The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HAVEN BEHAVIORAL HOSPITAL OF PHOENIX 1201 SOUTH 7TH AVENUE, SUITE 200 PHOENIX, AZ 85007 Oct. 25, 2016
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy/procedures, medical records, hospital documents, interviews, and Nursing Assignment Sheets, it was determined that the hospital failed to ensure an adequate number of registered nurses (RN)s, based on the hospital's requirement for staffing according to patient acuities, for 3 of 3 patients who fell during hospitalization (Patient #'s 2, 4 and 5). This deficient practice posed the risk that patients would not receive individualized patient care, as evidenced by nursing failure to:

1. identify/assign correct acuity levels for 3 of 3 fall patients, according to the "Acuity and Staffing Sheet" (Patient #'s 2, 4, and 5); and

2. meet the "Acuity and Staffing Sheet" requirement for "RN Maximum Patient Acuity and/or RN Maximum Patient Assignment" for 3 of 3 fall patients (Patient #'s 2, 4, and 5).

Findings include:

The hospital policy/procedure titled Acuity Based Staffing-Phoenix requires, "...Staffing for patient care is based on acuity and level of care needed...To provide an assessment tool based on patient behaviors and needs for the psychiatric patient...framework for nursing staff to evaluate the nurse-to patient ratio and nursing level of care needed...adequate coverage and ensure a safe and therapeutic environment...It is the responsibility of nursing leadership to ensure that the acuity patient level is consistently utilized in order to provide the staffing required for patient care...Patients will be assigned an acuity level of a Level 3, 2 or 1 based on the assigned category...."

The hospital document titled Acuity and Staffing Sheet requires,"...ACUITY rating: ...Level 1:...Low fall risk...Level 2:...Moderate to High fall risk...Level 3:...Line of sight ordered by MD...Recent fall (<8 hrs)...."

The Director of Education stated during an interview conducted on 10/20/16, that the hospital staffs 3 shifts: Day, Evening, and Night.

The Director of Nursing (DON) confirmed during an interview conducted on 10/25/16, that RNs assess and assign patient acuities and staffing "every shift".

1. Patient (Pt) #2's medical record revealed:

Nursing identified the patient as a "moderate fall risk" on the "Psychiatric Falls Risk Assessment, Admission Assessment'' on 6/19/16. Policy requires the patients' fall risk assessment re-evaluation every 3 days, however the nursing staff did not document any re-evaluations. The Acuity and Staffing Sheet required that a patient with a Moderate to High fall risk be scored Acuity Level 2.

Nursing Assignment Sheets 7/1/16 through 7/20/16 revealed:

Nursing recorded Acuity Level 1 as follows:

06/30/16: Night (shift)
07/01/16: Day, evening and night
07/03/16: Day, evening and night
07/04/16: Day. The patient fell during the shift and was transferred to an acute medical center for evaluation, treatment. Nursing completed a "Post Fall Assessment" and documented the patient was now "Highest Risk", requiring Acuity Level upgraded to 3 for 8 hours post fall and then lowered to a 2, per policy.
07/04/16: Evening Acuity Level 1
07/05/16: Day no acuity, evening and night Acuity Level 1
07/06/16: Evening and night Acuity Level 1
07/07/16: Day no acuity, evening and night Acuity Level 1

The physician ordered on [DATE] at 0900, "Line of sight for 24 hours." The Acuity and Staffing Sheet requires "Line of Sight" as Acuity Level 3.

07/19/16: Day and evening no acuity.
07/19/16: Night Acuity Level 1.
07/20/16: Day Acuity Level 2.

The DON and Chief Executive Officer (CEO) confirmed during interviews conducted on 10/25/16, that the nursing staff did not score Pt # 2's Acuity Levels according to the Acuity and Staffing Sheets required criteria.

Pt # 4's medical record revealed:

Nursing identified the patient as a "high fall risk" on the "Psychiatric Falls Risk Assessment, Admission Assessment'' on 7/12/16, which required a fall risk evaluation every day. The Acuity and Staffing Sheet required Acuity Level 2 assigned for any patient with high fall risk score.

