HospitalInspections.org

Based on review of credential files, policies/procedures, medical staff bylaws, rules and regulations, observation, and interviews, it was determined that the hospital failed to meet the Conditions of Participation for the Governing Body requiring that the medical staff have established criteria for the granting of privileges to an Allied Health Professional (AHP), that the AHP was functioning within her/his scope of practice, that contracted services are provided in a safe and effective manner, and the services are evaluated. The Governing Body therefore failed to assume responsibility for hospital operations, as determined by noncompliance with the following hospital regulations:

A-0046 the Governing Body approved the appointment of AHP #6 without meeting the requirements for privileges of a nurse practitioner;

A-0049 the Governing Body allowed the AHP to prescribe medications out of her/his scope of practice; and

A-0084 the Governing Body provided contracted services in an unsafe and ineffective manner and without evaluation of the services.

The cumulative effect of these systemic deficient practices resulted in the failure of the hospital to meet the requirements for the Condition of Participation for Governing Body.

Based on review of an allied health practitioner (AHP) credential file, medical staff bylaws, rules and regulations, and interview with staff, it was determined the governing authority failed to require the medical staff have criteria established for the granting of privileges for AHPs (Family Nurse Practitioner #6).

Findings include:

The current hospital Medical Staff Bylaws required: "...Allied Health Professionals (AHPs) are health care providers other than Providers who hold a license, certificate, or such other legal credentials as are required by this State, which authorizes the AHP to provide health care services...Clinical Privileges may be granted only upon formal request on forms provided by the Hospital with subsequent processing and approval...."

AHP #6's credential file contained a "Delineation of Psychiatric Clinical Privileges Form," dated 04/08/10 by the AHP. The contained items checked off by AHP #6 for the requested privileges revealed the following privileges:

General Adult: Admitting; Psychotherapy; Psychopharmacotherapy; Psychiatric Consultation; Medical History/Physical; Detoxification Treatment; and Geriatric Psychiatric Services.

Special Privileges: Suboxone/Subutex Treatment.

Scope of Privileges: Adolescents (13-18); Children (12 & under); Admitting; psychotherapy; Psychopharmacotherapy; Psychiatric Consultation; and Medical History/Physical.

The form listed the Privilege Requirements, which included: "...Board Eligible or Board Certified in General Psychiatry and/or Currently licensed to practice medicine by the State Medical Board of Arizona; DEA issued ID # to indicate qualifying physician...."

The form contained a signature from the Medical Executive Committee on 06/23/11, and a signature from the Board of Trustees on 06/24/11. The column titled "Granted/Approved" was left blank, thus indicating none of the privileges requested had been granted.

According to the hospital Medical Director on 06/29/11, the form used by the AHP, a Family Nurse Practitioner (FNP) was to be used for physicians only. The hospital used the incorrect form and he was not aware of this. He could not say what privileges the AHP had been granted according to the form in the credential file, nor could he indicate what requirements the AHP needed for privileges. The governing body did not require that the medical staff have criteria established for Allied Health Practitioners.

Based on review of Medical Staff Rules and Regulations, medical record review, and interviews, it was determined the governing body failed to ensure AHP #6 was functioning within their scope of practice.

Findings include:

Medical Staff Rules and Regulations requires: "...prescribing of medication is limited to Providers and Certified Nurse Practitioners...appropriate qualifications, licenses...."

Review of Patient (Pt) #6's medical record showed that AHP#6 phoned in telephone orders for admission orders on 04/28/11 at 1610 hours. The orders included the following medications:

"...Subutex 4 mg now and 2100, sublinguinal (SL), (for) detox...Subutex 4 mg three times daily, SL, detox on 04/29/11...Subutex 4 mg twice daily, SL, detox on 04/30...Subutex 2 mg twice daily, SL, detox on 05/01...Subutex 2 mg in am, SL, detox on 05/02...topamax 75 mg (milligrams) at bedtime, PO (orally)...."

Provider #7 confirmed during an interview on 06/28/11 at 1325 hours, that AHP #6 a Family Nurse Practitioner (FNP) could not order Subutex.

Based on review of hospital documents, policies/procedures, observations, and interviews, it was determined the governing body failed to ensure that:

1) the pharmacy's contracted services were provided in a safe and effective manner by allowing AHP/FNP #6 to write an inappropriate order for Subutex without having the required special privileges; and

2) the contracted services are evaluated.

Finding include:

The Board of Trustees Bylaws Section 6.5.2-Contracted Services requires: "...Board shall ensure that contracted services are performed safely...staff members are qualified and competent...."

Hospital policy/procedure #61 titled "Medication Ordering, Dispensing and Administration" requires: "pharmacy will verify...order...appropriateness...In the event...order...unclear...pharmacist...contact...to clarify order...."

1) Observation in the Pharmacy Department on 07/06/11, revealed a sign posted on the wall Only The Following Providers Can Order Subutex. Some provider names were crossed off the list indicating those practitioners who no longer possessed the special privileging required to order Subutex. AHP #6 was not listed on the posting.

The Director of Pharmacy stated during an interview on 07/06/11 at 1315 hours, s/he was unaware that AHP #6 could not write the order for Subutex. The Pharmacist also stated Provider #7 told her/him that he (Physician #7) was giving his OK for the AHP #6 to write the order for Subutex under the physician's special Drug Enforcement Agency (DEA) number.

Provider #7 confirmed during an interview on 06/28/11 at 1325 hours, that AHP/FNP #6 a Family Nurse Practitioner (FNP) could not order Subutex.

2) This surveyor was presented with a list of over 40 different contracted services such as pharmacy, nurses registry, bio-medical removal, pest control, etc.

The Director of Quality and Risk Management (brought in from a sister facility during the survey process) confirmed during an interview conducted on 07/07/11 at 1200 hours, the facility did not have documentation of the evaluation of any of the listed contracted services.

Based on review of medical records, policies/procedures, interviews, observation, and nationally accepted standards, it was determined the hospital failed to comply with the provisions of Patient Rights to protect and ensure the rights of all patients related to the grievance process, participation of the patient in his/her care plan, patient's informed decisions, and patient safety, as determined by non-compliance with the following regulations:

A-0118 Patient Rights - Grievance Process: The hospital failed to ensure 1 of 1 patient's (Patient # 4) grievance was investigated and resolved within a reasonable time frame;

A-0130 Patient Rights - Participation in plan of care: The hospital failed to ensure 1 of 1 patients (Patient #4) participated in the development and implementation of his/her care;

A-0131 Patient Rights-Informed Consent: The hospital failed to ensure 7 of 11 patients (Patient's # 7, 12,13,14,18,and 19) had completed Informed Consent for psychotropic medications; and

A-0144 Patient Rights-Privacy and Safety: The hospital failed to ensure the patients' right to receive care in a safe setting.

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

Based on review of hospital documents, policies and procedures, and interview with staff, it was determined the hospital failed to require the hospital followed their policy and procedure for a patient's complaint (Pt #4).

Findings include:

The hospital policy titled Patient and Family Grievances/The Role of the Patient Advocate required: "...The Patient Advocate must provide the patient/family with a verbal or written progress report within 7 days of receipt of the complaint and maintain ongoing communication until the point of resolution (not to exceed 30 days). The initial contact must include: Statement acknowledging receipt of the complaint/grievance...Specific time frame when the patient/legal representative can expect conclusion/resolution to their expressed grievance...In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion...."

The hospital provided the grievance log for 2011, which indicated the patient (#4) submitted a complaint/grievance on 05/02/11.

The Chief Nursing Officer (CNO) confirmed during an interview conducted on 07/06/11, that the Medical Director received the complaint and went to the unit to talk with the patient. The patient had already been discharged and left the hospital. The CNO verified the patient was supposed to be sent a letter however, the Medical Director did not notify the patient advocate that he was unable to talk with the patient. The patient was not sent a letter and the complaint was not investigated.

Based on review of a medical record, policies and procedures, and interview with staff, it was determined the hospital failed to ensure the patient's participation in the development and implementation of his/her care plan (Pt #4).

Findings include:

The hospital's policy titled Interdisciplinary Treatment Plan required: "...Each patient admitted to the hospital shall have a written, individualized treatment plan...Within 72 hours of admission, members of the treatment team shall further develop the Treatment Plan...The team will consist of the physician, the RN, the social services clinician, and the representatives from other clinical disciplines, as appropriate...The patient signs the Treatment Plan after review with a member of the treatment team...."

Review of Pt #4's medical record revealed the patient was admitted around noon on 04/28/11, for chemical detoxification and bipolar disorder.

An Interdisciplinary Inpatient Treatment Plan was established on 04/29/11. The team members who participated in the development of the treatment plan included a Registered Nurse (RN), Master of Social Work (MSW), and the Recreation Therapist. The Family Nurse Practitioner signed the form indicating participation on 05/16/11 (14 days after the patient was released and discharged home). The patient did not sign the Interdisciplinary Inpatient Treatment Plan.

Based on review of policies/procedures, medical records, and interviews, it was determined the hospital failed to ensure the patient's right to make informed decisions regarding his or her care as evidenced by:

1. failure to require that the medical providers complete the Physician Informed Consent for Medication form upon the patients initial admission interview in 6 of 11 patients (Pt #'s 7, 12, 13, 14, 18, and 19); and

2. failure to require that a patient who was maintained on Methadone be informed that he would not be able to receive Methadone if admitted for psychiatric treatment and the alternatives available (Pt #7).

Findings include:

1. Review of hospital policy # 300.135 titled "Informed Consent for Psychotropic Medication" required: "...When the provider sees the patient for the initial admission interview, he/she will complete the Informed Consent for Psychotropic Medication Treatment with the patient...."

The form listed 5 columns with the following headings: Medication & dosage range, Target symptoms to be addressed, How discussed (in-person, telephone, tele-medicine, previously), "Person/Guardian" initials & date, Behavioral health medical practitioner initials & date. At the bottom of the form are two separate lines for both "person/guardian" & medical practitioner to print name, sign and date the form.

Review of Patient #7, 12, 13, and 14's medical records revealed physician orders for psychotropic medications. None of the records contained a completed Informed Consent for Psychotropic Medication form.

Review of Patient # 18 and 19's medical record revealed the Informed Consent for Psychotropic Medication form did not contain the required "dosage range" for the medications listed. The forms were not initiated at the time of the initial admission interview as required by policy.

The Director of Nursing confirmed the above findings for the Informed Medication Consent forms on 07/07/11 at 1330 hours.

