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.

ARIZONA STATE HOSPITAL 2500 EAST VAN BUREN STREET PHOENIX, AZ May 26, 2015
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview and observation, it was determined the Director of Nursing failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the qualification based on competencies of the staff, which is a potential risk of harm to patients, if they are cared for by potentially unqualified staff.

Findings include:

The Mental Health Program Specialist (technician) (MHP's)stated during an interview on 05/20/2015, that he is given the names of the staff who will be working his shift and then he assigns the other MHP's to the patient care. This includes who will be caring for the individuals who are identified as 1:1, those on Close Observation. These assignments are made at the beginning of the shift and adjustments are made by the MHP's as the shift continues when there is a need for adjustments.

A registered nurse is not assigning care of each patient to other nursing personnel. This is being completed by a Mental Health Program Specialist.

A night shift RN revealed during an interview conducted on 05/26/2015, that the RN identifies the lead technician for the shift and determines the number of techs to be assigned to each side of the central unit. Then the lead technician makes the assignments for the technicians. The RN signs off on the assignments. The lead technician assigns the duties of each of the technicians.

A MHP confirmed during an interview on 05/26/2015, the information related to the MHP's completing the assignments and the RN signing off.

The hospital is under the state licensing rules, which required clinical oversight for the MHP's. The surveyors reviewed personnel files for the MHP's who are assigned to patient care and who make assignments for themselves.

Eight (8) of the twelve (12) personnel records for the MHP's were reviewed. The records for personnel #1, #2, #3, #5, #6, #8, #10, #12 did not contain documentation provided at the time of the survey to substantiate clinical oversight was provided by a Behavioral Health Professional. There was no documented evidence of supervision of the care being provided to patients by the MHP's.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on a review of documents, observations, and interviews, it was determined the governing body failed to ensure the hospital's systems and processes were identified and implemented to provide safe care and protect the patient's rights as evidenced by the following deficient practices.

Findings include:

The Condition level deficiency is the result of the Condition level and standard deficiencies found under the Conditions of Patient Rights, Quality Assurance and Performance Improvement QAPI), and Nursing Services in the following tags:

Tag 0115 Patient Rights: The Governing Body's failure to ensure the safety of patients and minimize the risk for adverse events, which has the potential risk for patient harm if safety issues and adverse events are not reviewed and addressed as evidenced by:

Tag 0119: Patient Rights: The Governing Body failed to ensure for 1 of 1 patient grievances reviewed there was a prompt investigation and the investigation followed the approved policies and procedures of the hospital's governing body;

Tag 0144: Patient Rights: The Governing Body failed to ensure patients received care in a safe environment as evidenced by: the Director of Nursing failed to ensure that rounds were made every 30 minutes to the patient rooms to ensure safety of the patient; the administration failed to rectify a documented shortage of staff radios used to summon staff to the site of an emergency behavioral situation; staff failed to perform Close Observation/15 Minute Checks; and the administrator failed to ensure there is adequate staffing on the "mall" to monitor the patients when patients are allowed to walk the mall area;

Tag 0166: Patient Rights: The Governing Body failed to ensure that the use of restraint and seclusion be in accordance with the patient's plan of care; and

Tag 0168: Patient Rights: The Governing Body failed to ensure that physical restraints, seclusions and mechanical restraints were implemented upon the order of a licensed independent practitioner (LIP) as required by hospital policy/procedure.

Tag 0263 Quality Assurance and Performance Improvement: The Governing Body failure to develop, implement and maintain an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement program as evidenced by there not being an approved quality assessment and improvement program approved by the governing body for the years of 2014 and 2015 as evidenced by:

Tag 0283: Quality Assurance and Performance Improvement: The hospital failed to identify indicators and set priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement which is a high potential risk of harm for patients when patient related issues i.e. seclusion and restraint usage, adherence to treatment plans and adverse events were not analyzed and addressed;

Tag 0286: Quality Assurance and Performance Improvement: The Governing body, medical staff and administrative officials failed to ensure the hospital-wide quality assessment and performance improvement efforts addressed patient safety, as evidenced by there not being any process or system in place to analyze and evaluate patient events or incidents that are documented as occurring within the hospital;

Tag 0308: Quality Assurance and Performance Improvement: The hospital's Governing Body failed to ensure the Quality Program reflected the complexity of the hospital's organization and services, which is a high potential risk for adverse outcomes for a vulnerable class of patients if their care issues are not addressed and evaluated; and

Tag 0309: Quality Assurance and Performance Improvement: The Governing Body, medical staff and administrative officials failed to assume the legal authority and responsibility to have a current quality performance improvement program, determined the number of distinct improvement projects conducted annually and defined a program for patient safety to address the patient/staff safety concerns; as evidenced by no documented improvement projects identified in 2015, the facility dashboard trends showing an increase in restraints, mechanical restraints and seclusion with no discussion why, and a 26% increase in patient complaints with no discussion why.

Tag 0385 Nursing Services: The hospital's failure to ensure nursing services were furnished and/or supervised by a registered nurse as evidenced by the following failures:

Tag 0386: The Director of Nursing failed to determine the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital by following the approved staffing plan, determining the skill mix required to meet patient needs, having accurate and consistent documents to demonstrate the staffing and assignments, and maintain adequate professional RN (registered nurse) staff on a unit to direct and evaluate patient care;

Tag 0395: The Director of Nursing failed to ensure that a registered nurse supervise and evaluate the care provided to patients as evidenced by the RN's failing to ensure documentation of patient observations; supervision of patients when one of the patients was on close observation line of sight orders; wound care was provided as ordered; patients were maintained in a safe environment; and physician orders were followed to monitor patients for weights, intake consumption of fluids and vital signs documents when a patient was identified at potential risk;

Tag 0396: The Director of Nursing failed to ensure nursing care plans were initiated and kept current based on the patient's needs in 23 of 23 medical records reviewed; and

Tag 0397: The Director of Nursing failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the qualification based on competencies of the staff, which is a potential risk of harm to patients if they are cared for by potentially unqualified staff.

The cumulative effect of these systemic failures has resulted in the hospital being out of compliance with the condition of Governing Body that demonstrated lack of responsibility for the operation of the facility resulting in adverse patient outcomes.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document reviews, interviews, and observations,it was determined, the hospital failed to require policies and procedures were implemented to protect the rights of patients as evidenced by the hospital's failure to ensure the safety of patients and minimize the risk for adverse events, which has the potential risk for patient harm if safety issues and adverse events are not addressed.

Findings include:

The Condition level deficiency is the result of the standard deficiencies found under the Conditions of Patient Right in the following tags:

Tag 0119: The Governing Body failed to ensure for 1 of 1 patient grievances reviewed there was a prompt investigation and the investigation followed the approved policies and procedures of the hospital's governing body;

Tag 0144: The Governing Body failed to ensure patients received care in a safe environment as evidenced by: failing to ensure that rounds made every 30 minutes to the patient rooms to ensure safety of the patient; failing to rectify a documented shortage of staff radios used to summon staff to the site of an emergency behavioral situation; failing to perform Close Observation/15 Minute Checks; and failing to ensure there is adequate staffing on the "mall" to monitor the patients when patients are allowed to walk the mall area;

Tag 0166: The Governing Body failed to ensure that the use of restraint and seclusion be in accordance with the patient's plan of care; and

Tag 0168: The Governing Body failed to ensure that physical restraints, seclusions and mechanical restraints were implemented upon the order of a licensed independent practitioner (LIP) as required by hospital policy/procedure.

The cumulative effect of these systemic failures resulted in the hospital's inability to protect and promote the patient rights.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on review of policies and procedures, facility documentation and staff interview, it was determined that the hospital failed to ensure that patient # 13's grievance was investigated within the time frame in the hospital approved and documented policy and procedure and the Arizona Administrative Code, Title 9, Chapter 21, as evidenced by 1 of 1 patient grievances reviewed revealed a patient grievance written on 7/11/14, was received at the "Arizona State Hospital Patient Rights Office" on 7/17/14, and the investigation did not begin until 10/16/14, 3 months after the grievance was received.

Findings include:

Based on review of facility policy and procedure titled "PATIENT GRIEVANCE, APPEAL, COMPLAINTS" revealed: "...It is the policy of the Arizona State Hospital (ASH) to preserve the humane statutory and constitutional rights of patients ...NOTE: Complaints/Requests for Investigations about alleged situations that endanger the patient, such as neglect or abuse, shall be reviewed immediately...For Requests for Investigation regarding SMI (Severely Mentally Ill ) patients, follow ADHS/DBHS Policy GA 3.1, "Conduct of Investigations Concerning Persons with Serious Mental Illness" which is now SECTION: 7: Chapter 1800: POLICY: 1803...Responsible Person: Chief Executive Officer or designee...Acknowledge (verbally or in writing) the complaint within five (5) working days of the receipt...Review, research and resolve complaints within a timeframe that is based on the type and severity of the complaint, with a goal of reaching resolution within ten (10) working days, but not to exceed thirty (30) days...If resolution cannot be reached within thirty (30) days, provide the patient with written notification that the Hospital is still working to resolve the complaint and the anticipated resolution within ninety (90) days from the original receipt...AUTHORITY Arizona Administrative Code, Title 9, Chapter 21...."