Nursing Assignment Sheets 7/12/16 through 7/19/16 revealed:

07/12/16: Night Acuity Level 1
07/13/16: Night no acuity
07/14/16: Day. The patient fell during the shift. Nursing completed a "Post Fall Assessment" and documented the patient was now "Highest Risk", requiring Acuity Level upgraded to Level 3 for 8 hours post fall. Pt #4 required transport to an acute medical center for evaluation and treatment.
07/14/16: Evening Acuity Level 2
07/15/16, 07/16/16 and 07/18/16: Night Acuity Level 1
07/19/16: Evening no acuity

Pt #5's medical record revealed:

Nursing identified the patient as a "high fall risk" on the "Psychiatric Falls Risk Assessment, Admission Assessment'' on 05/13/16. This required a fall risk evaluation every day. The Acuity and Staffing Sheet required Acuity Level 2 for any patient with high fall risk.

Nursing Assignment Sheets 5/13/16 through 5/21/16, revealed:

05/15/16: Day Acuity Level 1. Pt #5 fell at approximately 1930. The LPN completed a "Post Fall Assessment" and documented the patient was now "Highest Risk" requiring Acuity Level upgraded to Level 3 for 8 hours post fall.
05/15/16: Night Acuity Level 1
05/17/16 at 1530 the physician ordered "Line of Sight while awake"(Level 3).
05/17/16 and 05/18/16 Day Acuity Level 1
05/18/16 and 05/19/16: Night Acuity Level 1
05/20/16: Evening Acuity Level 2
05/20/16: Night Acuity Level 1
05/21/16: Day Acuity Level 1

Pt #5 was discharged on [DATE]. The physician's order for "Line of Sight" was not discontinued and still in place at the time of discharge.

The DON confirmed during interview conducted on 10/21/16, that nursing did not score Pt #s 2, 4 and 5, Acuity Levels according to the Acuity and Staffing Sheet requirements.

2. The hospital document titled Acuity and Staffing Sheet requires, "...STAFFING: Days RN maximum (max) acuity 22 RN max patient assignment 10...Eve RN max acuity 22 RN max patient assignment 10...Night RN max acuity 26...."

Nursing Assignment Sheets indicated nurse-to-patient assignments as follows:

05/17/16 and 5/18/16: Day RN #18 assigned 12 patients with total Acuity 24.

07/2/16: Evening RN #16 assigned 15 patients with a total Acuity 30.

07/4/16: Day RN #19 assigned 15 patients. Pt # 2 sustained a fall with head injury.

07/5/16: Day RN #19 assigned 15 patients with no Acuity Levels for any of the 15 patients.

07/7/16: Night RN #23 assigned patients with total Acuity 29.

07/13/16: Day RN #22 assigned 13 patients.

07/14/16 and 07/15/16: Day RN #22 assigned 14 patients with total Acuity 28 both dates.

07/19/16: Evening RN #20 assigned 12 patients with no acuity scores documented.

07/20/16: Days RN #20 assigned 12 patients.

The DON confirmed during interview conducted on 10/21/16, that the RNs exceeded the Maximum RN to Patient Acuity as required in the Acuity and Staffing documents and further confirmed the RNs' patient assignments exceeded the maximum number allowed according to the hospital's Acuity and Staffing requirements.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies/procedures, hospital documents, medical records and interviews, it was determined that a registered nurse (RN) failed to assess, direct and evaluate nursing services provided to 3 of 3 patients who sustained falls during hospitalization (Pt #'s 2, 4 and 5). This deficient practice posed the risk that necessary care is not provided according to individualized patient needs as evidenced by the failure to require nurses:

1. re-evaluated 3 of 3 fall patients post fall, according to policy (Pt #'s 2, 4 and 5);

2. implemented the "Fall Reduction Treatment Plan" for 1 of 3 patients who sustained a fall requiring transport to an acute medical center (Pt # 2);

3. complete and document post fall assessments for 2 of 3 patients (Pt #'s 2 and 5);

4. complete neurological assessments, as ordered and per Job Description, for 1 of 1 patient who sustained a fall and required neurological assessments (Pt #5);

5. documented assessments for 2 of 3 fall injured patients before and/or after transport to an acute medical hospital (Pt #'s 2 and 4);

