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.

SONORA BEHAVIORAL HEALTH HOSPITAL 6050 NORTH CORONA ROAD TUCSON, AZ 85704 May 11, 2016
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of medical record, documents, policy and procedure, Code of Conduct, personnel file, and interview, it was determined that a safe setting was not provided to a vulnerable child patient (Patient # 1), who was assaulted by a Behavioral Health Technician (BHT # 1), according to eyewitnesses. This posed a high potential risk of grave physical and emotional injury to a vulnerable child patient.

Findings include:

Cross reference Tag (A0145), in which a child, made decidedly vulnerable by diagnoses, weight and stature, and psychiatric hospitalization , was assaulted by a BHT with no documention of provocation.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of medical record, document review, policy and procedure, Code of Conduct, personnel file, and interview, it was determined that a patient was not maintained in a safe setting/environment, when a child patient was assaulted by a Behavioral Health Technician (BHT # 1), who according to eyewitnesses, reported that the child was "slammed" into a locked door (Patient # 1). This posed a high potential risk of grave physical and emotional injury to a vulnerable child.

Findings include:

The "Patient Rights and Responsibilities" "Clinical Rights" revealed: "...EACH PATIENT HAS THE RIGHT TO: 1. Be treated with dignity, respect, and consideration...19. To be free from: a. Abuse...."

The (Corporation) "Code of Conduct" revealed: "This Code of Conduct is an integral component of the (Corporation) Program. Our intent in developing the Code is not only to document (Corporation's) legal and ethical compliance requirements, but also to encourage each of us to regularly think about our actions and the consequences of our behavior in the workplace...Zero Tolerance Policy (Corporation) has and strictly enforces a Zero Tolerance policy prohibiting resident or patient physical or emotional abuse including but not limited (to) verbal or physical abuse, use of undue force...."

The (Corporation) "Patient Abuse and Neglect" policy revealed: "It is the policy of (Corporation) that no patient is to be mistreated or abused physically, verbally, psychologically...while in our care...Patient abuse is strictly prohibited...."

The "Abuse, Exploitation or Neglect Reporting-Child or Vulnerable Adult" policy revealed: "Policy: Appropriate reporting occurs when suspicion arises that a patient may have been or is at risk for abuse...Physical Abuse is a form of abuse which results in physical injury or injuries to a child under the age of eighteen years...Physical indicators...Missing or loose teeth...LEGAL REQUIREMENT TO REPORT CHILD ABUSE Legal Requirements to Report: Arizona Statute 13-3620 states: 'Any physician, hospital intern or resident...nurse...social worker...or any other person having the responsibility for the care or treatment of children whose observation or examination of any minor is or has been the victim of injury...which appears to have been inflicted upon such minor by other than accidental means...."

Patient # 1, a child younger than age (specific number identified), was admitted to the Child and Adolescent Unit after an episode in which the child was physically aggressive with others. The "Psychiatric Evaluation" revealed, among several psychiatric diagnoses, [specific name] Disorder. The evaluation revealed that the child had a weight of (specific number identified) pounds, and a height of (specific number identified) inches (specific number identified feet, (specific number identified inches).

The "(Hospital) Behavioral Health Observation Rounds" documentation dated 12-25-15, revealed the following for Patient # 1:

11:30 A.M. Location: Art (Room)
Behavior: Cooperative

11:45 A.M. Location: Art
Behavior: Cooperative

12:00 P.M. Location: Art
Behavior: Cooperative

12:15 P.M. Location: Cafeteria
Behavior: Cooperative

12:30 P.M. Location: Cafeteria
Behavior: Cooperative

12:45 P.M. Location: Patient Room
Behavior: Cooperative

1:00 P.M. Location: Dayroom
Behavior: Cooperative

An internal document of a witness account revealed that the date and time of the incident was 12-25-15 at 12:30 P.M. A second witness account revealed an incident time of 1:00 P.M. The second account revealed: "...then slam the youth into the unit door...."