Review of "Arizona Administrative Code...Behavioral Health Service for Persons with Severely Mental Illness...R9-21-406" revealed: "...Conduct of Investigation...Within 10 days...the investigator shall hold a private face to face conference with the person who filed the grievance... to learn the relevant facts...Within 15 days...but only after the conference with the person initiating the grievance...the investigator shall hold a private, face to face conference with the persons complained of or thought to be responsible for the rights violation...Within 10 days of completing all interviews with the parties but not later than 30 days...the investigator, shall prepare a written dated report briefly describing the investigation and containing findings of fact, conclusions, and recommendations...The investigator or any other official of a mental health agency acting according to this Article may secure and extension of any time limit provided in this Article with the permission of the director of the regional authority...R9-21-410. Miscellaneous...Request for extension time...The investigator or any other official of a mental health agency ...may secure an extension of any time limit provided in this Article with the permission of the director of the regional authority...."

Patient # 13 filed a grievance on 7/11/14, which involved sexual and physical abuse. The complaint was received at the "Arizona State Hospital Patient Rights Office" on 7/17/14. On 7/23/14, the patient was sent a letter that the grievance had been received.

On 9/25/14, 64 days later, a request was sent to the" Complaint, Grievance & (and) Appeals Manager" for a 30 day extension which was granted.

The investigation began on 10/15/14, with a private face to face conference with the complainant (patient # 13) and patient # 21 who was named in the grievance. However, there was no documentation that four (4) other persons named in the grievance had a private face to face conference within 15 days of the initial face

On 10/23/14 and 11/25/14, a request was sent to the Complaint, Grievance & Appeals Manager for a 30 day extension which was granted.

Employee # 15 verified, in an interview conducted on 5/20/15, that there was no full time investigator to investigate grievances and he/she was placed on this "Special Assignment" in late 9/14. Employee #15 also relayed that the 9/25/14, extension was filed greater than the date of when the complainant was to have had his/her initial conference. The conference with the complainant was not held until 10/15/14. Employee #15 confirmed there was no documentation that the other four person named in the complaint were interviewed.

Employee #1, verified in an interview conducted on 5/20/14, that there was not enough staff to investigate the grievances at the time patient # 13 submitted the grievance. The grievance was received in July of 2014 and not completed until February 2015.

There was no documented evidence the facility followed the procedures identified in the hospital policy and procedure.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a tour, video review, interviews, review of hospital policy/procedure and hospital documents, it was determined the hospital failed to ensure patients received care in a safe environment as evidenced by:

1. the Director of Nursing failed to ensure that rounds were made every 30 minutes to the patient rooms ,were conducted in a manner that would identify the patient was safe in the room and according to hospital policy and procedure;

2. the administration failed to rectify a documented shortage of staff radios used to summon staff to the site of an emergency behavioral situation, which resulted in injuries and loss of work by the RN (registered nurse) who was assaulted by Pt # 5;

3. the staff failed to perform Close Observation/15 Minute Checks on 1/8/15, which resulted in patient #8 swallowing a key and being sent to the emergency room and susequently admitted to the hospital; and

4. the administrator failed to ensure there was adequate staffing on the "mall" to monitor the patients when patients are allowed to walk the mall area.

Findings include:

1. The hospital policy on Census Management dated April 25, 2012 revealed the following: "... All patients in the care and custody (while on hospital ground) of Arizona State Hospital will have their location identified and documented every (30) minutes to ensure their well-being and whereabouts...Procedure A. Census Monitor...1. A nursing staff member will be assigned as Census Monitor throughout each shift...Shift Charge Nurse...7. During the night, when patients are in bed, the Census Monitor will ensure each patient is in his/her assigned bed and will also verify their well-being (Respirations are visible and the patient is in NO medical or psychological distress). a. Flashlights should include red colored lenses to prevent disturbing patients while allowing the Census Monitor full view of the patient...."

The surveyor reviewed the video of patient rounds for May 12, 2015 from 10 P.M. to 6 A.M. for the Ironwood unit North hallway. This video review was completed in the presence of the Director of Security. The video showed a male staff member doing rounds at 10:38 P.M. The video was slowed to normal speed. The surveyor observed the staff member opening the doors to the patient rooms and leaning his head into the room for approximately 2 seconds. The staff member did not go into any of the rooms. The next 30 minute rounds were observed and the technician who performed the procedure completed the rounds in the same manner as those conducted at 10:38. The rounds were reviewed on the video for 3:30 A.M. on May 13, 2015 and the same process was repearted by a third technician.

A tour of the patient rooms on Ironwood North was conducted on 05/19/2015. In the private patient rooms the head of the bed is at the furthest distance from the door. In order to view the patients upper body, you would need to enter the room. The semi-private rooms have the head of the bed on one wall and then the other head of the bed on the opposite wall. In order to view each of the patient's to determine if the patients were breathing and are safe, the staff member would need to go into the room and look at both patients.

On May 19. 2015, the Director of Nursing and the Assistant Director of Nursing was taken to the security area to view the same video. The Director and Assistant agreed that the census management being done on the night shift did not ensure the patient was breathing and/or the patient was safe in the environment.

2. Review of hospital policy titled Code Gray revealed: "...It is the policy of the (Name of Hospital) that an emergency code of 'Code Gray' will be utilized to summon additional personnel to the site of an emergency behavioral situation whenever it is determined that additional personnel are needed at the site to help de-escalate or help effectively manage the situation...Code Gray: An alert sent to Code Gray Response Team members to signify that additional personnel are requested to help manage a behavioral situation...Code Response members shall be identified on the assignment sheet each shift and assigned a pager...Staff shall call the Hospital Switchboard operator at 911 to initiate a Code Gray...Hospital Switchboard Operator shall page the Code Gray Response Team...shall announce over the radio the exact location of the Code Gray Incident...."

Review of hospital documentation of Pt # 5's assault of a unit RN revealed: "...5/13/15...Time: 1258...code gray was called...(Pt #5) swung at staff hitting staff on the face 2 times...Staff member who got hit on the face reports pain and the extent of injury is undetermined at this time. There was a delay in the code being broadcast to code responders due to the lack of radios available for staff to use...Action Taken or Recommendations to Prevent a Recurrence:...Staff to review EFC (Excessive Fluid Consumption) protocol and look for signs and symptoms of water intoxication...When (Pt #5) is becoming defiant and hard to redirect, staff will continue to utilize therapeutic communication...summon for additional support and utilize physical intervention as the last resort...."

The Recommendations to Prevent a Recurrence, completed by Charge/Supervisor, did not include attention to the shortage of staff radios.

On 5/20/15, the Assistant Director of Nursing (ADON) was asked for documentation of leadership follow-up to the event and correction of the shortage of staff radios. The ADON provided a copy of an E-mail initiated by a staff nurse 2 days after the patient assault.

Review of hospital documentation of E-mail communication revealed:

On 5/15/15, at 1147, an RN sent communication via Email to hospital leadership regarding Desert Sage's radios: "...we have attempted several times to get radios...we are short at least two to three radios every shift...without nurses carrying them...We have 7 one to one's and are split up a lot...Several MHPS and nurses are voicing their concerns for safety...."

On 5/15/15, at 1904 (7:04 PM) an RN sent communication via Email to hospital leadership: "...We got our radios...."

On 5/20/15, the ADON was unable to provide documentation of leadership initiated follow-up to the event re: the shortage of staff radios. The shortage of radios had occurred prior to the assault on 5/13/15 and caused a delay in staff response to the assault. The shortage of radios was corrected 2 days after the assault when a staff nurse made another request after several failed attempts as documented in the RN's E-mail.

3. Review of facility policy and procedure titled "CLOSE OBSERVATION" dated 11/2013, revealed: DEFINITIONS: Close Observation/15 Minute Checks is a method of observation implemented when a patient 's potential for an adverse event is elevated and warrants more frequent visual checks and engagement...For potential of impulsivity and identity disturbances...Self-mutilating behaviors...To reduce dependency and increase independence due to above factors...Assigned staff member shall complete the Close Observation Documentation Form...."

Patient # 8

Review of "Physician's Order Entry" revealed: "...Create New Nursing Order...Start: 12/30/2014...Close Observation 15 Minute Checks...."

Review of "Nursing Services" note dated 1/8/15, revealed: "...APPROX (approximately) 1100 HRS (hours), IT WAS REPORTED TO THE DAY SHIFT NURSE THAT...HAD SWALLOWED...LOCKER KEY, 1430 (2:30 pm), PT (patient) SENT TO ER (emergency room ) FOR XRAY AND FURTHER EVALUATION WITH STAFF TO MONITOR PT SAFETY...." The patient was admitted on [DATE] and discharged [DATE].

The surveyor asked for the "Close Observation Document Form" for 1/8/15, none was submitted.