6. implemented the physician's orders for suture removal for Pt #2; and

7. ensure 1 of 1 patient was bathed and weighed, per policy. (Pt #5)

Findings include:

Hospital policy/procedure titled "Falls Prevention and Monitoring", last revised 03/2016, requires: "...nursing staff will assess and re-assess the patient's level of risk for fall and implement appropriate interventions...All patients admitted to the hospital will be assessed using the Psychiatric Falls Risk Assessment as part of the Nursing Assessment...each patient will be placed in a risk category...10-17: Moderate risk for falls...Reevaluation every 3 days...18-24: High risk for falls...Reevaluation daily...25+: Highest risk for falls...Patient fall risk to be evaluated each shift...."

1. Pt #2's medical record revealed:

The RN completed the "Psychiatric Falls Risk Assessment, Admission Assessment", on 6/19/16. The RN recorded "Moderate Fall Risk". Nursing found Pt #2 on the floor in the bathroom after an unwitnessed fall on 07/04/16. The patient required suturing and transfer to an acute medical center. Nursing documented the "Post Fall Assessment" on 7/4/16, at 1145 indicating "Highest Risk". The medical record did not contain any further fall risk assessments 7/4/16 through 7/20/16.

Pt #4's medical record revealed:

The RN completed the "Psychiatric Falls Risk Assessment, Admission Assessment", with score of "25" indicating "Highest Risk" on 07/12/16. Nursing did not document another Fall Risk Assessment until the patient fell on [DATE] while attempting to get up from his/her wheelchair. The RN completed a "Post Fall Assessment" and scored "31" indicating "Highest Risk". The patient required transfer to a medical center. Nursing did not document any additional fall risk assessments, 7/14/16 through 7/19/16, as policy requires.

Pt #5's medical record revealed:

Admission RN completed the "Psychiatric Falls Risk Assessment, Admission Assessment", on 5/13/16 with score of "23" indicating "High". Nursing found Pt #5 on the floor after an unwitnessed fall on 5/15/16, at 1930. The LPN documented "No apparent injury" and completed a "Post Fall Assessment" with score of 25 indicating "Highest fall risk".

Nursing did not document any further risk assessments, 05/15/16 through 05/21/16.

The Director of Clinical Education, and the DON confirmed during interviews conducted 10/20/16, 10/21,16 and 10/25/16, that nursing did not follow the hospital's Fall Prevention and Monitoring policy/procedure requiring fall risk assessments conducted and documented every shift.

2. The hospital policy "Falls Prevention and Monitoring" requires: "...interventions to be individualized to patient's needs...."

Pt #2' medical record revealed:

The RN documented the admission "Interdisciplinary Treatment Plan-Problem Page" on 6/19/16, that included a Falls Risk Reduction Treatment Plan requiring nursing interventions as follows: "...Monitor environment for wet or slippery floors during the shift...wear skid proof socks...."

The RN documented Pt #2's fall on 7/4/16, at 1145, as described in section #1.

Director of Risk Management documented that Pt #2 "...described having difficulty operating the water flow...feeling secure on the shower floor...came out of the shower...and then fell ...." on 7/20/16.

Director of Risk Management confirmed during an interview conduced on 10/21/16, that nursing did not follow the individualized interventions for Pt #2 for monitoring the environment for wet or slippery floors and wearing skid proof socks.

3. The policy titled Assessment/Reassessment required, "...Reassessments...are completed by the RN on each shift on the 24 hour Nursing Reassessment form...In addition, each patient is reassessed as necessary based on the patient's plan for care or change in their condition...."

Pt #2's medical record revealed:

The patient fell during the day shift on 7/4/16, requiring transfer to an acute medical center for evaluation and suturing. The evening RN did not complete a complete shift reassessment as required when the patient returned.

The DON confirmed, during interview conducted on 10/25/16, that the RN did not complete and document the Evening Shift reassessment on 7/4/16, as required per policy.

Pt # 4's medical record revealed:

Night LPN #24 completed the "24 hour Nursing Reassessment" on 7/17/16.

The DON confirmed, during interview on 10/25/16, that the RN did not complete and document the Night Shift 24 Hour Reassessment on 07/07/16, as required by policy.