2. Review of hospital policy/procedure titled Scope of Inpatient Program revealed: "...For admission and readmission patients must meet the diagnostic criteria of the DSM-IV TR and one or more utilization criteria for hospitalization as follows: A. Behavior which is life threatening, destructive or disabling to self or others...1. Active or potential suicidal, assaultive or homicidal threats, plans or attempts in the past 24 hours...2. Self-mutilating behavior in the past 24 hours...Medical detoxification from Alcohol, Opiates, or Benzodiazepines that can not be managed in a lesser (sic) restrictive setting...A Provider has reviewed and agrees with the clinical assessment and gives an admission order. The patient or legal guardian agrees to voluntary admission in writing...."

Review of the patient's medical record revealed:

Pt #7 was admitted on 4/28/11 via the Intake and Referral Dept. as a "walk in." The patient was "brought in" by his parents. The patient completed the Patient Registration and Medical Screening form, indicating that he was experiencing "extreme depression and suicidal thoughts." He also provided written information to the Intake RN, at the time of his assessment, that he was on Methadone maintenance and had his last dose on the day of his admission to the hospital.

RN #37 (the Intake RN) stated during interview conducted on 6/27/11, that the patient informed her that he was on Methadone maintenance but that his Methadone was a secondary issue to her. She stated that her primary concern was his safety, since the patient had told her that he had suicidal thoughts and had considered running out in traffic or crashing his car. She did not recall specifically informing the patient that he would be unable to continue on the Methadone in the facility, or informing him of other facilities where he could receive Methadone. She confirmed that she did not document discussion of alternative hospitals where he could remain on Methadone. She stated that she did not confirm his dosage and thought that the inpatient staff would address that later. She stated that she is aware that the facility is a "no narcotic" hospital.

Employee #38, the PCM, stated during interview conducted on 6/28/11, that she didn't know what the patient wanted to do with his Methadone and that she didn't discuss it with him. She stated that her understanding is that patients "can't be off it." She stated that she was aware that there was an issue with the patient's Methadone and that someone discontinued it over a weekend. She stated that after his hospitalization, he would be able to follow-up with outpt CD Tx (Chemical Dependence Treatment) and remain on Methadone, but not at this facility.

During interview conducted on 6/27/11, the Director of Nursing (DON) stated that the hospital is not licensed for Methadone. She stated that if a patient wants to continue taking Methadone, the patient would need to be transferred, probably to (name of hospital).

Physician #11 could not recall during interview conducted on 6/28/11, whether the Intake RN informed Physician #11 that the patient was on Methadone maintenance when the physician accepted the patient for admission. Physician #11 could not recall whether he informed the patient at the time of the Psychiatric Evaluation that he could not continue Methadone at the hospital. Physician #11 ordered Methadone for the patient on 4/29/11: "...Methadone 40 mg daily...1st dose now...Varify (sic) dose from pts methadone clinic prior to giving pt the dose...."

On 4/29/11, at 1520, physician #7 wrote an order "...D/C (Discontinue) Methadone...."

Physician #7 wrote a progress note on 4/29/11, at 1400: "...CD Consult...on 60 mg MTD (Methadone) from (name of clinic)...got a dose today here...heroin addiction hx...5 yr hx of opiate dep & abuse...not wanting to come off methadone...D/W (Discussed with) (Medical Director)...Pt on MTD for Opiate Dependency from MTD clinic...We are not licensed for MTD...will have to D/C order...Pt not wanting to come off MTD...."

On 4/30/11 at 1100, physician #11 documented in the Physician Daily Progress Note: "...Symptom...Suicidal...Present...Yes...Pt angry that his Methadone was stopped. pt feels his mood is very unstable. Pt say (sic) 'I am stressing out over everything'...I feel his mood is very unstable...he is feeling very upset...."

On 4/30/11 at 1330, a nurse documented: "...Client stated did not sleep well. Stated wanted to continue on Methodone (sic), stated anxiety 9/10, depression 10/10. Client got into a fight (with) a peer...."

On 4/30/11 at 1000, an RN recorded physician #11's telephone order: "...Ativan 1 mg po every 4 hrs daily prn (as needed) anxiety...Percocet 5/325 mg po every 6 hrs prn daily...pain...."

On 4/30/11, at 1130, physician #11 wrote an order: "Skelaxin 800 mg po q (every) 4 (hrs) prn muscle cramps...."

On 5/1/11, at 1130, physician #11 documented on the Physician Daily Progress Note: "...Symptom...Hallucinations...Present...Yes...No...'night terrors'?...Delusions...Yes...paranoia...Suicidal...Yes...SI...Pt reports feeling 'dope sick'...Pt is having cramp (sic) & sweats. Pt is eating fair...Pt feels his anxiety is very high. Pt is still reporting depression...."

On 5/1/11, at 2350, a nurse documented: "...pains from withdrawing...'they cut my methadone off'...'I was used to 60 mg'...."

On 5/2/11, at 0900, physician #11 documented on the Physician Daily Progress Note: "...Symptom ...Delusions...yes...Paranoia...Suicidal...Yes...SI...pt missed his breakfast. pt says he was having major WD (Withdrawal) from opiates...pt was given Subutex which helped him settle down...Bipolar depression, opiate dependence...."

Physician #11 stated during interview conducted on 6/28/11, that he had started the patient on Methadone after admission, but when it was not possible for the patient to remain on the Methadone, that he informed the patient that he would begin to go through withdrawal. He ordered Percocet to prevent withdrawal and then later, when the patient agreed to take Subutex, he ordered Subutex to prevent withdrawal. Physician #11 stated that the patient did not want to detox from Methadone. He did not remember if he discussed alternative hospitals where the patient could continue Methadone.

Physician #7 stated during interview conducted on 6/28/11, that he was asked to do a CD consultation for the patient. He stated that the patient did not want to "get off" Methadone and he did not want Subutex. Physician #7 stated that the patient told him that if he couldn't have Methadone, he would leave the hospital. Physician #7 was not aware if the patient had been informed of alternative hospitals where the patient could continue Methadone.

On 6/27/11, the Clinical Director of the Methadone Clinic where the patient received Methadone stated, via telephone, the name of a local hospital where clients who are on Methadone maintenance can continue to receive Methadone while hospitalized for psychiatric treatment.

Pt #7 attempted suicide by hanging on 5/3/11.

Based on review of nationally accepted standards, policies/procedures, medical record, observation, and interview, it was determined that the hospital failed to provide care in a safe setting for patients as evidenced by:

1. failure to provide a patient care environment that is free of fixtures, surfaces, and equipment conducive to patient injury, self-injury, or suicide for all patients admitted to the facility;

2. failure to require policies/procedures or written guidelines for staff to utilize in order to provide reliability between staff completing suicide risk assessments and failure to require consistent implementation of the Clinical Risk Assessment;

3. failure to require one written policy/procedure for patient Safety Level Guidelines which is readily available to all staff; and

4. failure to require that the Safety Level Guidelines policy/procedure is implemented by all staff.

Findings include:

1. The American Institute of Architects' 2006 Guidelines for Design and Construction of Health Care Facilities, pp. 60 & 61 revealed: "...3.8 Psychiatric Nursing Unit...A3.8.1.4 A safe environment is critical...Patients of inpatient psychiatric treatment facilities are considered at high risk for suicide; the environment should avoid physical hazards while maintaining a therapeutic environment...Staff awareness of their environment, latent risks of that environment, and the behavior risks and needs of the patient served in the environment are absolute necessities...."

On 7/7/11, the bathroom located in the hallway near the facility cafeteria was observed to contain several safety hazards for a patient who may be self-injurious and/or suicidal. These hazards included: two toilets with exposed plumbing; 2 toilet stall doors with coat hooks; disability grab bars on the side of one toilet stall; two sinks with exposed plumbing; exposed hinges inside the door; and a large mirror above the two sinks. All of these items/risks provide the surface for an individual to harm himself/herself by hanging.

Review of policy and procedure titled "Clinical Services Safety Levels" requires: "...Level III-Close observation...staff...maintain visual and verbal contact sufficient to monitor patient's condition...allowed off...secure unit under direct staff supervision."

On 7/7/11 at 0830 hours, a patient was observed, unsupervised in the bathroom.

On 7/7/11 at 1210 hours, a second patient was observed, unsupervised, in the same bathroom.

The Chief Nursing Officer confirmed in an interview on 7/7/11 at 1200 hours, that the bathroom has not been modified for patient safety because patients must always be directly supervised when in the bathroom. She stated that staff members are to accompany patients in the bathroom. She confirmed that if patients are in the bathroom unsupervised, that the staff is not implementing the policy correctly.

2. Review of the hospital policy/procedure titled Admission Protocol revealed: "...A Comprehensive Intake Assessment...is completed by Intake on all patients who present to (hospital name)...On completion of the full assessment the case will be reviewed with a provider to determine if the patient meets criteria for admission...."

Employee #38 stated during interview conducted on 6/28/11, that the Comprehensive Intake Assessment is no longer utilized and that the policy/procedure has not been updated. She confirmed that the facility does not have a policy/procedure to accompany the Comprehensive Assessment Tool. She explained that the Patient Care Manager (PCM) completes the current Comprehensive Assessment Tool within 48 hours of the patient admission.

Review of Pt #7's medical record revealed:

Employee #38 completed a Comprehensive Assessment Tool on 4/29/11, which included a section titled Initial Risk Assessment. Review of the Initial Risk Assessment revealed: "...Recent Suicide Attempt...Denies...Was attempt lethal?...Denies...#Of Previous Attempts: 'A lot'...Date of Most Recent Attempt: 'Couple months ago'...Past Methods used: OD (Overdose) Hang...Risk For Harm To Self...Low...."

Employee #38 stated during interview conducted on 6/28/11, that she believed a "recent attempt" means within the past 30 days. She stated that she would consider a patient who had shot or stabbed themselves as a high risk.

Employee #39 stated during interview conducted on 6/28/11, that she also completes Comprehensive Assessment Tools. She stated that she believed a "recent attempt" means within 6 months. She confirmed that the facility has no standardized definition of terms or current policy/procedure and/or guidelines for completion of the Comprehensive Assessment Tool.

The DON confirmed during interview conducted on 6/28/11, that the facility does not have a standardized method that nurses utilize to assess patients for suicide risk. She stated that nurses interact with patients, ask questions, use their relationship and observations of the patient in the milieu to assess risk for suicide.

Employee #14 stated during interview conducted on 6/30/11, that a form titled Clinical Risk Assessment is completed by Social Work staff at the time of patient admission and discharge. The facility implemented use of the form in January, 2011 with no accompanying policy/procedure or guidelines for completion.

Employee #38 confirmed that the only risk assessment contained in Pt #7's medical record was within the Comprehensive Assessment Tool. The medical record did not contain a Clinical Risk Assessment.