Review of "Abd/Pelvis (abdomen) CT (computerized tomography)...." dated 1/8/15, revealed: "...IMPRESSION...Single ingested key is located within the terminal ileum, just proximal to the ileocecal valve...."

Review of X-ray of Abdomen dated, 1/14/15, revealed: "...IMPRESSION...Three radiopaque foreign bodies project of the right lower quadrant of the abdomen, likely located within the cecum...."

Review of X-ray of Abdomen dated, 1/20/15, revealed: "...IMPRESSION: Previously noted key shaped radiodense foreign body is no longer demonstrated...."

Review of X-ray of Abdomen dated, 1/29/15, revealed: "...IMPRESSION... Multiple radiodensities again noted within the pelvis, with slight interval inferior migration when compared with prior examination...."

"SURGICAL PROCEDURE" Colonoscopy dated, 1/29/15, revealed: "...A total of 10 coins, 2 AAA batteries, and two small watch metal parts were seen in the cecum. No foreign bodies were seen in the terminal ileum .... "

The surveyor asked employee #1 why the patient would be allowed to carry a key if he/she has a history of swallowing items. Employee #1 relayed that the patient has never swallowed a key before so the patient is permitted to have one. Also, it's the patient's right to have access to his/her locked personal items.

Employee #4, verified in an interview conducted on 5/19/15, that the key is always around the patient's wrist on a piece of yarn, and employee #4 believes that the patient should not have the key since the patient is a "swallower". Also, staff of the hospital could not find any documentation of observation of the patient on 1/8/15.

Employee #21 verified in an interview, conducted on 5/20/15, she was not surprised that the 1/8/15, observation form is missing. There was no further clarification of this statement.

4. The surveyors conducted tours of the mall on 05/18/2015, 05/19/2015, and 05/23/2015; which is an open area outside of the patient care units, where patients have freedom to travel about. During each of these tours, the surveyor(s) identified there were two staff members in the mall area. Each staff member was wearing a yellow vest. The yellow vests identified the employees who were responsible to monitor the mall when patients were in the area.

The surveyors stood by each of the employees responsible for monitoring, and it was recognized that where the employees were standing and walking it was not feasible to see four patients who were sitting on the cement benches stretched along the exterior wall of the rehab and auditorium.

There was one patient who had walked between the buildings, and there was no observation of this patient from either of the employees who were responsible for monitoring patients in the mall.

The surveyor counted the patients in the mall on the 05/23/2015 tour. There were 18 patients walking around with two employees tracking the 18 patients.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policy and procedure, medical record and interview, it was determined that the hospital failed to ensure that the use of restraint and seclusion be in accordance with the patient's plan of care for 3 of 3 patient records reviewed for restraints (Pt # 4. #2 and #14), which poses a risk of failing to implement alternative approaches to physical intervention and potential patient injury.

Findings include:

Review of hospital policy/procedure titled " Restraint" dated February 19, 2015, revealed: "...To establish and implement guidelines for the safe and uniform application of restraint...The use of restraint must be in accordance with a patient's plan of care...."

Review of hospital policy/procedure titled "Seclusion" dated February 19, 2015, revealed: "...To establish and implement guidelines for the safe and uniform implementation of seclusion...The use of seclusion must be in accordance with a patient's plan of care...."

There was no documented evidence of a nursing plan of care that addressed the need for restraints that was maintained in the medical records at the hospital. There was a Master Inpatient Treatment and discharge Plan that was created by the multidisciplinary team that was not updated with a change in the patient's condition.

Review of Pt # 4's medical record revealed:

Between 2/6/15 and 3/10/15, Pt # 4 underwent 17 physical restraints, 10 episodes of seclusion and 8 mechanical restraints for behavior which was dangerous to others. Between 4/6/15 and 4/19/15, Pt # 4 underwent 7 physical restraints, 4 episodes of seclusion and 5 mechanical restraints for behavior which was dangerous to others.

Pt # 4's Master Inpatient Treatment and Discharge Plan Reviews dated 3/10/15, 4/19/15 and 4/20/15 and Master Inpatient Treatment and Discharge Plan dated 4/20/15 did not contain review of the numerous episodes of restraint and seclusion between the dates of 2/6/15 and 4/19/15 and/or interventions directed toward reduction in these episodes.

Pt #4's Master Inpatient Treatment and Discharge Plan dated 4/20/15 contained a Short Term Goal: "...(Pt # 4) will continue cope (sic) with her emotions by demonstrating a decrease of dangerous behaviors...Start Date 4/20/15...Target Date 6/30/15...Interventions...Nursing will offer (Pt #4) the opportunity to go to the quiet room, when available, when she appears to be getting agitated or aggressive...."

A Behavioral Plan was added to her treatment plan on 4/20/15 to increase staff awareness and modify the way staff provide daily unit services to Pt # 4, to decrease her assaultive behaviors, but the Treatment Plan did not include mention of her restraints or seclusions.

The Interim Psychiatric Nurse Unit Manager for Desert Sage confirmed, during interview conducted on 5/20/15, that Pt # 4's Treatment and Discharge Plan and Reviews did not address the Pt's episodes of restraint or seclusion. The Interim Unit Manager stated that the patient's assaultive behavior was correlated with changes in her Clozapine. She provided documentation that the Staff Pharmacist entered an order to discontinue Pt # 4's Clozapine due to alteration in her "ANC" (Absolute [DIAGNOSES REDACTED] Count). Pt # 4's Treatment and Discharge Plan did not contain documentation of the relationship between her medication and her assaultive behavior or any mention of medication other than the fact that prior to her admission to the hospital, Pt # 4 "...did well with medication regimen of Clozaril and Geodon historically...."

Patient #2 was placed on a physical hold on 05/04/2015 for an attempted assault to a staff member. There was no documented evidence the plan was adjusted to address the patient's behavior at this time.

Review of the patient record identified the patient would state that she was going to "die" and the staff would not know until they found her. There was no direct reference to this type of verbal threat in the plan of care for this patient. The patient was on close observation line of sight.

A review of the close observation line of sight documentation by the staff revealed the only staff interventions from the dates 04/27/2015, through 05/11/215, was noted to be "ensure patient safety and monitor patient's behaviors." There are 19 potential interventions for staff to use with patients. However, the two identified interventions above were the only ones consistently documented as the interventions provided.

Other interventions included as options preprinted on the Close Observation Documentation Form included but not limited to: " Reassured patient; Read to Patient; Played game with patient; Watched TV Movie; Taken on walk; Provide Group Treatment; Redirected patient's attention; Encourage to use coping skills; Reduce stimiuli on the unit." None of these options were documented on the patient's medical record for this timeframe.

The Director of Nursing and the Assistant Director of Nursing reviewed the medical record documentation on 05/19/2015, and confirmed the only documentation was that of the two staff interventions by the employees doing the close observation line of sight for Patient#2.

Patient # 2 was injured in a fall on 05/11/2015, that lead to hospitalization while under the close observation line of sight plan and the documentation in the medical record revealed the only interventions by the employees responsible for the line of sight documentation was that of "ensure patient safety and monitor patient's behaviors." There was no other interventions attempted when the patient throughout the patient's stay, had identified a desire to "die" requesting the "death shot" and having assaultive outbursts.

There was no documented evidence of alternative approaches to the patient's care was identified and implemented.

The surveyor reviewed Patient #14's medical record from 04/05/2015 through 05/12/2015. During this timeframe the patient was ordered to be on 1:1 (close observation line of sight). The medical record revealed the patient was restrained on 05/03/2015 at 12:15 PM and again at 4:15 PM; 05/04/2015 at 10:15 Physical Hold for 15 minutes and mechanical restraints at 3:35 PM; 05/05/2015 Physical hold at 4:26 PM and mechanical restraints at 4:28 PM and remained in the restraints until 8:50 PM; and 05/07/2015 Physical restraint at 2:40 PM to 2:48 PM and then mechanical restraint at 2:48 PM to 3:55 PM.

The Master Inpatient Treatment and Discharge Plan for Patient #14 was dated 03/10/2015. There was no adjustments documented to this plan for a patient who was requiring frequent physical holds and mechanical restraints due to the patient's behavior.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital policy/procedure, medical record and interview, it was determined that the hospital failed to ensure the following:

1. that 22 of 24 physical restraints, 14 of 14 seclusions and 11 of 13 mechanical restraints implemented for the management of Pt # 4's behavior, were implemented upon the order of a licensed independent practitioner (LIP) as required by hospital policy/procedure, which poses a risk of unnecessary physical intervention and potential patient injury; and

2. there were appropriate orders documented in a format that recognized the orders by date, time, and if the order was being given as a phone/verbal order or documented and written at the time of the initiation of the restraints in 1 of 1 record reviewed for restraint order process. (Patient #14)

Findings include:

Review of hospital policy/procedure titled Restraint, dated February 19, 2015, revealed: "...To establish and implement guidelines for the safe and uniform application of restraint...Emergency application of restraint by trained personnel may occur prior to obtaining an order, as long as a registered nurse obtains the order during application of the restraint or immediately thereafter...All episodes of restraint require a written or telephone order given to a registered nurse by a licensed independent practitioner...All orders for restraint must include the name of the licensed independent practitioner ordering restraint, date and time of order...."

