and/or guardianship.

MD # 26, wrote order: DC (Discharge) to home, on 5/8/14, at 1045. Pt # 1's medical record contained prescriptions, dated 5/8/14, for 2 medications.

On 5/9/14, at 1128, MD # 26 documented in a Discharge Summary: "...ADDENDUM...It was decided by the patient that he did not want to leave yesterday that he would feel more comfortable giving himself a little bit more time on the Navane (antipsychotic) which was a new medication. His discharge is going to be going back to home while arrangements are being made for a new group home situation...."

The medical record did not contain a dictated Discharge Summary dated prior to the above "ADDENDUM." The Addendum did not contain documentation of plans to meet the patient's needs for medication management, management of his diabetes, insulin and diet or financial management.

On 5/9/14, at 1755, MSW # 36 documented: "...SAMHC Petition Evaluator met with this worker earlier in the day. Patient's sister initiated petition last night for patient. It has been marked as 'danger to self, danger to others, persistently and acutely disabled'...."

On 5/10/14, at 1046, MD # 26 documented in a Progress Note: "ADDENDUM...we are holding off waiting for the results of the petition...."

On 5/12/14, at 1030, MD # 26 documented: "...We will stop the Navane. He feels that right now he is doing much better. He wants to go home, although we just heard that his petition was invoked, and he will be going to another hospital...He will have to be transported to another facility...Though it is against our team's recommendation, he will be petitioned to another facility, and we will change his medication at this time...."

On 5/12/14, at 1507, MSW # 36 documented: "...T/C (Telephone Call) again to SAMHC...will serve patient with petition paperwork late today or tomorrow...they did not file the petition as emergent under 'DTS', or 'DTO' (Danger to Self or Danger to Others) because he is presently in a safe place (SBHU)...he will need to go to a petitioning facility...once he is served the papers...asked that we contact SAMHC if patient is discharged today...."

On 5/12/14, at 1525, MSW # 36 documented: "...T/C to patient's CODAC Case Manager...left...a message asking that she call me about patient re: discharge and his follow-up needs...."

On 5/13/14, at 1500, BSW # 34 documented: "... Pima County detective...delivered a Petition for evaluation to pt. The detective reported to pt that the petition states he is to be evaluated at (name of facility)...This writer contacted (name of facility) ER and notified them of pt's arrival. I also notified (MD # 26) that a dr-dr was necessary...prior to pts arrival...."

The medical record contained a form titled Physician Certification Statement of Medical Necessity for Ambulance Transportation, dated 5/13/14 and signed by the Director of the SBHU on 5/13/14.

On 5/14/14, at 0815, BSW # 34 documented: "...On 5/13/14, at 1600, Pt was ready for transport/D/C via...Fire Dept to (name of facility) however the Fire Dept would not accept the pt for transport because the pt's petition was 'not original'...D/C plans will continue to be arranged for pt on 5/14/14...."

On 5/14/14, at 1355, MD # 26 documented: "...Today we realized that there is no bed available and since he is on an non emergent patient (sic), this patient will prior (sic) be allowed to go home...we will notify the police that we have released him...and we will notify (SAMHC) as well, and he will have to work with (SAMHC) around the petition process...."

On 5/14/14, at 1430, MD # 26 wrote an order: "DC (Discharge) to home today."

On 5/14/14, at 1530, an RN documented: "...Pt ambulatory for discharge. Escorted out to taxi cab by unit tech. Pt discharged to home. Discharge instructions given to pt and gone over with pt. All questions answered. pt belongings returned...."

On 5/14/14, at 1535, BSW # 34 documented: "...Pt d/c from unit to taxi provided...to his apartment...."

The medical record did not contain documentation that Pt # 1's Case Manager was notified of his discharge or that his sister was notified. It did not contain documentation that SAMHC or law enforcement were notified of his discharge.

On 5/14/14, at 1555, BSW # 34 documented: "...This writer received a call from pt's sister...who reported that she had not 'heard from anyone/any agency like SAMHC'. This writer told sister that...had just been D/C from unit...."

MD # 26 was asked, during interview conducted on 11/18/14, at 1200 whether Pt # 1 had been evaluated for his capacity for self-care prior to his discharge on 5/14/14. She stated that she relies on the Registered Occupational Therapist (OTR # 35's) assessment of the patient.

On 11/18/14, at 1200, OTR # 35 referred to her Occupational Therapy Assessment of Pt # 1, completed on 5/2/14. She confirmed that she had assessed Pt # 1's ability for Medication Management, his ability for Meal Preparation and his ability for Money Management as "Unreliable/Questionable". Both MD # 26 and OTR # 35 confirmed that another assessment of Pt # 1's capacity for self-care was not completed prior to his discharge to his home to live independently.

Pt # 1's medical record did not contain documentation that SAMHC or the police had been notified of his discharge when he had an active Court Order for Inpatient Evaluation for Persistent or Acute Disability.

MD # 26 could not recall whether notifications had been made and was unable to provide documented evidence of notification of the police or SAMHC.

BSW # 34 confirmed during interview conducted on 11/18/14, at 1100, that Pt # 1's medical record did not contain documentation of notifications of Pt # 1's Case Manager or Pt # 1's sister of his discharge. She confirmed that the customary practice is to notify the patient's Case Manager. She confirmed that she had not done so, nor had she notified the patient's sister prior to Pt # 1's discharge.