3. Direct observation revealed that the policy/procedure manual located in Unit 100/300 nurses' station on 6/27/11, did not contain a policy/procedure for suicide precautions or patient safety levels. At 1050, the Clinical Educator provided the policy/procedure titled Safety Levels (effective August 1, 2006; reviewed July 7, 2008). At 1119, the Assistant Director of Nursing (ADON) provided the policy/procedure titled Safety Level Guidelines (effective August 1, 2006; reviewed January 16, 2009; revised January 16, 2009). The ADON stated that the latter policy/procedure was the current policy/procedure utilized by the facility for patient safety levels. The two policies differed in terms of content.

Direct observation revealed that the policy/procedure manual located in the Unit 400 nurses' station on 7/6/11, did not contain a policy/procedure for patient Safety Level Guidelines. The ADON provided the policy/procedure titled Safety Precautions and Levels (effective August 1, 2006; reviewed January 16, 2009; revised January 16, 2009). This policy differed in content from the other two policies related to patient safety levels.

4. Review of the policy/procedure titled Safety Level Guidelines (which the ADON indicated as current on 6/27/11) revealed: "...A Safety Level is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. Safety level procedures can be initiated by provider or nursing staff when a patient may be considered to be an increased risk for harm to self...Clinical staff should assess the patient's risk factors and initiate the following procedures to help protect the patient and others...An order for the appropriate safety level should be documented in the provider's order section of the medical record, and the charge nurse or designee should initiate the Safety Level Record. When safety levels are initiated by nursing order, the nurse should contact the provider as soon as possible and notify him/her of the need for the safety level. Initiation of the safety level should be documented in the provider orders...A licensed nurse or designee should ensure that all patient orders for safety levels are recorded and posted per facility policies and procedures...Reassessment by a provider should be completed and documented at least every 24 hours with clinical justification for renewal, modification, or discontinuation of orders for safety levels...The registered nurse should address the status of the patient on safety levels in the nursing reassessment documented every 24 hours...Level II-Continuous Observation on a Group Basis...patient is restricted to a secure, locked unit...The patient should be within visual range of the assigned staff at all times...During times for personal hygiene, toileting and other self care needs, the staff should be in visual and hearing range of the bathroom door...Medical Record documentation...A Safety Record, which reflects the patient's location and observed behaviors every 15 minutes...Level III-Observation on an every 15 minute, or greater, frequency...Staff should maintain visual and verbal contact sufficient to monitor the patient's condition on a frequency level as ordered by the provider (every 15 minutes, for example)...patient allowed off the secure unit under direct staff supervision...A Safety Record, which reflects the patient's location and observed behaviors, completed on the frequency level that has been ordered...The treatment team shares a responsibility to communicate any change in a patient's mental status and/or ability to effectively function within the patient community. Deterioration in a patient's condition should be reported immediately to the unit charge nurse...."

RN #13 and RN #40 stated during an interview conducted on 6/28/11, that patients who are on Safety Level II are checked every 15 minutes. Level II does not require continuous observation. They stated that all patients are admitted on Level II and that the physician usually changes their Level to III after he/she sees the patient. They stated that patients who require continuous observation can be placed on "Line of Sight" status. The Clinical Educator stated, during the interview, that Line of Sight is a nursing intervention. RN #13 and RN #40 were assigned to patients in Unit 100 on 6/28/11.

RN #41 was assigned to patients in Unit 300 on 6/28/11. She stated during interview conducted on 6/28/11, that patients are admitted on Level II and restricted to the unit. After the patient sees the physician, the physician usually changes the patient's Level to III. If the patient is not appropriate to leave the unit for meals and groups, the physician can maintain the patient on level II. She stated that a patient who requires continuous observation can be placed on "Line of Sight" status. Both of the Behavioral Health Technicians (BHT's) on the unit and the RN share the responsibility for observing patients on "Line of Sight."

BHT #42 was assigned to patients in Unit 300 on 6/28/11. She stated during interview conducted on 6/28/11, that all patients are checked every 15 minutes unless they are on "Line of Sight" or Level I. Level II patients are restricted to the Unit and Level III patients may leave the unit with supervision.

RN #21 was assigned to Unit 400 (the adolescent unit) on 6/28/11. She stated that patients on the "Red Level" are restricted to the unit. Patients on the "Yellow Level" can leave the unit with supervision. Patients on "Line of Sight" have a staff member with them at all times and can leave the unit.

The Clinical Educator confirmed during interview conducted on 6/29/11, that the policy/procedure does not contain any information regarding "Line of Sight" or "Red Level" or "Yellow Level," and that the policy/procedure for Safety Level II is not implemented on the nursing units according to the written policy.

Review of Pt #7's medical record revealed:

An RN wrote physician telephone orders on 4/29/11 at 0030: "...Precautions: Level 2...."

At 0700 on 4/29/11, an RN documented: "...will continue to monitor pt every 15 minutes...."

At 1530, on 4/29/11, an RN documented: "...monitor every 15 minutes for safety...."

At 0600, on 4/30/11, an RN documented: "...Safety checks completed every 15 minutes...."

At 1130 on 4/30/11, a physician wrote orders which included: "...Level III...."

On 4/30/11 at 1100, a physician documented in the Physician Daily Progress Note:"...Symptom...Suicidal...Present...Yes...Pt angry that his Methadone was stopped. pt feels his mood is very unstable. Pt say (sic) 'I am stressing out over everything'...I feel his mood is very unstable...he is feeling very upset...."

On 4/30/11 at 1330, a nurse documented: "...Client stated did not sleep well. Stated wanted to continue on Methodone (sic), stated anxiety 9/10, depression 10/10. Client got into a fight (with) a peer...."

The physician did not document clinical justification for modification of the patient's safety level from level II to III on 4/30/11, as required by policy.

Physician #11 stated during interview conducted on 6/28/11, that he changed the patient's Safety Level from II to III to enable the patient to leave the unit for meals. Physician #11 stated that the patient did have suicidal thoughts but that frequently, allowing a patient to leave the unit with supervision reduces the patient's agitation and the patient may feel better. Physician #11 confirmed that he did not document clinical justification for modification of the patient's Safety Level II and indicated that he was not aware of the requirement per policy.

In addition, the space designated on the Daily Nursing Assessment form for the 4/30/11 evening shift RN to document Suicidal/Self Harm assessment was blank.

At 1440 on 5/1/11, RN #44 documented: "...pt reports that he is +SI 'comes and goes.'...Pt contracts for safety with no observed reported self harming bx (behavior)...." RN #43 documented in the space designated for assessment of "Suicidal/Self/Harm": "No."

At 1000 on 5/3/11, RN #44 documented: "...Patient reports not sleeping well...Reports having thoughts of SI with no plan due to not knowing what to do after D/C...." RN #44 placed a check mark in the space designated for Suicidal/Self Harm "Thoughts" on the Daily Nursing Assessment form.

Review of the Daily Nursing Assessment forms from Pt #7's date of admission until the date of his suicide attempt revealed that no other Daily Nursing Assessment forms contained a check mark in the "Thoughts" space.

Review of the facility policy/procedure titled Assessment of Depression/Suicide Potential revealed: "...Communication of a change in patient status shall be made to the supervisor, attending provider and social services. Documentation of the communication to the provider and social services shall be entered in the progress notes...."

RN #44 stated during interview conducted on 6/29/11, that when the patient stated that he was having suicidal thoughts on 5/3/11, that he didn't have a plan and he did express some thoughts regarding the future. She didn't believe he was an imminent risk of self harm. She didn't assess him as any different from other interactions. She confirmed that the patient remained on Safety Level III which is the level for routine patient observation. The medical record did not contain documentation of communication of change in patient status.

The Clinical Educator stated during interview conducted on 6/29/11, that the RN's are trained to ask patients directly if they are having thoughts of hurting themselves. She stated that she doesn't train the nurses to use "contract for safety." "Contract for safety" is a nurse's style of charting. She stated that if the patient expresses thoughts of suicide or self/harm that the nurse would put interventions in place. She stated that the RN would notify the entire team that a patient is suicidal and the RN might initiate nursing "Line of Sight." She stated that an RN can initiate "Line of Sight" and remove "Line of Sight," and that the RN should notify the physician. She confirmed that the policy/procedure does not contain any information regarding "Line of Sight" and that the policy/procedure for Safety Level II is not implemented on the nursing units according to the written policy.

Review of a hospital document revealed: "...Housekeeper...walked into patient room slightly before 1100 hrs, and opened the bathroom door to clean when he found patient...hanging by his neck...shouting to BHT (#45)...who was in the hallway getting ready to perform patient observation rounds...."

Review of the patient's Patient Observation Record 5/3/11, revealed that an entry "R 12" was recorded for 1100, indicating that the patient was in his room, lying/sitting. This entry was initialed by BHT #45. A line was drawn through the entry and the word "error" written.

On 6/29/11, the DON confirmed that an entry was recorded in the 1100 space, with error written over the entry.

On 6/29/11, direct observation of patient care revealed:

Pt # 32 was hospitalized in Unit 600. He was on Safety Level III. BHT #10 was assigned to record on Pt #32's Patient Observation Record. At 1630, BHT #10 had recorded entries in spaces designated for 1645 thru 1745 (5 spaces).

BHT #46 was assigned to provide "Line of Sight" observation for Pt #33. BHT #46 and Pt #33 were seated in the unit Dayroom. At 1640, BHT #46 had recorded entries in spaces designated for 1645, and 1700. BHT #46 had also recorded entries on 3 other patients' Observation Records: Pt #34's record contained entries for 1645 and 1700, indicating that Pt #34 was in Dietary eating; Pt #35's record contained entries for 1645 and 1700, indicating that Pt #35 was in Dietary eating; Pt #36's record contained entries for 1645, indicating that Pt #36 was in his room awake. Pt #34 was on Safety Level III; Pt #35 was on Safety Level III: Pt #36 was on Safety Level II.

Pt #37 was in Unit 600 and was on Safety Level III. On 6/29/11, at 1630, his Patient Observation Record was blank from 1445 through 1515 (3 spaces).

On 6/29/11, the Clinical Educator confirmed that the Observation Records of Pts #32, #33, #34, #35, and #36 contained prerecorded entries (charting at times which had not occurred yet). She confirmed that Pt #37's Observation Record contained blank spaces. She confirmed that documentation on these Pt's Observation Records did not follow policy.

Based on review of hospital policies/procedures, medical records, hospital documents, and interviews, it was determined the hospital failed to implement and maintain an effective, ongoing, hospital-wide data-driven quality assessment and performance improvement program as evidenced by:

(A267) failing to investigate and analyze a Sentinel event for 1 of 1 patient (Pt #3) as required by policy and failing to monitor quality in key processes related to patient care delivered by medical staff; and

(A288) failing to identify numerous patient care issues in the analysis of an adverse patient event and implement preventive actions.

The cumulative effect of these systemic problems resulted in the failure of the hospital to meet the requirements for the Condition of Participation in Quality Assessment and Performance Improvement Program.