Review of hospital policy/procedure titled Seclusion, dated February 19, 2015, revealed: "...To establish and implement guidelines for the safe and uniform implementation of seclusion...All episodes of seclusion require a written or telephone order given to a registered nurse by a licensed independent practitioner...All orders for seclusion must include the name of the licensed independent practitioner ordering restraint, date and time of order...."

1. Review of Pt # 4's medical record revealed:

Between 2/6/15 and 3/10/15, Pt # 4 underwent 17 physical restraints, 10 episodes of seclusion and 8 mechanical restraints for behavior which was dangerous to others. The orders for 15 of the physical restraints, 10 of the seclusions and 6 of the mechanical restraints did not contain the name or signature of the ordering licensed independent practitioner (LIP) or an RN's signature for a telephone order. Ten (10) of the orders for physical restraints, 8 of the orders for seclusion and 5 of the orders for mechanical restraints did not contain the date and time of the order.

Between 4/6/15 and 4/19/15, Pt # 4 underwent 7 physical restraints, 4 episodes of seclusion and 5 mechanical restraints for behavior which was dangerous to others. None of the orders contained the name or signature of the ordering LIP or an RN's signature for a telephone order. Only one order for physical restraint and seclusion contained the date and time of the order.

The Interim Psychiatric Nurse Unit Manager for Desert Sage confirmed, during interview conducted on 5/20/15, that the orders were not dated and timed and did not contain the signature or name of the ordering LIP or RN recording the telephone order as required by hospital policy/procedure.

2. Patient #14's medical record revealed:

The orders for restraint on 05/03/2015 at 12:20 revealed the Psychiatrist as the RN and the RN obtaining the order as the psychiatrist. The order did not contain the type of restraints and it was not clear as to if this was a telephone order or a written order at the time of the restraint initiation.

The psychiatrist documented on the order form the need for physical restraint for one hour and 5 minutes then 4 point mechanical restraint for up to 3 hours. There is no date or time on this order. Below this order there was a documented statement by the psychiatrist that discussed the behavioral assessment and was dated 05/03/2015 at 1:30 PM.

The record revealed on 05/03/2015 at 4:15 PM, the patient was in a physical restraint for 22 minutes. The RN documented the psychiatrist was notified. The physician order is not dated or timed as to when the order was written. The assessment is dated for the third of May at 4:55 PM. The documentation revealed under the physician order section: "... Physical restraint for 22 minutes for DTS (detrimental to self) behavior 4 point mechanical restraint up to 3 hours ..." There was no ability to determine if the order was documented at the time of the initiation, if there was a phone order to initiate or if the physician was present at the time of the initiation. Based on documentation there was not a clear order by a physician to initiate the restraints until 4:55 PM..

The record revealed on 05/12/2015, a physician order for the patient to be placed in a physical hold for 15 minutes for administration of medications. There is not a date or time related to this order. The assessment completed by the physician is documented at 11:15 AM on 05/04/2015. The event was documented by the RN at 1015 to 1045 AM. The physical restraint was in place for 30 minutes and not 15 minutes according to the documentation. The only date and time for the order was at the end of the assessment by the physician, which was one hour after the initiation of the physical restraint.
VIOLATION: QAPI Tag No: A0263
Based on a review of documents, and interviews, it was determined the Governing Body failed to develop, implement and maintain an effective, ongoing hospital-wide, data-driven quality assessment and performance improvement program as evidenced by there not being an approved quality assessment and improvement program approved by the governing body for the years of 2014 and 2015.

Findings include:

This is a Condition Level deficiency based on there not being an approved program and the following standards were not in compliance in addition to the plan not being current.

Tag 0283: The hospital failed to identify indicators and set priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement, which is a high potential risk of harm for patients when patient related issues I.E seclusion and restraint usage, adherance to treatment plans and adverse events are not analyzed and addressed;

Tag 0286: The Governing body, medical staff and administrative officials failed to ensure the hospital-wide quality assessment and performance improvement efforts addressed patient safety, as evidenced by there not being any process or system in place to analyze and evaluate patient events or incidents that are documented as occurring within the hospital;

Tag 0308: The hospital's governing body failed to ensure the Quality Program reflected the complexity of the hospital's organization and services, which is a high potential risk for adverse outcomes for a vulnerable class of patients if their care issues are not addressed and evaluated; and

Tag 0309: The governing body, medical staff and administrative officials failed to assume the legal authority and responsibility to have a current quality performance improvement program, determined the number of distinct improvement projects conducted annually and defined a program for patient safety to address the patient/staff safety concerns as evidenced by no documented improvement projects identified in 2015, the facility dashboard trends showing an increase in restraints, mechanical restraints and seclusion with no discussion why, and a 26% increase in patient complaints with no discussion why.

The cumulative effect of these systemic problems resulted in the hospital's inability to have an effective quality assurance performance improvement program to assess opportunities for improvement.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on a review of documents and interviews, it was determined the hospital failed to identify indicators and set priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement which is a high potential risk of harm for patients when patient related issue i.e. seclusion and restraint usage, adherance to treatment plans and adverse events are not analyzed and addressed.

Findings include:

The surveyor reviewed the minutes of the Quality Council meeting minutes for the year of 2014 and March of 2015. The committee met monthly in 2014 and had met once in 2015, March 2015. The Director of Quality stated that the committee was changed to quarterly meetings for the year of 2015. The Director of quality confirmed the Quality Committee was a mechanism for reporting department indicators. The Director confirmed the Department indicators were more quality control indicators and did not lead to performance improvement activities.

Examples of the performance measure indicators included: Completion of all Codes accurately; Random EVS (environmental services) Customer Rounds; Human Resources to complete files and refer potential employees timely; Infection Control indicator was to ensure Compliance with TB screening for employees; Medical Record audit completion; and Medication consent forms were to be completed; and Pharmacy monitored the review of medication orders that have a limited duration to ensure they were addressed. There was no evidence of patient care indicators being addressed through the Quality Committee. There was no documented evidence of patient occurrence reports being reported for analysis and evaluated through the Quality Committee.

The Director of Quality stated on 05/22/2015, although there was no current quality plan approved by the Governing Body the hospital was continuing to function under the 2013 plan. The Director confirmed the plan was fragmented and not focused on the high-risk problem-prone areas. There were two plans provided to the surveyors. The Quality Assurance and Performance Improvement Plan and the Risk Management Plan.

The CNO (Chief Nursing Officer) provided to the surveyor on 05/18/2015, a performance improvement process for assaults. A review of the performance improvement process on assaults manual provided, revealed the documentation was dated during the year of 2013 through July 2014. There was no further action documented since July 2014, other than the tracking of assaults.

The outdated Quality Plan revealed the Chief Medical Officer (CMO) was to be reviewing all seclusion or restraint reports for appropriateness and timeliness at least monthly according to the Risk Management Plan. There was no evidence that the CMO documented a review of these activities occurring within the hospital.

The CMO stated in an interview conducted on 05/22/2015, that she was a member of the Executive Risk Management Team and in this meeting they review all incidents.

A review of the Executive Risk Management Team meeting minutes failed to document evidence of an analysis of seclusion and restraint as to the compliance with the policies and procedures, action taken by the hospital to prevent the use of restraint or seclusion, if the patient is appropriately placed at the hospital and whether the patients treatment plan should be reviewed or revised to ensure the patient's treatment is meeting the treatment needs. The review of activities was required of the CMO in the 2013 plan, and that was the only plan available to the surveyors at the time of the survey process.

The CMO on 05/22/2015, stated that she was not reviewing the seclusions and restraints to this extent that at some point in time this expectation was transitioned to the Quality Department. A review of the Quality Department documents revealed there was a tracing of the numbers of seclusions and restraints; however there was no documented evidence of an analysis of the activities or correlation with the patient's treatment plans.

The Director of Quality provided the surveyor the Quality Management Unit report that was presented on May 12, 2015, and the report provided to the Governing body the 1st. 2nd. and 3rd quarter report for 2015 on the risk program. The purpose of this presentation was to demonstrate the evaluation of the aggregate data in an effort to increase transparency, assess risk, and identify and correct potential issues. This report presented a comprehensive review of the data collected. There as no documented analysis of the data to drive action to improve the processes or decrease the number of seclusions and restraints.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on a review of documents and interview, it was determined the governing body, medical staff and administrative officials failed to ensure the hospital-wide quality assessment and performance improvement efforts addressed patient safety, as evidenced by there not being any process or system in place to analyze and evaluate patient events or incidents that are documented as occurring within the hospital.

Findings include:

The hospital Quality minutes and the Governing Body minutes failed to demonstrate the governing body, medical staff or administrative staff determined the number of distinct improvement projects annually. There were two performance improvement projects provided to the surveyors during the week of May 18, 2015. The two projects were Assault Management and Falls. Both of these projects were initiated in 2013 through 2014. There was no documented improvement projects identified for 2015.

