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Based on review of policy and procedure, documentation, direct observation and interview, it was determined that the administrator failed to maintain appropriate measures to protect patient information as evidenced by two open and unsecured nursing stations on the Mesquite Unit. Failure to protect a patient's medical record poses a potential risk that sensitive patient information is compromised.

Findings include:

Policy titled "Emergency Operations Plan - Haven Phoenix", #8605036, Revised 09/2020, revealed: "...Haven-Phoenix has an emergency preparedness program designed to provide for effective utilization of available resources so that patient care is maintained in the event of a...internal emergency...The Emergency Operations Plan is an "all hazards" response plan. The initial step in responding to any emergency is implementation of the immediate action procedures outlined in the specific policies for the specific occurrence...The hospital attempts to mitigate any event by participating in activities that help prevent emergency or reduce the chance of an emergency happening. Recent construction with behavioral health care hospital grade fixtures assists in mitigation as well as regular monthly, quarterly and annual systems inspections and checks to pre-actively identify areas for improvement...Conducting monthly...Safety meetings and including building representation assists in preparedness...Review of actual events help to identify areas of weakness to address and strengths...Emergency Codes Used...Code Gray-Combative Patient...Medical Records: Ensure that all Records file cabinet doors are closed to safeguard records...assist in maintaining patient status records throughout the emergency...."

Policy titled "Confidentiality & Security of Medical Records", #8659356, Revised 12/2019, revealed: "...To define the system of records and confidentiality and security...The medical record is privileged and confidential...The "medical record" includes communications record in any form or medium maintained for the purpose of patient treatment...The unit has a distinct patient record storage area to assure secure and confidential filing and storage of patient records...Records are kept out of view from patients. They are maintained at the Nurse's Station on carts. These carts can be transported to specific designated charting areas. Doors are to be securely locked when staff is not in chart room...."

Facility "Incident Log" revealed 3 incidents of theft of the ipad(s) used for documenting patient rounding from one and/or two of the nursing stations on the Mesquite Unit, for the time period of 01/30/21 through 02/01/21. Mesquite Unit is a high acuity, court ordered treatment unit. There was also a theft of the nursing station iPhone and Bluetooth speaker on 02/04/21. Findings include:

1-30-21 at 2030 Pt #14 Location: Patient Room, Mesquite, Stolen Property: "...saw a light trying to come from under patient's blanket...When we lifted up the blanket we found the I-pad without the case...."

2-1-21 at 0500 Pt #14 Location: Patient Room, Mesquite, Stolen Property: "...Entered the patient's room to take patient's vitals and found the tablet covered with his/her pillow...."

2-1-21 at 0730 Pt #14 Location: Nursing Station, Mesquite, Stolen Property: "...Pt took the ipad from the nurses station and put it in his room and denied taking it. Ipad was found in patient's room inside pillow case and the cover was in the trash can covered up...."

2-4-21 at 0245 Pt #14 Location: Nursing Station, Mesquite, Stolen Property: "...the unit iPhone was discovered missing...it was last seen at the back nurses station on the counter...a room search was conducted on Pt due to previous searches coming up with ipads in patient's room...the phone was not located at this time but a Bluetooth speaker that belongs to the unit was located wrapped up in multiple socks...a later search of the patient's room...turned up the cell phone hidden in the patient's pillow. There is damage to the back glass of the phone as well...."

A tour of Mesquite Unit was conducted on 04/13/21 with Employee #2. Two separate nursing stations were observed. The two nursing stations had counters that could be easily crossed or reached across by a patient. The counters were substantially lower than those observed on the Palo Verde and Juniper Units. There were no doors or gates blocking access to either nursing station, each housing computers, ipads and patient charts.

A tour of Mesquite Unit was conducted on 04/15/21. Approximately 20 medical records were observed to be unsecured at the nursing station. The RN was conducting q-15 minute checks of the patients. There was no BHT at the nursing station.

Employee #24 confirmed during interview on 4/13/21, that the gates to both nursing stations on Mesquite Unit have been missing for quite some time, having been ripped from the hinges by patients. Employee #24 relayed that s/he does feel that both nursing stations on Mesquite Unit are currently unsafe with no gates/doors and the current height of the nursing counter and no shield separating the patients from staff. Employee #24 relayed during interview that ipads are used by both BHT's and RN's for documenting patient rounding's. The information from the ipads are then transferred via computer to the individual patient charts. Employee #24 revealed that there is not a way to secure the patient charts at the two nursing stations on Mesquite Unit, as the nursing stations are not secured. Employee #24 confirmed that the intent is for at least one staff member to be at the nursing station at all times, but that the station may be left unattended in the case of a patient outburst.