Based on review of hospital policies/procedures, medical records, documentation, and interviews, it was determined that the hospital's quality program failed to include a means to identify, measure, analyze and evaluate quality indicators, that included sentinel events, that assess processes of care, and hospital services and operations as evidenced by:

1. failure to follow policy and procedure for investigation and analysis of information for Sentinel events through a Root Cause Analysis for Patient #3 who committed suicide within 72 hours of being discharged from the facility; and

2. failure to monitor quality in key processes related to patient care delivered by medical staff.

Findings include:

Review of the hospital policy/procedure titled Sentinel Event revealed: "...To focus the attention of the organization on understanding the underlying causes of a sentinel event and on making changes in systems and processes to reduce the probability of such an event in the future, with the goal of improving patient care and safety...The hospital will provide an effective and immediate mechanism for immediate investigation, analysis of information and response to Sentinel events through a Root Cause Analysis (RCA)...Definition...A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk that carries a significant chance of a serious adverse outcome...Sentinel Events may include, but is (sic) not limited to, the following:...Suicide of any patient within 72 hours of discharge...."

1. Patient #3 was admitted to facility on 5/25/11 at 0915 from another medical facility after overdosing on "...50 Oxycodone, 30 Soma and some Valium..." with a diagnosis of depressive disorder, recent overdose, suicidal ideations, and drug use, primarily opiates. Patient had a history of bipolar disorder, polysubstance abuse, and severe depression. Patient reported that she had numerous prior suicide attempts. Patient was discharged on 05/30/11 at 1130. Police reported patient expired on Aunt's couch the morning of 06/02/11.

MD #2's interview on 06/30/11 at 1444 revealed the following:

Police Department called on 06/02/11 in the morning for the risk manager. Police Sergeant left message that patient (#3) was found expired on her Aunt's couch the morning of 06/02/11. The Sergeant wanted information from the Doctors on the patient's treatment and when patient was discharged. The risk manager, MD #1 and MD #2 returned police Sergeant's telephone call. Prescriptions for pain medications were filled on 05/31/11. Police were given information about patient's diagnosis, patient status and medications prescribed at discharge. Police Sergeant telephoned an hour later and left message for MD #2 that during the investigation more pain medications and bottle were found under the patient and her pillow. MD #2 took this information to the risk manager and was told by the risk manager that the facility does not have to do a root cause analysis.

Risk Manager e-mail written 06/02/11 at 1409 concerning patient # 3, revealed the following: "...a former patient (patient # 3) discharged on 05/30/11 at 1130 passed away on the morning of 06/02/11...which is within the 72 hour window of being discharge from a licensed facility...only the Medical Examiner has not yet ruled on the case as a suicide...The police detective is calling the case an overdose, and Dr (#1) and Dr ( # 2) seem to concur as they feel that patient was not suicidal on discharge...and that she accidentally overdosed...The police clarified that Dr (#1) was her psychiatrist during her stay at Aurora, and that she filled her prescriptions and nothing was out of the ordinary...that she had been compliant with her psych meds...The police shared that (patient # 3) admitted to having morphine that was not prescribed for her and that she took this morphine and OD' d (overdosed) as a result...The medical examiner is following up on her death, but stated that it will take approximately 3 months to get an actual cause of death...."

The DON and the Medical Director confirmed there was no Root Cause Analysis completed on this patient on 06/30/11.

2. Review of hospital document titled 2011 Performance Improvement Plan revealed: "...The Performance Improvement Plan is developed under direction of the Quality Council. Its purpose is to establish mechanisms to objectively monitor quality in key processes throughout the organization. Data is systematically gathered on identified processes and outcomes related to patient care and organizational functions. Data is gathered from a variety of internal and external sources such as medical record review; patient satisfaction surveys and recommendations/findings from external sources...."

The document contained a column titled Performance Indicators; a column titled Goal, Source, and Measurement; a column titled Review Frequency; and a column titled Reporting Department. The document was divided in sections: "...Human Resources...Nursing...Medical Staff...Intake...Social Services...Outpatient Services...Adjunctive Therapy...Utilization Review...Medical Records...Business Development...quality Improvement...Risk Management...Plant Operations...Dietary...."

The section titled Medical Staff contained Performance Indicators: "...AIMS Testing...Informed Consent...History & Physical Evaluations...AMA Discharges...." The Review Frequency column contained "Monthly" for each Performance Indicator.

The hospital was unable to provide monthly reports for the Medical Staff Performance Indicators.

The Director Quality and Risk Management Tempe Facility confirmed during interview conducted 7/7/11, that the Review Frequency for Medical Staff reports regarding Performance Indicators was monthly and that the Quality Council had received no monthly reports for 2011 from Medical Staff regarding the Medical Staff Performance Indicators.

Based on review of policy/procedure, medical record and hospital documents, and interview, it was determined that the hospital failed to analyze an adverse patient event and implement preventive actions and mechanisms that included feedback and learning throughout the hospital.

Findings include:

Cross Reference Tag # A0267 for policy/procedure titled Sentinel Event.

Review of the hospital's documentation of the Root Cause Analysis (RCA) conducted to investigate Pt #7's suicide attempt revealed that the process did not identify the following patient care issues:

1. Cross Reference Tag #0131, #2.

The medical record did not contain documentation that the patient was informed at the time that he consented to psychiatric inpatient treatment, that he would be unable to continue Methadone maintenance at the facility. Review of the medical record and interviews revealed that the patient did not want to discontinue Methadone and did not want to detox. However, his Methadone was discontinued and he developed signs and symptoms of withdrawal which where managed with Percocet, Skelaxin and other comfort measures initially, and then Subutex was started. The patient had initially refused Subutex. Neither interviews nor documentation provided definitive evidence that the patient was informed that he could receive inpatient psychiatric treatment and continue his Methadone at another local facility.

2. Cross Reference Tag #0131, #1.

The medical record did not contain the required documentation of Pt #7's informed consent for psychotropic medication, including the Subutex.

3. Cross Reference Tag #0144, #1.

The Risk Assessment tools that are utilized by Social Service personnel have no current policy/procedure or guidelines to provide reliability between interviewers. The suicide assessment that the RN completes each shift varies regarding criteria, documentation, and follow-up.

4. Cross Reference Tag #0144, #2 and #3.

The facility has 3 versions of Safety Level Guidelines/Safety Precautions and Levels/Safety Levels which are available upon request. The version which was identified as current was not utilized in practice by nursing personnel or medical staff.

5. Cross Reference Tag #0144, #3.

The patient's Observation Record contained an entry, recorded by a BHT, that the patient was sitting/lying in his room at 1100 on 5/3/11. This entry was crossed out, with the word "error" written over it. The RCA contained documentation that the patient was discovered hanging in his bathroom shortly before 1100. The RCA did not contain any mention of the 1100 entry on the patient's Observation Record.

6. Cross Reference Tag #0395, #1.

The documentation of the discovery of the patient, assessment of his status, and interventions provided by nursing personnel was incomplete. The medical record was missing the Code Blue Flow Sheet until 6/29/11. The Code Blue Flow Sheet was incomplete.

The Director Quality and Risk Management-Tempe Facility acknowledged on 7/7/11, that the above issues would be considered Quality Management issues.

Based on review of a medical record, policies, procedures, and interview with staff, it was determined the hospital failed to ensure the organized medical staff operated under their bylaws evidenced by:

(A-0353) The medical staff failed to enforce its bylaws for completing an initial psychiatric/chemical dependency evaluation within 24 hours of admission; failing to ensure Pt #4 was seen within 24 hours of admission by the attending provider/AHP; failing to require telephone orders were authenticated within 48 hours for Pt #4; and failing to ensure AHP (FNP) wrote orders within the scope of their license.

The cumulative effect of these deficient practices resulted in the hospital's failure to meet the requirements of the Condition of Participation for the Medical Staff.

Based on review of a medical record, policies, procedures, and interview with staff, it was determined the hospital failed to ensure the organized medical staff enforced bylaws, as evidenced by failing to:

1. complete an initial psychiatric/chemical dependency evaluation within 24 hours of admission (Pt #4);

2. ensure Pt #4 was seen within 24 hours of admission by the attending provider and/or C.N.P;

3. require telephone orders were authenticated within 48 hours (Pt #4); and

4. ensure AHP #6 wrote orders within the scope of her license.

Findings include:

Patient #4 was admitted around noon on 04/28/11, for opiate detoxification (detox) and bipolar disorder.

The Medical Staff Bylaws required: "...Abide by the Medical Staff Bylaws, rules and regulations, Hospital and Hospital policies...."

1. According to the current Medical Staff Bylaws, Rules and Regulations: "...Each patient admitted to the hospital shall have an attending provider and a psychiatric or Chemical Dependency (if applicable) and physical evaluation...be dictated within 24 hours of admission by the admitting or the attending psychiatrist and/or C.N.P. (certified nurse practitioner)...."

The attending MD documented an Admission Psychiatric Evaluation/Chemical Dependency Evaluation Initial Progress Note on 04/30/11. The form did not include a time, however, the evaluation was not conducted within 24 hours according to the requirements of the medical staff bylaws.

2. The Medical Staff Bylaws, Rules and Regulations required: "...All patients must be seen within 24 hours of admission by the attending provider and/or C.N.P...."

Review of Pt #4's medical record revealed Pt #4 was not seen by the attending or the C.N.P. working with the attending until 04/30/11 at 0830 hours.

The Chief Nursing Officer confirmed on 06/27/11 at 1530, that the psychiatric/CD evaluation was not completed and the patient was not seen within 24 hours of admission.

3. The Medical Staff Bylaws, Rules and Regulations required: "...verbal orders shall be signed by the person whom dictated and authenticated by the attending or covering provider with 48 hours."

Review of Pt #4's medical record revealed a Family Nurse Practitioner (FNP) (Allied Health Professional (AHP) #6) phoned in telephone orders for the admission orders on 04/28/11 at 1610 hours. The orders included the following medication orders: "...Subutex 4 mg now and 2100, sublinguinal (SL), (for) detox...Subutex 4 mg three times daily, SL, detox on 04/29/11...Subutex 4 mg twice daily, SL, detox on 04/30...Subutex 2 mg twice daily, SL, detox on 05/01...Subutex 2 mg in am, SL, detox on 05/02...topamax 75 mg (milligrams) at bedtime, PO (orally)....." The FNP authenticated the telephone orders on 05/16/11.

Provider #7 confirmed during an interview on 06/28/11 at 1325 hours, that AHP #6 did not authenticated the telephone orders within 48 hours.

4. The hospital's Medical Staff Bylaws required: "...Write orders to the extent established for him in the rules of the Staff and of the service to which he / she is assigned, but not beyond the scope of his license, certificate or other legal credential...."