The surveyor reviewed the minutes of the governing body provided to the surveyor on 05/18/2015. The minutes on 05/12/2015 revealed "Dashboards" were presented. The Dashboards consisted of hospital census; admissions; discharges; and a rolling monthly tracking of restraints; seclusions; falls; and assaults. There was no documented evidence within the minutes of a discussion by the governing board of the dashboard trends.

The Dashboard revealed physical restraints increased over the months of January, February, March and April 2015. The Mechanical restraints were also showing an increase in the number of hours a patient is in mechanical restraints. Seclusions were showing an increase over January, February, March, and April.

There was no documented discussion as to the need to evaluate why the restraints and seclusions were showing an increase in the data.

The Patient Rights Ombudsman report in the Governing Body minutes on 05/12/2015 revealed there was an increase in patient complaints of 26% for a total number of 163 for the quarter. The Governing Body documented response revealed a request to continue to bring the chart showing outcomes. There was no discussion documented as to the Governing Body's response to a 26% increase in the patient complaints.

There was no documented evidence of incident reports or adverse events being reported to the Governing Authority. There was documentation of an Executive Committee that had reviewed a couple of sentinel events; however the day to day incidents and adverse events were not presented or discussed at the Governing Board or the Quality Council based on the minutes reviewed.

There was an established Executive Risk Management Team that met up to three times a week. The purpose of this team was to review the incident reports that were presented to the team. An interview with one of the members of the team who was responsible for the tracking and documentation of the activity revealed he lists out on a spreadsheet the incidents, the team reviews the incidents and makes a decision as to who was to do follow up when follow up was required. The individual who was identified to do the follow was notified and then was to provide the team with the follow up that was taken place. The follow up was then documented by posting the email or other documentation of the follow up to the spreadsheet. There was no process in place for the team to trend the action and evaluate if the action taken was appropriate and/or effective. The team did not review the action taken by the individual assigned to do the follow up.

A review of the Executive Risk Management Team (ERMT) follow-up spreadsheet for May 4, 2015 revealed there were 36 events from 2014 sent to the ERMT team that was still awaiting follow up. Of the 36 events, 10 were assigned to the CMO (Chief Medical Officer); 9 to Quality; 4 to a physician on staff; and the remainder were assigned to miscellaneous individuals. There are 5 reports from January 2015 through March 2015 requiring follow up.

A review of the Medical Executive Committee minutes and the Pharmacy and Therapeutics committee meeting minutes provided to the Medical Executive Committee revealed there were several reports of medication errors tracked and referred to various departments for review. There was no documented evidence of the analysis of these errors or adverse events and the action taken and how effective the action when taken was to change or minimize the risk of the error occurring again.

There was no documented evidence the work of the Pharmacy and Therapeutic Committee was provided to the Quality Council, Executive Risk Committee, or the Governing Authority.

The Director of Nursing, during an interview on 05/20/2015, revealed the leadership had put into place a group of employees called the "E" Team.

The "E" Team: The Vision statement revealed: "...To provide the best personal care, service and education with the utmost respect to our clients, employees, and anyone else we may come in contact with who is in need of assistance. Our vision is to assist the hospital with building a foundation and standard of operation that is the model for quality health care and treatment. We strive to define a positive culture at A.S.H.(Arizona State Hospital), through our actions and behavior. We will collaborate with other leaders of this hospital, to build a system of care that puts our staff and clients in a position to succeed. As leaders our goal is to evaluate, educate and empower our staff to be successful. By doing this, we will build moral and make this a place that people want to work at, while giving our patients the best care possible...."

The surveyor requested documentation as to the activity of the E Team. The documentation provided to the surveyor on 05/20/2015 revealed a sampling of the Census Management Monitoring tool utilized by this team as they observe and roam the various care areas of the hospital. One of the forms for 05/19/2015 was identified as an observed activity for the Palo Verde unit which revealed "...Pt.'s were on mall, no visual check was done. No radio confirmation was done..." There was a place on the form for on spot training and if this was done or not done and the documentation revealed it was not done. This was identified on the form as an observed event.

A second Census Management Monitoring tool dated 05/19/2015 at 0833, and identified as having been completed for Ironwood North, was reviewed and revealed: "staff did not visibly check pt. in bedroom...."

A third Census Management Monitoring tool dated 05/19/2015 timed at 0835, revealed the staff member was not positioned in a way to view the patient. The observer documented verbal check with staff member on COS/LOS (close observation/line of sight) when patient in the room.

On 05/26/2015, the surveyor interviewed one of the E Team members and asked what occurs with the reports that are completed. The member stated they go to the Director of Nursing. The staff member did not know if there was any trending or action taken related to the activities of observation that they do on a daily basis.

A review of the quality minutes of the Executive Risk Team, Quality Council, Medical Executive Committee, and Governing Body revealed there was no evidence of trending or evaluation of the findings from the E Team.

On 05/21/2015 the surveyor reviewed the Quality findings with the Chief Medical Officer, Chief Nursing Officer, Assistant Director of Nursing, and the Director of Quality. There was no additional information provided during this discussion to demonstrate the Governing Body, Medical Staff, or Administrative staff demonstrated compliance to the regulation.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on a review of the documents and interviews, it was determined the hospital's governing body failed to ensure the Quality Program reflected the complexity of the hospital's organization and services which is a high potential risk for adverse outcomes for a vulnerable class of patients if their care issues are not addressed and evaluated.

Findings include:

The Director of Quality provided to the surveyor a Quality Assurance and Performance Improvement Plan dated Calendar Year 2013. There was no current Quality Plan for for 2015. The Director stated that there was a presentation to the Governing Body in December of 2014 for a new proposed Quality program. A review of the December 2014 Governing Body minutes revealed a plan that would integrate risk program; compliance program; process improvement; records and data management; and patient rights. A review of the approved minutes of the December 9, 2014 revealed the Governing Body reviewed the report and discussed and a follow up was to occur at the March Governing Body meeting. The March 3, 2015 minutes revealed no further discussion of a quality plan or approval of a quality plan.

The governing body minutes were reviewed with the Director of Quality and there was no further documentation to support there was an approved Quality Plan for the hospital for the year of 2014 and 2015.

The 2013 Quality Plan required the Governing Body to approve the QAPI (Quality Assurance Performance Improvement) Program and activities of the hospital. The Governing Body was to ensure full implementation of the QAPI Plan and provide feedback regarding QAPI activities. The Governing Body was to establish priorities for the hospital.

There was no documented evidence this was completed by the Governing Board.

The hospital's documented quality program failed to demonstrate and document the complexity of the needs of the patients.

There was no documented evidence the Governing Body and the Medical Staff evaluated the provision of medical and nursing care provided to the patients; there was no documented evidence of nursing care indicators; there was no documented evidence of restraint mechanical and physical being evaluated once the data was collected; there was no documented evidence of the NVCI (non viloent crisis intervention) process; there was no documented evidence of pharmaceutical review of medication administration related to the PRN (as needed) administered and there was no documented analysis of incident reports.

There was a performance improvement project on assaults initiated in 2013, which showed a small decrease in the assaults; however there are individuals who remain at the hospital who continue to have aggressive behaviors who are repeated offenders. There was no documented evidence of this being addressed on an ongoing basis through patient treatment plans or through nursing and medical documentation.

There was no documented evidence of multidisciplinary review of events or incident trending.

The patients at the hospital have medical as well as behavioral health needs. There was no documented evidence the physical health program is incorporated into the quality program.

The hospital utilized a staffing agency for the Mental Health technicians when staffing needs indicate additional staffing due to vacancies or sick calls. There was no documented evidence of this contract review in the Quality Council minutes or the Governing body minutes for 2014 or 2015.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on a review of documents and interview, it was determined the governing body, medical staff and administrative officials failed to assume the legal authority and responsibility to have a current quality performance improvement program, determine the number of distinct improvement projects conducted annually and define a program for patient safety to address the patient/staff safety concerns, as evidenced by no documented improvement projects identified in 2015, the facility dashboard trends showing an increase in restraints, mechanical restraints and seclusion with no discussion why, and a 26% increase in patient complaints with no discussion why.

Findings include:

The Governing Body failed to have an approved current Quality program and continued to expect the staff work with a program that was developed in 2013. The Quality program for 2013 revealed no documented analysis that it would be appropriate to continue to provide the process required to enhance patient care for 2014 and 2015.

The hospital Quality minutes and the Governing Body minutes failed to demonstrate the governing body, medical staff or administrative staff determined the number of distinct improvement projects annually. There were two performance improvement projects provided to the surveyors during the week of May 18, 2015. The two projects were Assault Management and Falls. Both of these projects were initiated in 2013 through 2014. There was no documented improvement project identified for 2015.