Employee #15 confirmed during interview on 4/15/21 at 0939 that s/he has worked the Mesquite Unit. Employee #15 revealed that s/he does not remember how long the doors have been missing or where they were placed upon removal. Employee #15 relayed that in event of an emergency situation, a code would be called, and whomever is manning the nurses station would probably leave said station until additional help arrives, explaining that "Safety comes first".

Based on review of policy and procedure, documentation, direct observation and interview, it was determined that the administrator failed to ensure that the facility premesis were kept free from a condition that may cause an individual to suffer physical injury which poses a potential risk for patients, staff, and/or equipment to become seriously injured or damaged.

Findings include:

Policy titled "Emergency Operations Plan - Haven Phoenix, #8605036, Revised 09/2020, revealed: "...Haven-Phoenix has an emergency preparedness program designed to provide for effective utilization of available resources so that patient care is maintained in the event of a...internal emergency...The Emergency Operations Plan is an "all hazards" response plan. The initial step in responding to any emergency is implementation of the immediate action procedures outlined in the specific policies for the specific occurrence...The hospital attempts to mitigate any event by participating in activities that help prevent emergency or reduce the chance of an emergency happening. Recent construction with behavioral health care hospital grade fixtures assists in mitigation as well as regular monthly, quarterly and annual systems inspections and checks to pre-actively identify areas for improvement...Conducting monthly...Safety meetings and including building representation assists in preparedness...Review of actual events help to identify areas of weakness to address and strengths...Emergency Codes Used...Code Gray-Combative Patient...."

Policy titled "Safety Management Plan", #9462730, Revised 03/2021, revealed: "...To promote a culture of safety to eliminate preventable patient harm by...equipping patient-care staff, patients...to safe practices through identification of safety risks and the planning and implementing of processes to minimize the likelihood of those risks...The scope of the Safety Management Plan defines the processes which the Hospital utilizes to provide our patients, staff...with a physical environment free of hazards and manages activities pro-actively through risk assessment to reduce the risk of injuries to patients, staff...The objective of Hospital's Safety Management Plan is to know and prevent potential safety hazards to our patients, staff...The goals of Hospital's Safety Management Plan include...Maintain a safe environment and conditions for patients, staff...Reduce and control environmental hazards and risks of safety-related incidents...Reduce and prevent accidents and injuries to patients, staff...The CEO...has delegated to the Safety Committee...the authority to take action when hazardous conditions or potential hazardous conditions exist...Any risks that are identified through proactive risk assessments, environmental tours, reporting mechanisms, etc., will be evaluated, selected and have procedures and controls put into place to reduce to the lowest possible point the adverse impact on the safety and health of patients, staff..Risks identified may include patient safety issues and employee safety...employee injury...The Safety Committee shall review all summaries of property damage...or injuries to patients...staff...Safety hazard reports will be received by the Safety Officer and will be tracked, investigated and repaired/corrected as needed...The Safety Committee will provide safety-related information through...By recommending purchase of safety equipment and suggesting any necessary physical changes to improve safety conditions...."

Policy titled "Behavioral Management and Code Response", #9143645, Revised 12/2019, revealed: "When a patient demonstrates a loss of self-control, and/or becomes aggressive toward others, all safety measures shall be provided to the patient...and staff...All staff receive training related to de-escalation and skill techniques that supports the clinical philosophy of the hospital which stresses the importance of safety, non-violence...Staff will attempt to verbally assist the patient to maintain self-control...Staff will not attempt to approach patient until adequate help is available...."

Facility "Incident Log" revealed 21 incidents of attacks to the two nursing stations on the Mesquite Unit for the time period of 10/09/2020 through 04/13/2021. Mesquite Unit is a high acuity, court ordered treatment unit. These attacks included injuries to staff, damage to equipment, and theft of equipment and personal nursing items. Findings include:

10-9-2020 at 0730 Pt #20 Location: Nursing Station, Mesquite: "...Patient reached over nurse station and stole a cup of coffee sitting on desk that belonged to staff. Empty contents later recovered...."