Review of Pt #4's medical record showed that AHP#6 phoned in telephone orders for the admission orders on 04/28/11 at 1610 hours. The orders included the following medication orders: "...Subutex 4 mg now and 2100, sublinguinal (SL), (for) detox...Subutex 4 mg three times daily, SL, detox on 04/29/11...Subutex 4 mg twice daily, SL, detox on 04/30...Subutex 2 mg twice daily, SL, detox on 05/01...Subutex 2 mg in am, SL, detox on 05/02...topamax 75 mg (milligrams) at bedtime, PO (orally)...."

Provider #7 confirmed during an interview on 06/28/11 at 1325 hours, that AHP #6 a Family Nurse Practitioner (FNP) could not order Subutex.

Based on review of medical record, hospital policy/procedure, and interview, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care for each patient as evidenced by:

1. failure to document the nursing assessment and specific nursing interventions provided to a patient who was found by non-clinical staff hanging from a bed sheet in a suicide attempt; and

2. failure to ensure that patients are directly observed every 15 minutes by Behavioral Health Technicians and that the observations are recorded per policy.

Findings include:

1. Review of Pt #7's medical record on 6/29/11, revealed that it did not contain specific documentation of the patient's suicide attempt on 5/3/11 or subsequent emergency care, including cardiopulmonary resuscitation provided by nursing personnel. The medical record did not contain a Flow Sheet with record of the Code.

Review of documentation of the facility's investigation and analysis of information (Root Cause Analysis) revealed a detailed account of the discovery of the patient by housekeeping personnel. In addition, two BHT's removed the bed sheet from the patient's neck and placed the patient on the floor. Nursing staff initiated CPR. Several nurses assisted; two physicians arrived; nurses brought the Code Cart and the AED machine. Emergency Medical Services arrived and continued with resuscitative efforts and transported the patient to a hospital emergency department. This documentation was separate from the medical record.

On 6/29/11, the DON provided the "Code Blue Flow Sheet" which was separated form the medical record. It contained brief documentation of nursing care from the point at which chest compressions were initiated. The documentation did not include assessment of the patient or identity of the individuals who specifically provided nursing assessment and intervention. A nurse recorded a summary progress note on 5/3/11 at 1230, of the staff's response to the emergency.

Review of the hospital policy/procedure titled Code Blue Responsibilities revealed that it did not contain requirements for documentation of a Code Blue (cardiac or respiratory arrest).

Review of the hospital policy/procedure titled Emergency Plan of Services revealed: "...The emergency situation should be fully documented in the clinical record in a timely manner by the charge nurse or his/her designee and should include the following: Signs/symptoms...Treatment interventions and response...Condition at time of transfer...."

The DON confirmed during an interview conducted on 6/29/11, that the documentation in the patient's medical record regarding the patient's suicide attempt, nursing assessment and intervention did not meet the requirements of the above referenced policy and were not sufficiently detailed.

2. Cross Reference Tag #0144, #3 for information regarding Safety Level Guidelines.

On 6/29/11, direct observation of patient care revealed:

Pt # 32 was hospitalized in Unit 600. He was on Safety Level III. BHT #10 was assigned to record on Pt #32's Patient Observation Record. At 1630, BHT #10 had recorded entries in spaces designated for 1645 thru 1745 (5 spaces).

BHT #46 was assigned to provide "Line of Sight" observation for Pt #33. BHT #46 and Pt #33 were seated in the unit Dayroom. At 1640, BHT #46 had recorded entries in spaces designated for 1645, and 1700. BHT #46 had also recorded entries on 3 other patients' Observation Records: Pt #34's record contained entries for 1645 and 1700, indicating that Pt #34 was in Dietary eating; Pt #35's record contained entries for 1645 and 1700, indicating that Pt #35 was in Dietary eating; Pt #36's record contained entries for 1645, indicating that Pt #36 was in his room awake. Pt #34 was on Safety Level III; Pt #35 was on Safety Level III: Pt #36 was on Safety Level II.

Pt #37 was in Unit 600 and was on Safety Level III. On 6/29/11, at 1630, his Patient Observation Record was blank from 1445 through 1515 (3 spaces).

On 6/29/11, the Clinical Educator confirmed that the Observation Records of Pts #32, #33, #34, #35, and #36 contained prerecorded entries (charting at times which had not occurred yet). She confirmed that Pt #37's Observation Record contained blank spaces. She confirmed that documentation on these Pt's Observation Records did not follow policy.

Based on review of medical record, policy and procedures, and interview, it was determined: the hospital failed to:

(A-0806) identify the specific needs of the patient after discharge in 1 of 1 patients (Patient #3);

(A-0820) require a the discharge plan was implemented before the patient was discharged in 1 of 1 patients (Patient #3): and

(A-0821) require that the discharge plan was reassessed when changes in the patient's condition occurred for 1 of 1 patients (Patient #27).

The cumulative effect of these systemic deficient practices resulted in the failure of the hospital to meet the requirements for the Condition of Participation for Discharge Planning.

Based on review of medical record, policy and procedures, and interview, it was determined the administrator failed to require for 1 of 1 patient (pt) that discharge planning identify the specific needs of the patient after discharge (Pt #3).

Findings include:

Review of medical record revealed patient # 3 was transferred to facility on 5/25/11 at 0915 from another medical facility after overdosing on 50 Oxycodone, 30 Soma and Valium with a diagnosis of depressive disorder, recent overdose, suicidal ideations, and drug use, primarily opiates. Patient has a history of bipolar disorder, polysubstance abuse, and severe depression. Patient reported that she had numerous prior suicide attempts. This patient has recently lost two children to CPS, boyfriend to jail and her "...Mother has disowned her...." This patient upon admission has made a statement of "... I'm just tired, I don't care anymore about anything...." Patient reported an increase in isolation, increase drug use and decrease in sleep upon admission. Employee #1 completed the Comprehensive Assessment Tool on 05/26/11. Review of the Occupational history section revealed: "... Patient able to support self...No...Patient receives disability...No...Currently Employed...No...Identified Barriers to Employment...Not Interested...." MD #1 documented in the Admission Psychiatric Evaluation/Initial Progress Note at 0925 on 05/26/11: "...Unstable Housing...." Employee # 33 (RN) reported the patient's chronic back pain on the Initial Nursing Assessment as: "...neck pain, bulging L5 disk back pain...back pain is constant, always there...percocet doesn't take the pain away, not enough doses...."

Patient was discharged on 05/30/11 at 1130.

There was no policy or procedure available for surveyor to review concerning Clinical Risk Assessment Tool and Comprehensive Assessment Tool. This was confirmed by employee # 14 on 06/30/11 at 1250.

Review of the policy and procedure titled "Plan for Provision of Care" with a review date of December 31, 2008, revealed: "...Discharge planning begins on the day of admission and is considered a part of the initial assessment and treatment plan. The Social Services department...explores the patient's resources and, when necessary, arranges referral to other agencies prior to a patient's discharge from the Hospital...."

Review of the policy and procedure titled "Discharge-Aftercare Planning" with a review date of January 9, 2009, revealed: "...The development of a discharge plan begins at admission...The social service staff shall discuss with the patient and identified support system members, the tentative discharge plan...shall be included in the Psychosocial Assessment...The Discharge Plan should: Prepare the patient...for the transition to the next level of care; Address the patient's plan for continued treatment; Identify problems to be addressed in the next level of care...In Developing discharge aftercare plans, the following is assessed: Family relationships, physical and psychiatric needs, financial needs, housing needs...employment needs...personal support systems...aftercare treatment...Addressing...appropriate living arrangements, Assist in coordinating necessary follow up care...."

Employee #1 completed a Comprehensive Assessment on 5/26/11. The Comprehensive Assessment revealed: "...Pt (patient) needs a 30 day in pt facility to help her stop abusing the drugs. SW (social work) will look into finding a facility...."

Review of medical record, no further documentation of 30 day in pt facility for patient discharge planning was mentioned. Employee # 14 on 6/30/11 at 1250pm confirmed there was no follow up to the 30 day treatment note made by the SW during admission.

Employee #1 completed the Clinical Risk Assessment Tool on 05/26/11 at 0812. The Clinical Risk Assessment Tool revealed that there were eight risks listed that were checked "...No...." These risks are as follows: "...Patient has lost or anticipates losing an essential sustaining relationship...Patient has lost or anticipates losing their main reason for living...Patient has physiological issues (i.e. Physical illness, chronic pain, delirium...Patient is vulnerable to painful affects (i.e. being alone, self contempt, rage, shame, panic)...Patient has had recent stresses in their life (within 30 days)...Patient doesn't have the capacity for self regulation...Patient has experienced losses of any coping mechanisms...and Patient has a lack of social support systems...."

Employee #14 reviewed on 06/30/11 at 1250, the Clinical Risk Assessment Tool, patient transfer notes, nursing triage, Admission Psychiatric Evaluation Initial Progress Note, Comprehensive Assessment Tool and Initial Nursing Assessment notes. Employee # 14 confirmed answers that were filled out as a "...no..." for these eight risks should have been marked "...yes..." on the Clinical Risk Assessment Tool.

Employee #14 confirmed that the Clinical Risk Assessment is subjective, and there was no formal training or policy/procedure on filling out the form. Employee #14 confirmed the Clinical Risk Assessment is a pilot program in place since January 2011. Employee #14 also stated the forms "...just appeared..." and Social Service just started using the assessment tools.

Employee #1 completed the Clinical Risk Assessment 05/30/11 at 0900. Review of of the Clinical Risk Assessment form revealed: "All boxes checked No...Scoring Guide...total score of 0(zero)...."

Employee #14 confirmed during an interview conducted on 06/30/11 at 1250, that the information on the Clinical Risk Assessment form dated 5/30/11, was to be inaccurate. Employee #14 confirmed that the patient's problems could not all have been fixed during her hospitalization (i.e. the issue with CPS). Employee # 14 confirmed the total score could not be a zero. Employee #14 confirmed that upon discharge, any remaining clinical risks needed to be addressed in the aftercare plan as stated on the clinical risk assessment form.

Based on review of medical record, policy and procedure, and interview, it was determined the hospital failed to require for 1 of 1 patient (pt) that a discharge plan was implemented before the patient was discharged (Pt #3).

Findings include:

Review of the policy and procedure titled "Discharge-Aftercare Planning" with a review date of January 9, 2009, revealed: "...Include timely and direct communication with and transfer of information to other programs, agencies, or individuals that will be providing continuing care...Assist in coordinating necessary follow up care...social service staff shall insure that an outpatient appointment is scheduled...All professionals who will follow-up with the patient...Aftercare plans are communicated to the patient...provided in writing to the patient via the "Discharge Instruction Sheet" and documented in the medical record...."