The surveyor reviewed the minutes of the governing body provided to the surveyor on 05/18/2015. The minutes on 05/12/2015, revealed "Dashboards" were presented. The Dashboards consisted of hospital census; admissions; discharges; and a rolling monthly tracking of restraints, seclusions; falls; and assaults. There was no documented evidence within the minutes of a discussion by the governing board of the dashboard trends.

The Dashboard revealed physical restraints increased over the months of January, February, March and April 2015. The Mechanical restraints was also showing an increase in the number of hours a patient is in mechanical restraints. Seclusions was showing and increase over the months of January, February, March, and April.

There was no documented discussion as to the need to evaluate why the restraints and seclusions were showing an increase in the data.

The Patient Rights Ombudsman report in the Governing Body minutes on 05/12/2015 revealed there was an increase in patient complaints of 26% for a total number of 163 for the quarter. The Governing Body documented response revealed a request to continue to bring the chart showing outcomes. There was no discussion documented as to the Governing Body's response to a 26% increase in the patient complaints.

There was no documented evidence of incident reports or adverse events being reported to the Governing Authority. There was documented Executive Committee to review sentinel events; however the day to day incidents and adverse events were not presented or discussed at the Governing Board or the Quality Council based on the minutes reviewed.

On 05/21/2015, the surveyor reviewed the Quality review findings with the Chief Medical Officer, Chief Nursing Officer, Assistant Director of Nursing, and the Director of Quality. There was no additional information provided during this discussion to demonstrate the Governing Body, Medical Staff, or Administrative staff demonstrated compliance to the regulation.

The Governing Body meeting minutes for 03/03/2015, revealed a request by a committee member for the Nursing Director to track and document data as it correlates to the number of codes called, restraints and seclusions; and improvement in sleep. There was no documented evidence of follow up of this request in the May 2015 Governing Board meeting minutes. There was no request by the Governing Body for follow up.

The Performance Indicators for each of the Departments was included in the minutes. There was no discussion or recommendations from the Governing Authority on the specific performance measures. The performance measures for Dietary, Nursing has the initials "NA" and "ND" on the performance measure matrix that was presented to the Governing Body.

The Director of Quality confirmed during an interview on 05/22/2015, there was no Quality program identified for the year of 2015.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document reviews and interviews, it was determined the Director of Nursing failed to ensure nursing services were furnished and/or supervised by a registered nurse as evidenced by the following failures:

Tag 0386: The Director of Nursing failed to determine the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital by following the approved staffing plan, determining the skill mix required to meet patient needs, having accurate and consistent documents to demonstrate the staffing and assignments, and maintain adequate professional RN (registered nurse) staff on a unit to direct and evaluate patient care.

Tag 0395: The Director of Nursing failed to ensure that a registered nurse supervise and evaluate the care provided to patients as evidenced by the RN's failing to ensure documentation of patient observations; supervision of patients when one of the patients was on close observation line of sight orders; wound care was provided as ordered; patients were maintained in a safe environment; and physician orders were followed to monitor patients for weights, intake consumption of fluids and vital signs documents when a patient was identified at potential risk.

Tag 0396: The Director of Nursing failed to ensure nursing care plans were initiated and kept current based on the patient's needs in 23 of 23 medical records reviewed; and

Tag 0397: The Director of Nursing failed to require that a registered nurse assign the nursing care of each patient to other nursing personnel in accordance with the patient's needs and the qualification based on competencies of the staff, which is a potential risk of harm to patients if they are cared for by unqualified staff.

The cumulative effect of these systemic failures has the potential to result in patient needs being identified so that early intervention and/or redirection could occur prior to an adverse outcome.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on document review, video tape review and interview, it was determined the hospital's Director of Nursing failed to determine the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital as evidenced by:

1. failure to follow the approved staffing plan requirement for a Staffing committe;

2. failure to determine the skill mix required to staff the unit based on the acuity;

3. failure to have accurate and consistent documents to demonstrate the staffing and assignments made for each shift; and

4. failure to maintain adequate professional RN staff on a unit to direct the patient care.

Findings include:

1. The policy for staffing includes a requirement for a Staffing committee consisting of four licensed nursing staff two mental health technicians and four nursing leadership members who will meet monthly to discuss any matters concerning staffing including but not limited to making recommendations to the Chief Nursing Officer on staffing issues.

There was no documented evidence of a Staffing Committee. The Director of Nursing confirmed on 05/19/2015, there was no Staffing Committee established.

2. The Staffing Acuity and Effectiveness Plan dated August 1, 2013 revealed the purpose was to establish an acuity-based staffing plan for nursing services to meet patient care and organizational needs.

A review of the nursing staffing acuity records and the assignment sheets revealed there was no identified method to determine the staffing needs for the individual patient units. The staffing acuity is identified and a formula calculates the total number of hours per shift based on the acuity. There is no method to determine the skill mix required to meet the patient's needs.

The Director of Nursing and the Assistant Director of Nursing confirmed on 05/22/2015, there was no method to determine the professional and technical staff required to meet the needs of the patients.

3. Throughout the survey process the Surveyor attempted to match the General Staffing sheet to the Acuity sheets to the unit assignment sheet. There were multiple inconsistencies and the surveyor was not able to consistently determine who was working on the unit and who was assigned to care for the patients. The documents were not clear, coordinated and consistent.

The Assistant Director of Nursing confirmed this finding on 05/19/2015, when she was not able to find consistency with the documents.

4. The Director of Nursing made a determination the RN's assigned to patient care on the unit would be the individuals responsible for staffing the following shift. One RN per unit was expected to go to the Nursing Office to participate in the "Huddle" discussions to facilitate staffing for all of the inpatient units. The RN was expected to leave the unit for a minimum of 30 minutes and sometimes up to an hour. The RN on the evening and night shifts is responsible for up to 17 patients. The RN leaves the patients with non-licensed personnel to care for the patients.

Each of the freestanding patient care areas are divided into two separate assignment units. Each of these units are staffed with an RN. One of the RN's assigned to the patient care area must go to the staffing office to review staffing for the next shift. This can leave one RN to care for 30 to 36 patients who are divided into two separate physical areas of the patient care center.

Staff interviews conducted throughout the survey with staff who performed this function confirmed the RN's were pulled off the units to do staffing and this has taken up to 30 to 60 minutes depending on the availability of staff and the phone calls that need to be made to obtain staff for the unit.

The Director of Nursing on 05/22/2015, was asked by the surveyor about the safety of pulling an RN from the patient care centers and physically leaving the area for an undetermined amount of time during the shift and not providing relief coverage. The Director agreed that this was a concern and she had not thought about this as an issue.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of hospital policies/procedures, hospital documents, medical records and interviews, it was determined that the Director of Nursing failed to ensure that a registered nurse supervise and evaluate the care provided to patients as evidenced by:

1. staff failed to record required documentation of patient observation at 15- minute intervals as required for Pt # 4 posing a risk to patient safety;

2. staff failed to supervise Pt # 5 when he was able to engage in sexual relations with Pt # 6, posing a risk of physical and/or psychological trauma;

3. staff failed to ensure the safety of Pt # 6 when she engaged in sexual relations with Pt # 5;

4. staff failed to ensure the safety of Pt# 6 when she sustained two self-inflicted head injuries, requiring medical intervention, while she was on "Close Observation/High Risk" supervision;

5. the RN failed to ensure that the post sexual contact mental status exam of both Pt #s 5 and 6 include whether each patient is capable of consenting to sexual activity, as required by hospital policy/procedure, posing a risk of physical and/or psychological trauma;

6. the RN staff failed to provide wound care for one of one patient (Pt # 19) as ordered by the physician which has the increased risk that the patient's infection would not be resolved;

7. the RN failed to require the assigned staff to 1:1 activities, that they maintain a safe environment for the patients by continually observing patients; respond when the patient is attempting to put themselves at risk; and stay in their assigned areas of responsibility; (Patient #2 and Patient #14.); and
8. the RN failed to require physician orders were followed for weights (Patient #7), intake documentation (Patient #14), and vital signs (Patient #15).

Findings include:

1. Review of hospital policy titled Close Observation revealed: "...To establish procedural standards to help ensure safety of the patient whose potential for an adverse event warrants close observation. Adverse events include, but are not limited to...assaultive behavior...to provide close observation...to assure the safety of the patients and other individuals...Close Observation/15-Minute Checks is a method of observation implemented when a patient's potential for an adverse event is elevated and warrants more frequent visual checks and engagement...documentation of checks every 15 minutes...for potential of impulsivity...Close Observation-All levels...Registered Nurse...Assign a staff member to monitor the patient on Close Observation and enter the assigned staff member's name on the Assignment of Care Form...Assigned staff member shall complete the Close Observation Documentation Form...."

Review of Pt # 4's medical record revealed:

Pt # 4 is diagnosed with Schizophrenia, Paranoid Type and Borderline Intellectual Functioning. She has engaged in multiple episodes of assaultive behavior which have required physical restraint, seclusion and/or mechanical restraint (see Tag 0168, for information regarding the restraints and seclusions which were implemented for Pt # 4 ).