A hospital document revealed: "Witnesses described...(BHT) having ahold of the patient's arm while walking the patient back to the (Child and Adolescent) unit from the cafeteria...while being overheard stating to the patient 'You don't know who you are dealing with' as they walked through the breezeway and the patient stating 'Ow.' A witness described (BHT's) tone as 'angry and hostile.'...It was further substantiated by other witnesses that (BHT) was observed to have 'slammed' or 'pushed' the...patient into (Child and Adolescent) unit locked door...(BHT) violated the Zero Tolerance policy by... and acting in an aggressive manner leading to the abuse of a patient...."

On 12-25-15, Staff #15, the Assistant Director of Nursing at the time, documented: "Writer spoke c (Latin for abbreviation for 'with') pt. (patient) re (regarding): coming back from cafeteria. Pt did not say why she/he was brought back. Did not want to talk about it. Very fidgety-moving around constantly-Skin assessment of upper arms-L (Left) upper arm slight redness on inner aspect...."

A nursing note several days following the assault documented that the patient lost a tooth (specific tooth unknown) "due to normal aging."

Staff #17, the Director of Health Information Management (HIM) stated, during interview conducted on 05-04-16 at 4:10 P.M., that she was unable to find documentation that a referral had been made regarding the assault to the Arizona Department of Child Safety.

Staff #16, the Assistant Director of Nursing, stated, during interview conducted on 05-05-16 at 8:45 A.M., that there was no record that anyone at the hospital had reported the assault to The Department of Child Safety or to law enforcement.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of hospital policies and procedures, medical records, documents, Code of Conduct, personnel file, and interviews, it was determined that the hospital failed to protect and promote each patient's rights as evidenced by:

(A144) failure to ensure that patients received care in a safe setting, posing a risk to the health and safety of patients; and

(A145) failure to ensure that a child patient was maintained in a safe environment.

(A0117) failure to notify a child's parent of assault on a child.

The cumulative effect of these systemic problems, and the egregious assault of a vulnerable child patient, resulted in the hospital's failure to meet the requirements of the Condition of Participation for Patient Rights.
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on review of policy and procedure, Code of Conduct, personnel file, and interview, it was determined that the chief executive officer failed to be responsible for the management of the hospital as evidenced by:

1. failure to ensure that a vulnerable child patient was maintained in a safe environment, when the child was "slammed" into a door by a Behavioral Health Technician (BHT). There is a grave potential risk to the physical and emotional health of a highly vulnerable child being assaulted in a psychiatric hospital environment.

2. failure to ensure that the assault of a vulnerable child patient by a BHT was reported to law enforcement as required by policy. The potential risk is that the failure to report the assault leaves patients in other psychiatric or behavioral health facilities at risk of assault by the BHT should he/she seek subsequent employment in a psychiatric setting.

Findings include:

1. Cross reference Tag (A0145) regarding the assaul of a vulnerable child patient by a Behavioral Health Technician (BHT), when eyewitnesses described the child being "slammed" into a closed door.

2. Cross reference Tag (A0145) regarding the failure of licensed persons, employed by the hospital, to report the child assault to legal authorities.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on review of the medical record, policy and procedure, and interview, it was determined that the Hospital failed to assure the patient's right to receive assistance of a family member, when the patient's parent was not informed of the the child's assault. The potential risk is that the patient continued to be hospitalized in an unsafe setting, without his/her representative (parent) being aware of the risks of continued hospitalization at the hospital.

Findings include:

The Sonora Behavioral Health Hospital policy titled: "Patient Rights and Responsibilities" revealed: "...PURPOSE: To assure all patients are aware of their options and obligations...4. Patient Surrogates- Patient rights, care, comfort and service are a priority at (hospital). While patients are recognized as having the right to participate in their care and treatment to the fullest extent possible, there are circumstances under which the patient may be unable to do so. In these situations, the patient's rights are to be exercised by the patient's designated representative or other legally designated person. In the event that a patient can't make or communicate health care decisions and has no advance care directives, decision makers must be chosen in this order...5. Parent of patient...EACH PATIENT HAS THE RIGHT TO: 8. To receive assistance from a family member, designated representative, or other individual in understanding, protecting, or excising the patient's rights...."