Review of Facility Policy and Procedure titled "Discharge Process/Guideline" dated January 14, 2009, revealed: "...a Discharge After-Care Plan will be provided upon discharge...Nursing must write a narrative Final Discharge Note in the progress notes; to include the following:...Statement about discharge paperwork provided to the patient, comments pertaining to D/C (discharge) paperwork...Give a brief summary of the patient's condition on discharge as to psychiatric/physical/functional condition and Document any concerns/comments observed by discharge nurse or made verbally by patient...."

Review of the treatment Plan-Problem Sheet revealed the following written by employee #1: "...Schedule medical follow-up appointments and provide these to patient in writing at discharge...."

Employee #13's (RN) telephone order written on 05/29/11 at 2135, revealed: "...Dr ( #4) consult for boil on L (left) lower back...." Employee #13 Nurse's Notes on 05/29/11 at 2215, revealed: "...Pt (patient) has apparent boil on L (left) lower back...Pt (patient) scheduled for visit with internist about boil...."

There was no documentation in the medical record that the consult with Dr.# 4 was completed. The DON confirmed on 07/07/11 at 1200, there was no documentation in chart that consult with Dr #4 for boil was completed.

Employee # 16 filled out the Discharge Aftercare Plan dated 05/30/11. The Discharge Aftercare Plan did not have a referral to the patient's family doctor to follow-up for the boil on her left lower back. Employee # 14 confirmed the referral was not present.

Employee #33's (RN) discharge note written on 5/30/11 at 1130, revealed: "...Pt (patient) discharging. Go over discharge information with pt. Give all valuables, contraband items and prescriptions to pt. Pt verbalized understanding of discharge info (information). Pt took all items with her. Pt discharged. Picked up by mother...."

The discharge nursing note written 5/30/11 at 1130, did not contain as per the hospital's policy a summary of patient's condition at time of discharge, or the boil on patient's back. The DON confirmed this on 07/07/11 at 1200.

MD # 1's dictated discharge summary for a discharge date of 5/30/11 on 06/02/11 at 1131 revealed: "...she (patient) shared that she was displeased with her (Name) Clinic as she did not feel as well as they were helpful enough and invested enough in her treatment, and was hopeful to transfer to a (Name)...."
There was no mention of the medical issue of the boil on patient's back in the discharge note by the MD. The DON confirmed this on 07/07/11 at 1200.

Employee #16's progress note written on 5/30/11 at 0950, revealed: "...Therapist met with pt (patient) for D/C (discharge) planning...Pt states she previously received services from (Name) but was not happy w/ (sic) (with) services. Pt states she has requested multiple times to be closed from (Name) or transferred. Therapist called (Name) w/(sic) pt and was told pt would have to call back during regular business hours. Therapist gave pt written step by step instructions w/(sic) numbers for (Name) and (Name) as to how to close w/ (sic) (Name) and schedule with (Name). Pt states she understands d/c plan and agrees w/ (sic) plan...Pt states she will F/U (follow up) with D/C plans...."

Review of the Discharge Aftercare Plan revealed: "...The outpatient Provider...(Name)...call to schedule an intake...pt (patient) will schedule...Patient refused to continue service with following outpatient providers...(Name)...Additional Discharge Instructions...Pt (patient) and therapist contacted (Name). Pt (patient) has to call (Name) during normal business hours (phone number is listed) to request to be closed with (Name). Pt (patient) then to call (Name) (phone number is listed) to request an Intake...."

Employee #14 confirmed the findings of this discharge plan on 6/30/11 at 1250pm. Employee #14 confirmed that appointments could not be made with (Name) as the 30th of May was a Holiday. Employee #14 also confirmed that it is rare that they can not make an appointments with (Name) or (Name). She also confirmed the discharge information is faxed to (Name) upon discharge when a patient is in the (Name) system and needs follow up. Employee #14 confirmed there was no documentation of the fax being sent to (Name) for patient follow up. Employee #14 also confirmed that all patients are able to attend one year of Aftercare at Aurora Behavioral Health at no charge. The information of the date and time of initial Aftercare Session is filled out for the patient on the Discharge Aftercare Plan. Employee # 14 confirmed that for patient # 3, this section was left blank.

Patient Registration and Medical Screening form filled out by patient and reviewed by employee #2 (RN) revealed: "...Outpatient Providers for Family Dr...(name of doctor)...pain mgmt (management) Dr- Broke Contract...." Upon discharge, there was no documentation in the chart to notify the family physician or the pain management physician of patient's recent admission. Employee #14 confirmed this on 06/30/11 at 1250.

Based on review of policy and procedure, medical records and interview, it was determined the hospital failed to require that the discharge plan was reassessed when changes in the patient's condition occurred for 1 of 1 patients. (Patient #27).

Findings include:

Review of policy and procedure titled "Discharge-Aftercare Planning" required: "...social service staff shall update ...progress of Social Service interventions/discharge planning at regular scheduled staffings and via discharge process documentation...clearly document progress...in progress notes...medical record...as well as...identified problems/issues in the process...."

Review of policy and procedure titled "Admission, Continued Stay, and Discharge Criteria" revealed: "...Discharge Criteria...exhibits ability to control self in less restrictive environment; not unsafe to self...patient is not at risk for harm to self or others...."

Review of the Medical record revealed the following:

Patient #27 was admitted on 4/29/11. On 5/8/11, this patient was placed in Seclusion/Restraints from 1242 hours until 1330 hours due to combative behavior. On 5/9/11 at 1030 hours, patient # 27 was discharged to (Name/City).

Last documented social worker progress note was 5/6/11 at 0900 hours. No Clinical risk assessment was completed on admission or discharge. There was no follow-up note on patient condition/behavior by social worker after seclusion/restraint incident documented in medical record.

The physician discharge note was illegible and absent of a documented discharge plan and follow-up recommendations.

An interview on 7/5/11 at 1120 hours, with RN employee #27 confirmed that completion of the "Clinical Risk Assessment" form is done by the Social worker. The Social worker discusses discharge planning with the patient and the nurse, completes the form titled "Comprehensive Assessment Tool" on admission, and works with the nursing staff on reassessment of the written plan of care through-out the hospital stay.

The Chief Nursing Officer, employee # 19 confirmed in an interview on 7/7/11 at 1205 hours the following:

1.) patient was in seclusion/restraints on 5/8/11 and patient discharged 5/9/11; and

2.) there were no Social worker progress notes after 5/6/11 and no Clinical Risk assessment completed on admission or discharge.

The Chief Nursing Officer, employee # 19 confirmed in an interview on 7/7/11 at 1320 hours, that physician #5's discharge note was illegible and absent of documentation of the discharge plan and follow-up recommendations.

Medical staff #2 confirmed in an interview on 7/7/11 at 1325 hours, that the form titled "Physician Discharge Note" completed by medical staff # 5 was illegible and all areas on the form that needed to be completed were not filled out.

Based on review of policies/procedures, medical records, and interviews, it was determined the hospital failed to ensure the patient's right to make informed decisions regarding his or her care as evidenced by:

1. failure to require that the medical providers complete the Physician Informed Consent for Medication form upon the patients initial admission interview in 6 of 11 patients (Pt #'s 7, 12, 13, 14, 18, and 19); and

2. failure to require that a patient who was maintained on Methadone be informed that he would not be able to receive Methadone if admitted for psychiatric treatment and the alternatives available (Pt #7).

Findings include:

1. Review of hospital policy # 300.135 titled "Informed Consent for Psychotropic Medication" required: "...When the provider sees the patient for the initial admission interview, he/she will complete the Informed Consent for Psychotropic Medication Treatment with the patient...."

The form listed 5 columns with the following headings: Medication & dosage range, Target symptoms to be addressed, How discussed (in-person, telephone, tele-medicine, previously), "Person/Guardian" initials & date, Behavioral health medical practitioner initials & date. At the bottom of the form are two separate lines for both "person/guardian" & medical practitioner to print name, sign and date the form.

Review of Patient #7, 12, 13, and 14's medical records revealed physician orders for psychotropic medications. None of the records contained a completed Informed Consent for Psychotropic Medication form.

Review of Patient # 18 and 19's medical record revealed the Informed Consent for Psychotropic Medication form did not contain the required "dosage range" for the medications listed. The forms were not initiated at the time of the initial admission interview as required by policy.

The Director of Nursing confirmed the above findings for the Informed Medication Consent forms on 07/07/11 at 1330 hours.

2. Review of hospital policy/procedure titled Scope of Inpatient Program revealed: "...For admission and readmission patients must meet the diagnostic criteria of the DSM-IV TR and one or more utilization criteria for hospitalization as follows: A. Behavior which is life threatening, destructive or disabling to self or others...1. Active or potential suicidal, assaultive or homicidal threats, plans or attempts in the past 24 hours...2. Self-mutilating behavior in the past 24 hours...Medical detoxification from Alcohol, Opiates, or Benzodiazepines that can not be managed in a lesser (sic) restrictive setting...A Provider has reviewed and agrees with the clinical assessment and gives an admission order. The patient or legal guardian agrees to voluntary admission in writing...."

Review of the patient's medical record revealed:

Pt #7 was admitted on 4/28/11 via the Intake and Referral Dept. as a "walk in." The patient was "brought in" by his parents. The patient completed the Patient Registration and Medical Screening form, indicating that he was experiencing "extreme depression and suicidal thoughts." He also provided written information to the Intake RN, at the time of his assessment, that he was on Methadone maintenance and had his last dose on the day of his admission to the hospital.

RN #37 (the Intake RN) stated during interview conducted on 6/27/11, that the patient informed her that he was on Methadone maintenance but that his Methadone was a secondary issue to her. She stated that her primary concern was his safety, since the patient had told her that he had suicidal thoughts and had considered running out in traffic or crashing his car. She did not recall specifically informing the patient that he would be unable to continue on the Methadone in the facility, or informing him of other facilities where he could receive Methadone. She confirmed that she did not document discussion of alternative hospitals where he could remain on Methadone. She stated that she did not confirm his dosage and thought that the inpatient staff would address that later. She stated that she is aware that the facility is a "no narcotic" hospital.

Employee #38, the PCM, stated during interview conducted on 6/28/11, that she didn't know what the patient wanted to do with his Methadone and that she didn't discuss it with him. She stated that her understanding is that patients "can't be off it." She stated that she was aware that there was an issue with the patient's Methadone and that someone discontinued it over a weekend. She stated that after his hospitalization, he would be able to follow-up with outpt CD Tx (Chemical Dependence Treatment) and remain on Methadone, but not at this facility.

During interview conducted on 6/27/11, the Director of Nursing (DON) stated that the hospital is not licensed for Methadone. She stated that if a patient wants to continue taking Methadone, the patient would need to be transferred, probably to (name of hospital).