On 4/13/2015 at 1530, a physician entered an order: "Close Observation 15 Minute Checks...Q (Every) 15 min checks with 1:5 privileges for impulsive behaviors...."

On 4/13/2015 at 1930, an RN recorded an occurrence whereby "...Pt #s 5 and 4 were seated in the day room awaiting evening med pass. Suddenly, and without provocation, (Pt # 4) hit (Pt # 5) in the face with a book. (Pt # 5) defended hiself (sic) and a fight ensued...."

Review of the Close Observation Documentation Form for Pt # 4, dated 4/13/15, revealed that from 1800 through 2315, the spaces for intervention codes and staff initials were blank and from 2330 through 2345, the spaces for observation codes, intervention codes and staff initials were blank.

The Interim Nursing Unit Manager for Desert Sage confirmed, during interview conducted on 5/19/15, that the documentation of the Q 15-minute observations was not completed as required.

Employee # 4 confirmed during an interview conducted on 5/19/15, that the documentation of the Q 15 minute observations from 1800 through 2345 was not completed as required.

Review of The Daily Staff Task Sheet for the 3-11 shift on 4/13/15, revealed that it did not contain the name of a staff member specifically assigned to complete the Q 15 minute observations of Pt # 4.

The ADON stated, on 5/19/15, that 15 minute observations are completed by the individual responsible for the Census Management. Employee # 4 confirmed during an interview conducted on 5/19/15; and Employee # 5 confirmed during an interview conducted on 5/20/15, that the individuals responsible for the Census Management from 1800 through 2345 had additional simultaneous responsibilities and task
assignments.

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

Pt # 5 is diagnosed with Undifferentiated, Chronic Schizophrenia and Borderline Intellectual Functioning. He is court ordered for treatment due to Danger to Others and Grave Disability. He was readmitted to the hospital in 2005 in the Restoration to Competency program. His Master Inpatient Treatment and Discharge Plan dated 2/19/15, contained the short term goal: "...will refrain from having sexual encounters with peers and discuss why the hospital is an inappropriate setting for this behavior...Intervention...discuss the importance of refraining from sexual relationships in hospital settings...."

Review of hospital policy/procedure titled "Civil Patient Privileges-Granting Of" revealed: "...Off Unit/On Hospital Ground Privileges...1:5 Privileges (Inside facility)-The patient should attend meals and off-unit activities with staff escort only within the enclosed, locked civil hospital facility. No more than five (5) patients may go with any one clinical staff member. The patient must remain in the line of sight of staff at all times when off the unit...."

On 4/1/15, Pt # 5 had off-unit privileges with supervision at a 1:5 (1 staff for 5 patients) ratio.

Employee # 2 confirmed, during interview conducted on 5/20/15, that patients who require 5:1 supervision are staffed by Camp Cool staff and that there is no limit to the number of patients with Full Grounds Privileges who may attend Camp Cool. Employee # 2 also confirmed that additional staff from the nursing units may assist with patient supervision in Camp Cool, but there is no specific number of patients with Full Grounds Privileges that require additional staff to assist with supervision at Camp Cool.

The Interim Psychiatric Nursing Unit Manager for Desert Sage confirmed that Pt #s 5 and # 6 were able to engage in sexual activity when they were to be supervised by hospital personnel.

3. Review of hospital policy/procedure titled Close Observation revealed: "...To establish procedural standards to help ensure safety of the patient whose potential for an adverse event warrants close observation. Adverse events include, but are not limited to...non-suicidal self-injurious behavior, sexually inappropriate behaviors...being sexually exploited...It is the policy of (Name of Hospital) to provide close observation...to assure the safety of the patients and other individuals at (Name of Hospital)...Close Observation/High Risk (COS/HR) is a method of observation implemented when a patient's potential behavior poses an imminent threat to the patient's well-being...requires continuous visual observation of the patient at ALL times and within 6 feet range of the patient unless the patient is in their room...."

Review of hospital policy/procedure titled Sexual Interaction Between Patients revealed: "...It is the policy of the (Name of Hospital) that all patients will be maintained in a safe and therapeutic environment...The hospital does not condone any agreement, offer, or the exchange of items, i.e., money, soda, etc. In addition, pregnancy and sexually transmitted diseases, when they occur, carry legal obligations on each individual's part...."

Review of hospital document revealed: "...(Pt # 6) told me that at Camp Cool her 1:1 was not paying attention and (Pt # 5) wanted a soda they made the agreement that if they had sex she would buy him a soda...."

Review of Pt # 6's medical record revealed:

Pt # 6 is diagnosed with Post Traumatic Stress Disorder, Schizoaffective Disorder, Borderline Personality Disorder and Borderline Intellectual Functioning. She has a court appointed public guardian.

On 4/1/15, at 1513, an MD documented: "...Notified by RN that pt (Pt #6) just had sexual intercourse with a male peer...."

On 4/1/15, at 1727, an RN documented: "...She (Pt #6) went off the unit and went down to Camp Cool. She is COS/HR (Close Observation/High Risk) and has a 1:1. While down at Camp Cool she had a sexual interaction with a peer...."

On 4/1/15, at 1745, a Social Worker documented: "...(Pt # 6) indicated that she was at Camp Cool and a peer approached her for a soda she stated 'what do I get?' peer responded and stated 'what do you want?' (Pt # 6) stated that she wanted 'sex'...."


On 4/2/15, at 1336, a Social Worker documented: "...Both patients stated it was consensual. However, this patient's guardian requested an APS report to be completed. This writer notified Adult Protective Services...The 'Arizona Adult Abuse, Neglect, and Exploitation Reporting Form'...."

Review of hospital internal investigation of the event revealed that the staff member who was assigned to be within 6 feet of Pt # 6 who was COS/HR, was playing basketball, when Pt #6 left his supervision and engaged in sexual activity with another patient.

On 5/20/15, the Interim Psychiatric Nurse Unit Manager for Desert Sage confirmed that Pt # 6, who was to be supervised on a 1:1 basis due to her high risk of self-harm, was able to engage in sexual relations with Pt # 5 while in a supervised area of the hospital. The staff member who was responsible for the patient is a Mental Health Specialist (MHPs), working under the direction of an RN on the Desert Sage Unit.

4. Review of Pt #6's medical record revealed:

On 4/4/15, at 1714, an RN documented: "...Patient ran away from her 1:1 down the east dorm hall. When she got to the end of the hall she hit her head on the brick wall twice. She laid down on the floor and hit her head on the floor...Patient sustained a 1 1/2" open wound to her forehead...."

On 4/5/15, at 2111, an RN documented: "...(Pt # 6) was sent to (Name of acute medical hospital) for evaluation of a wound on her forehead...."

On 4/7/15, at 0808, an RN documented: "...(Pt # 6's) 1:1 staff member...stated that she and the patient were in the library when patient walked out onto the mall area to the side of the library. Patient dropped down to her knees and in the push up position she banged her head on the concrete approximately 12-13 times...Wound on forehead re-opened and bleeding...Doctor on scene...made the decision to send patient to the ER...."

While on Close Observation/High Risk status, Pt # 6 was able to engage in sexual intercourse with Pt # 5 on 4/1/15; "run away" from her 1:1 assigned staff and sustain a self- inflicted head injury, on 4/4/15; and sustain another self-inflicted head injury on 4/7/15, while in the presence of her 1:1 assigned staff.

5. Review of hospital policy/procedure titled Sexual Interaction Between Patients revealed: "...Responsible Person: Unit Shift Charge Nurse...Conduct a mental status exam on the patients involved, whether consensual or alleged sexual assault. NOTE: The mental status exam must include whether or not the patient(s) is capable of consenting, if consensual...."

Review of Pt # 5's medical record revealed:

On 4/1/15, at 1731, an RN completed a form titled Nursing Mental Health Status. The RN completed categories titled Dress, Eye Contact, Mood/Affect, Speech, Psychomotor, Insight, Suicidal, Speech Intensity, Speech Flow,Thought Content, Aggressive/Threatening, and Thought Clarity. Categories of Hallucinations and Delusions were blank. The RN documented: "...He stated that him and the peer had sex but not forced, they both agreed. She was talked with by staff about the importance of refraining from sexual interactions with peers and the dangers. He understood and was agreeable to not going (sic) to groups where this peer is at or taking turns to avoid interactions..." The Mental Status Exam did not contain any notation regarding assessment of Pt # 5's capability to consent.

Review of the Post-incident Treatment Team Staffing revealed that it did not contain documentation of Pt # 5's capability to consent. It contained documentation that the sexual contact was "consensual".

Review of Pt # 6's medical record revealed:

On 4/1/15, at 1721, an RN completed the form Nursing Mental Health Status. The RN completed categories titled Dress, Eye Contact, Mood/Affect, Speech, Psychomotor, Insight, Suicidal, Speech Intensity, Speech Flow, Thought Content, Aggressive/Threatening, and Thought Clarity. Categories of Hallucinations and Delusions were blank. The RN documented: "...She is COS/HR and has a 1:1. While down at Camp Cool she had a sexual interaction with a peer...It was decided that her and the peer were no longer allowed to be at groups at the same time including Camp Cool. She was educated about sexual boundaries and the risk that comes with it. She was examined by the doctor and spoken with by the psychiatrist...."