10-17-2020 at 1755 Pt #21 Location: Nursing Station, Mesquite: "...Patient approached nursing station stating BHT at the nursing station was calling her names. RN attempted to redirect patient and informed patient that the BHT was not calling her names. She was just asking both RNs at the nursing station a question. Patient then walked toward BHT to strike so RN stepped in the way...."

11-15-2020 at 1330 Pt #22 Location: Nursing Station, Mesquite: "...Patient then knocked over computer monitor at Front Nursing Station and walked off to room. As Techs began to approach patient she then turned around and went into provider room where she knocked all patient binders on to floor and then pushed computer monitor to floor...."

11-16-2020 at 1435 Pt #23 Location: Nursing Station, Mesquite: "...Patient came up to nurses station...Patient became upset and started yelling hovering over the nurse desk throwing anything her hands can reach, phone, water jug at the nurses and ripping all the paper sticking to the nurses desk...."

12-20-2020 at 1902 Pt #24 Location: Patient Room, Mesquite: "...Patient manic and aggressive. Reached behind nurses station and grabbed 2 nicotine gum...."

12-26-20 at 1705 Pt #25 Location: Nursing Station, Mesquite: "...Patient...grew frustrated, she appeared to be tense and angry, and pushed a computer screen into a nurse's face when the nurse was sitting at the desk. The nurse immediately righted the computer screen and then held her mask to her nose in order to try to staunch the blood flow...staff intervened to encourage the staff who was injured out of the situation to a place where she could recover...."

1-17-21 at 1500 Pt #26 Location: Nursing Station, Mesquite: "...Patient appeared to be upset...at that point patient went to the nurses station and picked up the computer and dropped it down...."

1-17-21 at 1855 Pt #26 Location: Nursing Station, Mesquite: "...Patient became verbally aggressive and approached the nurses station. Patient again became verbally aggressive and attempted to grab the telephone and computer. Upon grabbing for the computer, patient was able to push it down and caused damage to the computer monitor...."

1-26-21 at 1045 Pt #13 Location: Nursing Station, Mesquite: "...Patient observed talking on the cordless phone to clinic, passing the nursing station, Pt suddenly yells...and violently threw the phone towards the nursing station. Phone almost hit staff, peer suddenly caught it before it hits staff...."

1-26-21 at 1630 Pt #15 Location: Nursing Station, Mesquite: "...Patient was on unit pushing over computers on the nurses station...."

1-29-21 at 2240 Pt #26 Location: Nursing Station, Mesquite: "...Patient was agitated and uncooperative. Patient came to the nursing station...patient became upset, lifted the computers and destroyed the screen of one of them...."

1-30-21 at 2030 Pt #14 Location: Patient Room, Mesquite, Stolen Property: "...saw a light trying to come from under patient's blanket...When we lifted up the blanket we found the ipad without the case...."

2-1-21 at 0500 Pt #14 Location: Patient Room, Mesquite, Stolen Property: "...Entered the patient's room to take patient's vitals and found the tablet covered with his/her pillow...."

2-1-21 at 0730 Pt #14 Location: Nursing Station, Mesquite, Stolen Property: "...Pt took the ipad from the nurses station and put it in his room and denied taking it. Ipad was found in patient's room inside pillow case and the cover was in the trash can covered up...."

2-2-21 at 2334 Pt #26 Location: Patient Room, Mesquite: "...Patient is threatening to harm staff stating s/he was "going to cut everyone's boob". Patient shoved the computer monitor, RN was able to catch it before it fell...Patient was unable to be redirected...."

2-3-21 at 1845 Pt #15 Location: Nursing Station, Mesquite: "...Patient is upset and angry...is quickly walking between nursing stations, yelling and cursing at staff...was not able to be redirected...patient picked up the nursing station phone in an attempt to throw it...writer was able to take the phone from patient before patient was able to throw it. The patient continued to try to grab the phone to throw it, when patient was not able to, patient threw multiple punches with a closed fist at this writer striking me multiple times in the hands and fingers while attempting to block patients punches. Staff was able to direct patient's attention elsewhere and take pt out of the area...."

2-4-21 at 0245 Pt #14 Location: Nursing Station, Mesquite, Stolen Property: "...the unit iPhone was discovered missing...it was last seen at the back nurses station on the counter...a room search was conducted on Pt due to previous searches coming up with ipads in patient's room...the phone was not located at this time but a Bluetooth speaker that belongs to the unit was located wrapped up in multiple socks...a later search of the patient's room...turned up the cell phone hidden in the patient's pillow. There is damage to the back glass of the phone as well...."