Physician #11 could not recall during interview conducted on 6/28/11, whether the Intake RN informed Physician #11 that the patient was on Methadone maintenance when the physician accepted the patient for admission. Physician #11 could not recall whether he informed the patient at the time of the Psychiatric Evaluation that he could not continue Methadone at the hospital. Physician #11 ordered Methadone for the patient on 4/29/11: "...Methadone 40 mg daily...1st dose now...Varify (sic) dose from pts methadone clinic prior to giving pt the dose...."

On 4/29/11, at 1520, physician #7 wrote an order "...D/C (Discontinue) Methadone...."

Physician #7 wrote a progress note on 4/29/11, at 1400: "...CD Consult...on 60 mg MTD (Methadone) from (name of clinic)...got a dose today here...heroin addiction hx...5 yr hx of opiate dep & abuse...not wanting to come off methadone...D/W (Discussed with) (Medical Director)...Pt on MTD for Opiate Dependency from MTD clinic...We are not licensed for MTD...will have to D/C order...Pt not wanting to come off MTD...."

On 4/30/11 at 1100, physician #11 documented in the Physician Daily Progress Note: "...Symptom...Suicidal...Present...Yes...Pt angry that his Methadone was stopped. pt feels his mood is very unstable. Pt say (sic) 'I am stressing out over everything'...I feel his mood is very unstable...he is feeling very upset...."

On 4/30/11 at 1330, a nurse documented: "...Client stated did not sleep well. Stated wanted to continue on Methodone (sic), stated anxiety 9/10, depression 10/10. Client got into a fight (with) a peer...."

On 4/30/11 at 1000, an RN recorded physician #11's telephone order: "...Ativan 1 mg po every 4 hrs daily prn (as needed) anxiety...Percocet 5/325 mg po every 6 hrs prn daily...pain...."

On 4/30/11, at 1130, physician #11 wrote an order: "Skelaxin 800 mg po q (every) 4 (hrs) prn muscle cramps...."

On 5/1/11, at 1130, physician #11 documented on the Physician Daily Progress Note: "...Symptom...Hallucinations...Present...Yes...No...'night terrors'?...Delusions...Yes...paranoia...Suicidal...Yes...SI...Pt reports feeling 'dope sick'...Pt is having cramp (sic) & sweats. Pt is eating fair...Pt feels his anxiety is very high. Pt is still reporting depression...."

On 5/1/11, at 2350, a nurse documented: "...pains from withdrawing...'they cut my methadone off'...'I was used to 60 mg'...."

On 5/2/11, at 0900, physician #11 documented on the Physician Daily Progress Note: "...Symptom ...Delusions...yes...Paranoia...Suicidal...Yes...SI...pt missed his breakfast. pt says he was having major WD (Withdrawal) from opiates...pt was given Subutex which helped him settle down...Bipolar depression, opiate dependence...."

Physician #11 stated during interview conducted on 6/28/11, that he had started the patient on Methadone after admission, but when it was not possible for the patient to remain on the Methadone, that he informed the patient that he would begin to go through withdrawal. He ordered Percocet to prevent withdrawal and then later, when the patient agreed to take Subutex, he ordered Subutex to prevent withdrawal. Physician #11 stated that the patient did not want to detox from Methadone. He did not remember if he discussed alternative

Based on review of nationally accepted standards, policies/procedures, medical record, observation, and interview, it was determined that the hospital failed to provide care in a safe setting for patients as evidenced by:

1. failure to provide a patient care environment that is free of fixtures, surfaces, and equipment conducive to patient injury, self-injury, or suicide for all patients admitted to the facility;

2. failure to require policies/procedures or written guidelines for staff to utilize in order to provide reliability between staff completing suicide risk assessments and failure to require consistent implementation of the Clinical Risk Assessment;

3. failure to require one written policy/procedure for patient Safety Level Guidelines which is readily available to all staff; and

4. failure to require that the Safety Level Guidelines policy/procedure is implemented by all staff.

Findings include:

1. The American Institute of Architects' 2006 Guidelines for Design and Construction of Health Care Facilities, pp. 60 & 61 revealed: "...3.8 Psychiatric Nursing Unit...A3.8.1.4 A safe environment is critical...Patients of inpatient psychiatric treatment facilities are considered at high risk for suicide; the environment should avoid physical hazards while maintaining a therapeutic environment...Staff awareness of their environment, latent risks of that environment, and the behavior risks and needs of the patient served in the environment are absolute necessities...."

On 7/7/11, the bathroom located in the hallway near the facility cafeteria was observed to contain several safety hazards for a patient who may be self-injurious and/or suicidal. These hazards included: two toilets with exposed plumbing; 2 toilet stall doors with coat hooks; disability grab bars on the side of one toilet stall; two sinks with exposed plumbing; exposed hinges inside the door; and a large mirror above the two sinks. All of these items/risks provide the surface for an individual to harm himself/herself by hanging.

Review of policy and procedure titled "Clinical Services Safety Levels" requires: "...Level III-Close observation...staff...maintain visual and verbal contact sufficient to monitor patient's condition...allowed off...secure unit under direct staff supervision."

On 7/7/11 at 0830 hours, a patient was observed, unsupervised in the bathroom.

On 7/7/11 at 1210 hours, a second patient was observed, unsupervised, in the same bathroom.

The Chief Nursing Officer confirmed in an interview on 7/7/11 at 1200 hours, that the bathroom has not been modified for patient safety because patients must always be directly supervised when in the bathroom. She stated that staff members are to accompany patients in the bathroom. She confirmed that if patients are in the bathroom unsupervised, that the staff is not implementing the policy correctly.

2. Review of the hospital policy/procedure titled Admission Protocol revealed: "...A Comprehensive Intake Assessment...is completed by Intake on all patients who present to (hospital name)...On completion of the full assessment the case will be reviewed with a provider to determine if the patient meets criteria for admission...."

Employee #38 stated during interview conducted on 6/28/11, that the Comprehensive Intake Assessment is no longer utilized and that the policy/procedure has not been updated. She confirmed that the facility does not have a policy/procedure to accompany the Comprehensive Assessment Tool. She explained that the Patient Care Manager (PCM) completes the current Comprehensive Assessment Tool within 48 hours of the patient admission.

Review of Pt #7's medical record revealed:

Employee #38 completed a Comprehensive Assessment Tool on 4/29/11, which included a section titled Initial Risk Assessment. Review of the Initial Risk Assessment revealed: "...Recent Suicide Attempt...Denies...Was attempt lethal?...Denies...#Of Previous Attempts: 'A lot'...Date of Most Recent Attempt: 'Couple months ago'...Past Methods used: OD (Overdose) Hang...Risk For Harm To Self...Low...."

Employee #38 stated during interview conducted on 6/28/11, that she believed a "recent attempt" means within the past 30 days. She stated that she would consider a patient who had shot or stabbed themselves as a high risk.

Employee #39 stated during interview conducted on 6/28/11, that she also completes Comprehensive Assessment Tools. She stated that she believed a "recent attempt" means within 6 months. She confirmed that the facility has no standardized definition of terms or current policy/procedure and/or guidelines for completion of the Comprehensive Assessment Tool.

The DON confirmed during interview conducted on 6/28/11, that the facility does not have a standardized method that nurses utilize to assess patients for suicide risk. She stated that nurses interact with patients, ask questions, use their relationship and observations of the patient in the milieu to assess risk for suicide.

Employee #14 stated during interview conducted on 6/30/11, that a form titled Clinical Risk Assessment is completed by Social Work staff at the time of patient admission and discharge. The facility implemented use of the form in January, 2011 with no accompanying policy/procedure or guidelines for completion.

Employee #38 confirmed that the only risk assessment contained in Pt #7's medical record was within the Comprehensive Assessment Tool. The medical record did not contain a Clinical Risk Assessment.

3. Direct observation revealed that the policy/procedure manual located in Unit 100/300 nurses' station on 6/27/11, did not contain a policy/procedure for suicide precautions or patient safety levels. At 1050, the Clinical Educator provided the policy/procedure titled Safety Levels (effective August 1, 2006; reviewed July 7, 2008). At 1119, the Assistant Director of Nursing (ADON) provided the policy/procedure titled Safety Level Guidelines (effective August 1, 2006; reviewed January 16, 2009; revised January 16, 2009). The ADON stated that the latter policy/procedure was the current policy/procedure utilized by the facility for patient safety levels. The two policies differed in terms of content.

Direct observation revealed that the policy/procedure manual located in the Unit 400 nurses' station on 7/6/11, did not contain a policy/procedure for patient Safety Level Guidelines. The ADON provided the policy/procedure titled Safety Precautions and Levels (effective August 1, 2006; reviewed January 16, 2009; revised January 16, 2009). This policy differed in content from the other two policies related to patient safety levels.

4. Review of the policy/procedure titled Safety Level Guidelines (which the ADON indicated as current on 6/27/11) revealed: "...A Safety Level is defined as an intensified level of staff awareness and attention to patient safety/security needs requiring the initiation of specific protocols and supplemental documentation. Safety level procedures can be initiated by provider or nursing staff when a patient may be considered to be an increased risk for harm to self...Clinical staff should assess the patient's risk factors and initiate the following procedures to help protect the patient and others...An order for the appropriate safety level should be documented in the provider's order section of the medical record, and the charge nurse or designee should initiate the Safety Level Record. When safety levels are initiated by nursing order, the nurse should contact the provider as soon as possible and notify him/her of the need for the safety level. Initiation of the safety level should be documented in the provider orders...A licensed nurse or designee should ensure that all patient orders for safety levels are recorded and posted per facility policies and procedures...Reassessment by a provider should be completed and documented at least every 24 hours with clinical justification for renewal, modification, or discontinuation of orders for safety levels...The registered nurse should address the status of the patient on safety levels in the nursing reassessment documented every 24 hours...Level II-Continuous Observat

Based on review of hospital policies/procedures, medical records, documentation, and interviews, it was determined that the hospital's quality program failed to include a means to identify, measure, analyze and evaluate quality indicators, that included sentinel events, that assess processes of care, and hospital services and operations as evidenced by:

1. failure to follow policy and procedure for investigation and analysis of information for Sentinel events through a Root Cause Analysis for Patient #3 who committed suicide within 72 hours of being discharged from the facility; and

2. failure to monitor quality in key processes related to patient care delivered by medical staff.

Findings include:

Review of the hospital policy/procedure titled Sentinel Event revealed: "...To focus the attention of the organization on understanding the underlying causes of a sentinel event and on making changes in systems and processes to reduce the probability of such an event in the future, with the goal of improving patient care and safety...The hospital will provide an effective and immediate mechanism for immediate investigation, analysis of information and response to Sentinel events through a Root Cause Analysis (RCA)...Definition...A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk that carries a significant chance of a serious adverse outcome...Sentinel Events may include, but is (sic) not limited to, the following:...Suicide of any patient within 72 hours of discharge...."