Pt # 1's medical record did not contain a signed copy of his discharge instructions. Review of prescriptions dated 5/8/14, revealed that one prescription was for Navane 5 mg po at HS (by mouth at bedtime). MD # 36 had discontinued the Navane on 5/12/14. The medical record did not contain prescriptions for the discharge date 5/14/14. Review of a list of medications, titled Home Medications revealed that it was signed by Pt # 1 and an RN on 5/14/14, at 1512. The list did not contain instructions for the patient's next dose of medications and it contained Thiothixene (Navane), which was discontinued on 5/12/14.

RN # 37 confirmed, during interview conducted on 11/18/14, at 1440, that Pt # 1's medical record did not contain a copy of the discharge instructions. He also confirmed that the medical record did not contain copies of prescriptions that were current for Pt # 1's discharge date and that the list of Home Medications was incomplete.

Pt # 1 was court ordered for an inpatient evaluation due to persistent or acute disability. The order was not filed as emergent because he was residing in an inpatient unit at the time (SBHU). He was discharged from that unit to his apartment with no documentation of his ability to provide for his own self-care needs, including medication management and food preparation. He signed a list of medications which was incomplete and inaccurate. Neither his family, nor his case manager were notified at the time of his discharge and the hospital could provide no documented evidence that law enforcement or SAMHC were notified of his discharge home.

Based on record review, policy and procedure review, and interview, it was determined that personnel on the Senior Behavioral Health Unit (SBHU) failed to conduct a timely discharge planning evaluation in one (1) of one (1) SBHU patient records reviewed to ensure that discharge planning on the unit followed the Hospital's policy and procedure (Patient #6).

Findings include:

The SBHU Policy #18013 titled: "Discharge/Aftercare Planning Treatment Team" Senior Behavioral Health Unit revealed: "POLICY Discharge planning begins on admission... PROCEDURE 1.0 As a component of the assessment process, treatment recommendations are formulated. These recommendations include the various levels of care indicated to assure patients are treated at the appropriate levels of care. 2.0 The Discharge Plan should: 2.1 Prepare the patient and family for the transition to the next level of care...."

Record review revealed that Patient #6, an elderly female, was admitted to the SBHU with Suicidal Ideation, on 10-31-14.

Record review conducted on 11-05-14, revealed that although the patient was admitted on 10-31-14, the initial evaluation for discharge planning was not conducted until 11-02-14.

The Director of Case Management acknowledged, during interview conducted on 11-05-14, that by policy, the initial discharge evaluation should have been conducted within twenty-four (24) hours of admission.

Based on review of hospital policy/procedure, medical record and interviews, It was determined that the hospital discharged a patient prior to reassessment and modification of the patient's discharge plan when factors caused a change in discharge plan for 1 of 1 patient who was discharged home from the SBHU with documented deficits in capability for self-care and an active court order for inpatient evaluation due to persistent or acute disability (Pt # 1).

Review of hospital policy/procedure titled SBHU Discharge Process/Plan revealed: "...Patient discharged (sic) from the Senior Behavioral Health program occur as planned events at the conclusion of inpatient treatment...The Social Worker/Therapist will review the following with patient and family prior to discharge...Discharge/Aftercare plan and safety plan...In developing discharge aftercare plans, the following is assessed:...Family relationships...Physical and psychiatric needs...Financial needs...Housing needs and/or placement issues...Home environment safety...Transportation problems related to aftercare treatment...Potential for relapse...The discharge/aftercare plan should define the following:...A listing of all medications that the patient is to continue taking after discharge and patient's method for obtaining medications...All professionals who will follow-up with the patient, including medical follow-up to monitor medications...Specific efforts to educate the family regarding the patient's treatment interventions, medication and prognosis...Development of a crisis/safety plan...The discharge plan is communicated to the patient and family, as appropriate, and documented in the medical record. The discharge plan is signed by the
patient and the patient is given a copy...."

Cross reference Tag 0806 regarding Pt # 1 who was discharged to his apartment/condo without notification of his CODAC Case Manager, family or law enforcement. Pt # 1 was originally admitted to the acute medical portion of the hospital after being found unconscious at the side of the road when he attempted to walk from Tucson to Phoenix. He had not taken his medication, including insulin, for approximately 2 weeks. He was stabilized medically and admitted to the SBHU where he did quite well in the program. He was assessed by the Occupational Therapist (OTR) as having unreliable/questionable abilities for medication management, meal preparation and money management. He was unable to drive. His sister communicated to the MSW, that she and his other sister were unable to to provide the supervision that he required and that he was no longer able to live alone. He was being considered for a Group Home, but the Group Home facility required that his diabetes and medication be stabilized, which was not the case, according to his sister. His sister filed a petition for Court Ordered Evaluation on the grounds of Danger to Self, Danger to Others and Persistently or Acutely Disabled. The Petition was accepted and the patient was court ordered for an inpatient evaluation due to Persistent and Acute Disability. The court order did not include Danger to Self or Others since the patient was in a safe environment (the SBHU) at the time. After the Fire Department refused to transport Pt # 1 to the involuntary facility for evaluation, and a bed was not available at an involuntary facility, the SBHU psychiatrist and team discharged him back to his apartment/condo, without reassessment of his discharge plan, notification of family and without documented evidence of notification of the SAMHC or law enforcement for follow-up of the court ordered evaluation.