2-8-21 at 0815 Pt #26 Location: Nursing Station, Mesquite: "...Patient at nurse's station agitated and wanting to leave. Pt shoved the monitor and broke it...."

3-15-21 at 0745 Pt #16 Location: Nursing Station, Mesquite: "...Patient refused a.m. meds and has been refusing medication, which has caused an increase in paranoia and delusional thought process. Patient came up to the nurses station this a.m. charging at the nurse in a threatening manner yelling that the white Americans were going to kill him because he is [Muslim]...."

3-22-21 at 1608 Pt #17 Location: Nursing Station, Mesquite: "...Pt got agitated while RN was doing an admission and came over behind the nursing station and tried to grab and throw things. Staff tried to talk to her but she wouldn't come out so they escorted her out...."

4-13-21 at 0855 Pt #18 Location: Nursing Station, Mesquite: "...Patient becomes irritable...he then walked up to the nursing station and picked up the computer monitor and slammed it on the desk...."

A tour of Mesquite Unit was conducted on 04/13/21 with Employee #2. Two separate nursing stations were observed. The two nursing stations had counters that could be easily crossed or reached across by a patient. The counters were substantially lower than those observed on the Palo Verde and Juniper Units. There were no doors or gates blocking access to either nursing station, each housing computers, ipads and patient charts.

Employee #24 confirmed during interview on 4/13/21, that the gates to both nursing stations on Mesquite Unit have been missing for quite some time, having been ripped from the hinges by patients. Employee #24 relayed that s/he does feel that both nursing stations on Mesquite Unit are currently unsafe with no gates/doors, and the height of the nursing counter.

Employee #15 confirmed during interview on 4/15/21 at 0939 that s/he has worked the Mesquite Unit. Employee #15 revealed that s/he does not remember how long the doors have been missing or where they were placed upon damage by patients. Employee #15 relayed that in event of an emergency situation, a code would be called, and whomever is manning the nurses station would probably leave said station until additional help arrives, explaining that "Safety comes first".

Based on review of facility policies/procedures, observation on tour, and interviews, it was determined that the administrator failed to require that expired supplies, used for patient care, were discarded and not used after the expiration date. This deficient practice poses a potential risk to the health and safety of the patients, including risk for infection, negative outcomes, and/or false laboratory testing when the facility cannot ensure that expired supplies are being discarded and are not being used for patient care.

This is a repeat deficiency, previously cited on 09/17/2020.

Findings include:

Policy titled "Storage of Patient Care Supplies", #8855766, Approved 11/2020, revealed: "...All patient care supplies will be stored in a manner consistent with State and Federal law, Joint Commission Standards, and the highest standards of professional practice...b. Monitoring: It is the responsibility of the nursing staff to ensure that storage standards on the nursing unit are inviolate. Nursing staff will inspect integrity of the patient care supplies routinely inspecting that the supply is not expired and if so will be discarded properly. The Director of Nursing will assume responsibility in this function through that department's monthly nursing unit inspections. Any deviations from these standards will be documented by the Director of Nursing or designee on the Leadership Rounding tool. Once the inspection is complete, the results will be shared with the unit nurse. The results of units inspections will be reviewed during monthly Quality and Safety committees for resolution and action steps. Discussions of non-compliance of these standards and any subsequent plan of correction will be facilitated through the Quality and Safety committees...."

Observations on tour conducted 04/15/21, throughout the hospital's premises revealed the following:

A total of three hundred and thirty-six (336) expired supplies, with outdates ranging from 11/05/2020 through 03/31/2021, were found. The expired supplies were collected and given to Employee #1.

Employee #1 confirmed that the identified supplies were expired.

Based on review of the Emergency Plan (EP), record review, and staff interview, it was determined the facility failed to develop a means for sharing information on occupancy, needs, and it's ability to provide assistance to the authority having jurisdiction. Failure to develop a means to report occupancy levels and/or needs may result in patients not receiving care and services as needed.

Findings include:

Observations during EP review on April 14, 2021, revealed the facility's Emergency Plan documentation related to requirements for a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center did not include a method to share occupancy levels and/or facility needs to other facilities or to the authority having jurisdiction or the Incident Command Center.

During the exit interview on April 14, 2021, the above finding was again acknowledged by the management staff.