1. Patient #3 was admitted to facility on 5/25/11 at 0915 from another medical facility after overdosing on "...50 Oxycodone, 30 Soma and some Valium..." with a diagnosis of depressive disorder, recent overdose, suicidal ideations, and drug use, primarily opiates. Patient had a history of bipolar disorder, polysubstance abuse, and severe depression. Patient reported that she had numerous prior suicide attempts. Patient was discharged on 05/30/11 at 1130. Police reported patient expired on Aunt's couch the morning of 06/02/11.

MD #2's interview on 06/30/11 at 1444 revealed the following:

Police Department called on 06/02/11 in the morning for the risk manager. Police Sergeant left message that patient (#3) was found expired on her Aunt's couch the morning of 06/02/11. The Sergeant wanted information from the Doctors on the patient's treatment and when patient was discharged. The risk manager, MD #1 and MD #2 returned police Sergeant's telephone call. Prescriptions for pain medications were filled on 05/31/11. Police were given information about patient's diagnosis, patient status and medications prescribed at discharge. Police Sergeant telephoned an hour later and left message for MD #2 that during the investigation more pain medications and bottle were found under the patient and her pillow. MD #2 took this information to the risk manager and was told by the risk manager that the facility does not have to do a root cause analysis.

Risk Manager e-mail written 06/02/11 at 1409 concerning patient # 3, revealed the following: "...a former patient (patient # 3) discharged on 05/30/11 at 1130 passed away on the morning of 06/02/11...which is within the 72 hour window of being discharge from a licensed facility...only the Medical Examiner has not yet ruled on the case as a suicide...The police detective is calling the case an overdose, and Dr (#1) and Dr ( # 2) seem to concur as they feel that patient was not suicidal on discharge...and that she accidentally overdosed...The police clarified that Dr (#1) was her psychiatrist during her stay at Aurora, and that she filled her prescriptions and nothing was out of the ordinary...that she had been compliant with her psych meds...The police shared that (patient # 3) admitted to having morphine that was not prescribed for her and that she took this morphine and OD' d (overdosed) as a result...The medical examiner is following up on her death, but stated that it will take approximately 3 months to get an actual cause of death...."

The DON and the Medical Director confirmed there was no Root Cause Analysis completed on this patient on 06/30/11.

2. Review of hospital document titled 2011 Performance Improvement Plan revealed: "...The Performance Improvement Plan is developed under direction of the Quality Council. Its purpose is to establish mechanisms to objectively monitor quality in key processes throughout the organization. Data is systematically gathered on identified processes and outcomes related to patient care and organizational functions. Data is gathered from a variety of internal and external sources such as medical record review; patient satisfaction surveys and recommendations/findings from external sources...."

The document contained a column titled Performance Indicators; a column titled Goal, Source, and Measurement; a column titled Review Frequency; and a column titled Reporting Department. The document was divided in sections: "...Human Resources...Nursing...Medical Staff...Intake...Social Services...Outpatient Services...Adjunctive Therapy...Utilization Review...Medical Records...Business Development...quality Improvement...Risk Management...Plant Operations...Dietary...."

The section titled Medical Staff contained Performance Indicators: "...AIMS Testing...Informed Consent...History & Physical Evaluations...AMA Discharges...." The Review Frequency column contained "Monthly" for each Performance Indicator.

The hospital was unable to provide monthly reports for the Medical Staff Performance Indicators.

The Director Quality and Risk Management Tempe Facility confirmed during interview conducted 7/7/11, that the Review Frequency for Medical Staff reports regarding Performance Indicators was monthly and that the Quality Council had received no monthly reports for 2011 from Medical Staff regarding the Medical Staff Performance Indicators.

Based on review of hospital policies/procedures, medical records, documentation, and interviews, it was determined that the hospital's quality program failed to include a means to identify, measure, analyze and evaluate quality indicators, that included sentinel events, that assess processes of care, and hospital services and operations as evidenced by:

1. failure to follow policy and procedure for investigation and analysis of information for Sentinel events through a Root Cause Analysis for Patient #3 who committed suicide within 72 hours of being discharged from the facility; and

2. failure to monitor quality in key processes related to patient care delivered by medical staff.

Findings include:

Review of the hospital policy/procedure titled Sentinel Event revealed: "...To focus the attention of the organization on understanding the underlying causes of a sentinel event and on making changes in systems and processes to reduce the probability of such an event in the future, with the goal of improving patient care and safety...The hospital will provide an effective and immediate mechanism for immediate investigation, analysis of information and response to Sentinel events through a Root Cause Analysis (RCA)...Definition...A Sentinel Event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk that carries a significant chance of a serious adverse outcome...Sentinel Events may include, but is (sic) not limited to, the following:...Suicide of any patient within 72 hours of discharge...."

1. Patient #3 was admitted to facility on 5/25/11 at 0915 from another medical facility after overdosing on "...50 Oxycodone, 30 Soma and some Valium..." with a diagnosis of depressive disorder, recent overdose, suicidal ideations, and drug use, primarily opiates. Patient had a history of bipolar disorder, polysubstance abuse, and severe depression. Patient reported that she had numerous prior suicide attempts. Patient was discharged on 05/30/11 at 1130. Police reported patient expired on Aunt's couch the morning of 06/02/11.

MD #2's interview on 06/30/11 at 1444 revealed the following:

Police Department called on 06/02/11 in the morning for the risk manager. Police Sergeant left message that patient (#3) was found expired on her Aunt's couch the morning of 06/02/11. The Sergeant wanted information from the Doctors on the patient's treatment and when patient was discharged. The risk manager, MD #1 and MD #2 returned police Sergeant's telephone call. Prescriptions for pain medications were filled on 05/31/11. Police were given information about patient's diagnosis, patient status and medications prescribed at discharge. Police Sergeant telephoned an hour later and left message for MD #2 that during the investigation more pain medications and bottle were found under the patient and her pillow. MD #2 took this information to the risk manager and was told by the risk manager that the facility does not have to do a root cause analysis.

Risk Manager e-mail written 06/02/11 at 1409 concerning patient # 3, revealed the following: "...a former patient (patient # 3) discharged on 05/30/11 at 1130 passed away on the morning of 06/02/11...which is within the 72 hour window of being discharge from a licensed facility...only the Medical Examiner has not yet ruled on the case as a suicide...The police detective is calling the case an overdose, and Dr (#1) and Dr ( # 2) seem to concur as they feel that patient was not suicidal on discharge...and that she accidentally overdosed...The police clarified that Dr (#1) was her psychiatrist during her stay at Aurora, and that she filled her prescriptions and nothing was out of the ordinary...that she had been compliant with her psych meds...The police shared that (patient # 3) admitted to having morphine that was not prescribed for her and that she took this morphine and OD' d (overdosed) as a result...The medical examiner is following up on her death, but stated that it will take approximately 3 months to get an actual cause of death...."

The DON and the Medical Director confirmed there was no Root Cause Analysis completed on this patient on 06/30/11.

2. Review of hospital document titled 2011 Performance Improvement Plan revealed: "...The Performance Improvement Plan is developed under direction of the Quality Council. Its purpose is to establish mechanisms to objectively monitor quality in key processes throughout the organization. Data is systematically gathered on identified processes and outcomes related to patient care and organizational functions. Data is gathered from a variety of internal and external sources such as medical record review; patient satisfaction surveys and recommendations/findings from external sources...."

The document contained a column titled Performance Indicators; a column titled Goal, Source, and Measurement; a column titled Review Frequency; and a column titled Reporting Department. The document was divided in sections: "...Human Resources...Nursing...Medical Staff...Intake...Social Services...Outpatient Services...Adjunctive Therapy...Utilization Review...Medical Records...Business Development...quality Improvement...Risk Management...Plant Operations...Dietary...."

The section titled Medical Staff contained Performance Indicators: "...AIMS Testing...Informed Consent...History & Physical Evaluations...AMA Discharges...." The Review Frequency column contained "Monthly" for each Performance Indicator.

The hospital was unable to provide monthly reports for the Medical Staff Performance Indicators.

The Director Quality and Risk Management Tempe Facility confirmed during interview conducted 7/7/11, that the Review Frequency for Medical Staff reports regarding Performance Indicators was monthly and that the Quality Council had received no monthly reports for 2011 from Medical Staff regarding the Medical Staff Performance Indicators.

Based on review of policy/procedure, medical record and hospital documents, and interview, it was determined that the hospital failed to analyze an adverse patient event and implement preventive actions and mechanisms that included feedback and learning throughout the hospital.

Findings include:

Cross Reference Tag # A0267 for policy/procedure titled Sentinel Event.

Review of the hospital's documentation of the Root Cause Analysis (RCA) conducted to investigate Pt #7's suicide attempt revealed that the process did not identify the following patient care issues:

1. Cross Reference Tag #0131, #2.

The medical record did not contain documentation that the patient was informed at the time that he consented to psychiatric inpatient treatment, that he would be unable to continue Methadone maintenance at the facility. Review of the medical record and interviews revealed that the patient did not want to discontinue Methadone and did not want to detox. However, his Methadone was discontinued and he developed signs and symptoms of withdrawal which where managed with Percocet, Skelaxin and other comfort measures initially, and then Subutex was started. The patient had initially refused Subutex. Neither interviews nor documentation provided definitive evidence that the patient was informed that he could receive inpatient psychiatric treatment and continue his Methadone at another local facility.

2. Cross Reference Tag #0131, #1.

The medical record did not contain the required documentation of Pt #7's informed consent for psychotropic medication, including the Subutex.

3. Cross Reference Tag #0144, #1.

The Risk Assessment tools that are utilized by Social Service personnel have no current policy/procedure or guidelines to provide reliability between interviewers. The suicide assessment that the RN completes each shift varies regarding criteria, documentation, and follow-up.

4. Cross Reference Tag #0144, #2 and #3.

The facility has 3 versions of Safety Level Guidelines/Safety Precautions and Levels/Safety Levels which are available upon request. The version which was identified as current was not utilized in practice by nursing personnel or medical staff.

5. Cross Reference Tag #0144, #3.

The patient's Observation Record contained an entry, recorded by a BHT, that the patient was sitting/lying in his room at 1100 on 5/3/11. This entry was crossed out, with the word "error" written over it. The RCA contained documentation that the patient was discovered hanging in his bathroom shortly before 1100. The RCA did not contain any mention of the 1100 entry on the patient's Observation Record.

6. Cross Reference Tag #0395, #1.

The documentation of the discovery of the patient, assessment of his status, and interventions provided by nursing personnel was incomplete. The medical record was missing the Code Blue Flow Sheet until 6/29/11. The Code Blue Flow Sheet was incomplete.

The Director Quality and Risk Management-Tempe Facility acknowledged on 7/7/11, that the above issues would be considered Quality Management issues.