The Mental Status Exam did not contain any notation regarding assessment of Pt # 6's capability to consent. The Post-incident Treatment Team Staffing documentation and Progress Notes did not contain documentation of Pt # 6's capability to consent to "consensual" sex. Pt # 6's medical record did contain documentation that an APS report was filed and that the patient's guardian consented to intramuscular medication for birth control. It also contained documentation of Pt # 6's desire to become pregnant and the risk of damage to any fetus from the patient's medications.

The Interim Psychiatric Nursing Unit Manager for Desert Sage confirmed, during interview conducted on 5/20/15, that nursing did not include in the mental status exams of Pt #s 5 and 6 their capability to consent to sexual intercourse. She also confirmed that the Treatment Team Staffing documentation for both patients did not contain documentation of their capability to consent to sexual intercourse.

6. The surveyor requested the policy and procedure on wound care, none was submitted.

Patient # 19

Review of "Client Profile - Order Details" (Pt # 19) dated 1/5/15, revealed: "...apply aquacel AG piece to b/l (bilateral) great toe ulcerated area and cover it with dry dressing One Time Every Day...DC (discontinue) 2/25/15...."

Review of "Nursing Symptom Review and Physical Assessment" revealed that on 2/2/15, 2/7/15, 2/8/15, 2/9/15, 2/11/15, 2/22/15, 2/24/15 and 2/25/15, wound care was not performed as ordered.

Review of "Nursing Symptom Review and Physical Assessment...MONTHLY ASSESSMENT" dated 2/28/15, revealed: "...(patient) HAS ULCERS TO BOTH OF ...GREAT TOES. THESE ULCERS ARE DRY AND APPEAR TO BE HEALING WELL. THESE WOUNDS ARE ADDRESSED AND VISUALLY INSPECTED WITH DRESSING CHANGES BY NURSING ON A DAILY BASIS...."

Review of "Client Profile - Order Details" dated 2/2/15, revealed: "...MOISTURIZING CREAM (Cetaphil) to BL (bilateral) feet/legs liberally G TOPICAL CREAM 2 Times Per Day...."

Review of "Nursing Symptom Review and Physical Assessment" revealed that on 2/2/15, 2/7/15, 2/8/15, 2/9/15, 2/11/15, 2/22/15, 2/24/15 and 2/25/15, the Cetaphil and G topical cream was not being applied as ordered.

Review of "Client Profile - Order Details" dated 2/25/15, revealed: "...apply non adherent gauze to b/l great toe prior ulcerated area after cleaning with normal saline and cover it with dry dressing One Time Every Day...."

Review of "Nursing Symptom Review and Physical Assessment" revealed that on 2/27/15, 3/6/15, 3/8/15, 3/9/15, 3/16/15, 3/17/15 and 3/18/15, wound care was not performed as ordered.

Review of "Physician's Order Entry" dated 4/27/15, revealed: "...Apply nonadherent gauze to b/l great toe after cleaning with normal saline and cover it with dry dressing One Time Every Day...."

Review of "Nursing Symptom Review and Physical Assessment" revealed that on 4/28/15, 4/30/15, 5/1/15, 5/3/15, 5/4/15, 5/5/15, 5/9/15, 5/10/15, 5/11/15, 5/17/15 and 5/18/15, wound care was not performed as ordered.

The DON verified, during an interview conducted on 5/21/15, that they do not have a wound care policy and that the nursing staff was not following the physician's orders on wound care.

7. The surveyor reviewed medical records for Patients #2 and #14. Both of these patients were ordered on 1:1 at a minimum. Both patients had adverse events when ordered on 1:1.

Patient #2 was up in the hallway on 05/11/2015 and the 1:1 staff member was stated to have been beside the patient throughout the night and early am. The staff member told the surveyor the patient was walking around the hall and then went to an area of the unit on Ironwood East where there had been telephone booths. The patient sat on a shelf within the booth and the staff member sat on the shelf next to the patient. The staff member did not instruct the patient to get off of the shelf according to an interview with the staff member on 05/26/2015.

The hall monitor, which was a second staff member responsible to monitor the hallway and provide support to the staff who were managing patient that were ordered on a 1:1 was reported as being in the nurses station which is located behind a glass wall.

The 1:1 staff member stated to the surveyor that she was not directly watching the patient and was writing on the Close Observation Form when she heard a scream from the nursing station and then saw Patient #2 on the floor.

The RN on duty stated on 05/26/2015, that the patient stood up on the shelf and dove head first onto the floor.

The patient was transported to the hospital with severe injury.

The 1:1 staff member failed to maintain continued observation of the patient and the hall monitor staff member failed to remain in the hallway monitoring the hallway activity and being available to support the other staff members.

Patient #14 was continually on a 1:1 monitor and during the patient's stay he was transitioned at times to a 2:1. On 05/03/2014 at 12:15 PM, the patient was on a 1:1 and was instructed to stay in the day room by the charge nurse. The patient "manipulated the staff member doing the 1:1 to go to the room and when in the room the staff member allowed the patient to turn away and the patient put a sock in his mouth. The patient was mechanically restrained for 130 minutes after this event. Then at 4:15 on the 3rd of May the patient after being released from restraints and ordered to be on a 1:1 with a sterile environment was able to put another sock in his mouth. This again required a physical hold and restraint for another 168 minutes.

The RN failed to adjust the patient's plan of care and remove the socks from the patient so that he did not have access to the socks, which may have prevented the second event with the sock and may have prevented the need for a second physical hold and restraint.

The patient remained on a 1:1 and in the following days was able to pick at his toenails and eventually tear the toenail requiring medical treatment. The staff were present when he tore toenail.

The staff revealed during an interview conducted on 05/20/2015, that the staff are not allowed to do "solo" intervention when a patient is acting in a self-harming manner. The technician or other staff who observe self-harming or assaulative behavior are required to call a Code Gray and are not allowed to intevene until at least one other person is present. Asking a patient to stop the behavior is the limit the staff can do as a solo person.

8. Patient #7's medical record revealed an order for weight every Sunday prior to breakfast. A review of the vital sign record revealed there was no weight documented every Sunday as required by the order.

The Dietician documented on 04/30/2015 "No new weight this month".

The record was reviewed with the Assistant Director of Nursing and confirmed there was no documented evidence of a weight documented each Sunday.

Patient #14's medical record revealed the patient was to be on intake monitoring. A sample of the intake documentation was reviewed for the dates of 05/11/2015 through 05/17/2015. The records revealed there was no documented intake for the night shift on 05/11/2015 through 05/17/2015. There was no documented intake record on the intake flow sheet for the day shift on 05/13/2015 and 05/17/2015. There was no documented intake on 05/17/2015.

This documentation was reviewed with the Director of Nursing on 05/26/2015 and she confirmed there was not adequate documentation of the patient's intake.

Patient #15's medical record revealed an order for vital signs every 2 hours after the patient had reported having taken an overdose of medications on 04/03/2015. A review of the Vital Signs record revealed on 04/03/2015 at 7:50 PM, there was a note in the record stating "Declined Giving Vitals". There was no documentation the physician was made aware vital signs were not completed as ordered and the patient had refused the vital signs. There was only one note documented at 7:50 PM on the flowsheet for vital signs. There was no further documentation of attempts to assess the patients vital signs.


The RN documented on 04/03/2015 at 8:51 PM, the patient's vital signs are "WNL" (within normal limits).
There was no documented evidence of the vital signs that were referenced by the RN.

This documentation was reviewed with the Assistant Director of Nursing on 05/26/2015, who indicated there was no further documentation that would indicate the vitals signs were completed, attempted, or that the physician was made aware they were not completed.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on a review of medical records and interview, it was determined the Director of Nursing failed to require there be a nursing care plan that is ongoing and current based on the patient's needs in 23 of 23 medical records reviewed.

Findings include:

A review of the 23 patient medical records was completed for nursing care plans. There were no identified nursing care plans identified in the patient medical records. A review of the interdisciplinary care plans revealed some nursing actions and interventions.

These interdisciplinary care plans were developed for a timeframe of two months. There was no documentation by the nursing personal of follow up to the nursing actions identified on the care plans on a consistent basis. There was no updates to the interdisciplinary plans by nursing when there were events that occurred with the patients or the patient's condition changed.

Some of the records had Behavioral Management plans that had some directions for patient activities and management. There was no documented follow up and adherence to the behavioral management plans.

The Director of Nursing and the Assistant Director of Nursing confirmed during interviews conducted on 05/20/2015 and 05/21/2015, there was not a consistent method for nursing to document implementation of the actions identified on the care plans or a process identified to keep the plan current.

On 05/22/2015, the Assistant Director of Nursing provided the surveyors with a manual from the Palo Verde Unit that had documentation for each patient on this unit that would be a care plan for each patient; however this document was not maintained as a part of the patent's medical record.