Pt # 5's medical record revealed:

The patient sustained a fall during the evening shift, on 5/15/16.

The Evening LPN completed the 24 hour Nursing Reassessment form on 5/17/16. The RN did not complete the assessment on 5/17/16, as required by policy.

The DON confirmed, during interview conducted on 10/21/16, that the RN did not complete and document the above Evening Shift reassessments as required.

4. The policy titled Job Description, Job Title: Registered Nurse (RN) requires: "...Conducts patient assessments and provides nursing interventions to patients as assigned...reassessments...any time a change in status...Document...nursing notes...."

The policy titled Job Description, Job Title: Licensed Practical Nurse (LPN) requires: "...Under the supervision of the Registered Nurse, provides direct patient care to patients as assigned...as directed by the Charge Nurse...Document...patient observations/activity, medication administration, patient education, incident reports and medication variances...."

Pt #5's medical record revealed:

LPN #8 documented the "Psychiatric Falls Risk Assessment, Post Fall Assessment" on 5/15/16, at 1930, "...Pt found on floor-unwitnessed fall. No apparent injury noted. Neurological checks implemented (with) MD order...."

LPN #8 documented MD #3's telephone order: "Neurochecks due to fall"
on 5/15/16, at 1935.

LPN #8 documented the patient's "Neurological Assessment" on 5/15/16, at 1930, 1945, 2000, 2015, 2045, 2115, 2145 and 2215. Medical record contains no documentation by a registered nurse.

The DON confirmed, during interview conducted on 10/21/16, that the RN is required to complete all assessments of patients, including the Fall Risk Assessment and the Neurological Assessment. Only RNs complete patient assessments.

5. The policy titled Transfer, Patient requires, "...The registered nurse will assess the patient before transferring and upon return...."

Pt #2's medical record revealed that the RN did not document an assessment before or after the patient's transfer to an acute care medical center for evaluation post fall, and return on 07/04/16.

The DON confirmed, during an interview conducted on 10/25/16, that nursing did not assess Pt # 2, as required by hospital policy.

Pt #4's medical record revealed that the RN documented Pt # 4 was transported to an acute medical center after a fall with head injury/laceration on 7/14/16, at 0945. The RN did not document an assessment upon the patient's return from the acute medical center.

The Director of Education confirmed, during interview conducted on 10/20/16, that nursing did not assess the patients upon return from the acute medical center, as required by hospital policy/procedure.

6. The Job Description titled Registered Nurse (RN) requires, "...Review practitioner orders...and treatment team documentation daily to ensure the treatment plan is current and fully implemented...."

Pt # 2's medical record revealed:

The physician ordered, "...Remove scalp sutures-3 sutures-moisten area so that sutures can be visualized and removed...." on 7/18/16, at 1530.

RN documented on 07/19/16, at 1700"...Pt has scab to back of head with 3 blue stitches...."

The DON confirmed, during interview conducted on 10/25/16, that there was no documented evidence that nursing implemented the physician's order to remove Pt # 2's scalp sutures on 07/18/16.

7. Job description policy titled "Registered Nurse" requires, "...Provides supervision to Licensed Practical Nurses and Behavioral Health Technicians (BHT)...."

"RN Skills Competency Check Off" document requires, "...Skin Care...Ensure patient bathing and ADL's (Activities of Daily Living) are completed, assists BHT as necessary...."

"BHT Clinical Skills Competency Checklist" requires: "...Skin Care...Patient care regarding completion of ADL's (bathing, peri care, oral care and overall hygiene)...."

Policy/procedure titled Vital Signs requires, "...Weights will be taken upon admission and then weekly unless ordered more frequently...Pericare and bathing will also be documented...."

Review of Pt #5's medical record revealed:

No documented evidence that the staff bathed or showered the patient on 5/14/16, 5/15/16 and 5/17/16 through 5/21/16.

No documented evidence of patient's weight at the time of admission, or on any date during the patient's hospitalization [DATE] through 6/21/16.

The DON and BHT #17 confirmed during interviews conducted on 10/25/16, that Pt #5 was not bathed or weighed, as required by hospital policy/procedure.