Cross reference Tag (A0145) regarding a child under the age of ( specific age identified) who was assaulted by a Behavioral Health Technician by being "slammed into a closed door.

Review of Patient #1's medical record revealed no documentation that the patient's parent had been notified of the assault.

Staff #16, the Assistant Director of Nursing, stated during interview conducted on 05-05-16 at 8:45 A.M., that the child's parent had not been notified of the assault.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on review of the Registered Nurse (RN) job description, hospital policy and procedure, direct observation of a med (medication) pass, medical record and interviews, it was determined that medications were not administered according to accepted standards of practice, hospital policy/procedure and/or physician orders, as evidenced by:

1. RN staff documenting administration of medication prior to actual administration, and failing to observe that patients swallowed their medication, for 2 of 2 adolescent patients (Pt #s 23 and 24). The potential risk is that medications documented as given prior to actually being given could be inadvertently assumed to be administered by another nurse, therefore not given; a patient could "cheek" and save medications for later ingestion if not observed to have swallowed the medication;

2. RN staff failing to document administration of medication ordered for alcohol withdrawal for 1 of 1 patient with a history of withdrawal seizures who required transfer to an acute medical center (Pt # 25), posing a risk of overmedication of the patient; and

3. RN staff administering medication for anxiety, without an order, for 2 of 2 patients who were receiving treatment for alcohol withdrawal (Pt #s 28 and 29), posing a risk to patient health and safety if the wrong dosage of medication was given.

Findings include:

The RN job description revealed: "...Maintains a safe...working and treatment environment...."

The "Medication Administration" policy revealed: "Medications are administered safely and accurately by the professional staff listed below within the specifications of approved job descriptions, licensure, certifications and scope of practice...Registered Nurses...H. Once a patient has taken an oral medication, the administering nurse checks the patient's mouth to assure the medication has been consumed. J. The administering nurse will then document in the patient's MAR (Medication Administration Record) the medication (s) administration or refusal...2. A. Each dose of medicine is recorded on the Patient's Medication Administration Record (MAR) by the person who administers the drug, stating the...time given...."

1. Direct observation of a med pass, conducted on 05-11-16, at 9:00 A.M., on the Child and Adolescent unit, revealed Staff #17, a contracted RN, conducting a medication pass.

Observation revealed medications being passed for Patients # 23, and # 24, both adolescents. Observation of the paper medication record for each patient revealed that the 9:00 A.M. medications had been documented prior to actual administration of the medications.

Observation of the administration of medications to Patient # 23, and # 24, respectively, revealed that the RN failed to observe the adolescents swallow the medications.

Staff #17 acknowledged, during interview conducted on 05-11-16, at 9:30 A.M., that she should not have documented that medications that had not yet been administered had been given, and acknowledged that she should have observed that the medications had been swallowed by the adolescents.

2. Review of Pt # 25's medical record revealed:

On 4/29/16, at 1018, MD # 8 wrote medication orders:
"...Librium 50 mg PO BID (by mouth twice a day) for ETOH WD (alcohol withdrawal), 1st dose now, last dose evening of 4/30/16, X2 days, hold for oversedation...Librium 50 mg PO q AM (every morning) x 2 days for ETOH WD, 1st Dose 5/1/16 AM, last dose 5/2/AM, hold for oversedation...."

Review of the Medication Administration Record for Pt # 25 revealed documentation of 50 mg of Librium on 4/29/16, at 2100 and on 4/30/16, at 0900 and 2100. The "now" dose for 4/29/16, at 1018 was not documented. Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 4/29/16, at 1043.

Review of the Medication Administration Record for Pt # 25 revealed that it did not contain documentation of administration of 50 mg Librium on 5/2/16, as ordered.

Pharmacy provided a report from the automated medication dispensing station that 50 mg was removed on 5/2/16, at 0803.

RN # 30 and the Acting Director of Nursing confirmed, during interview conducted on 5/5/16, the nursing did not document administration of medication as required by policy/procedure.

3. Patient # 28

Review of Pt # 28's medical record revealed:

On 5/3/16, at 1330, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) and repeat (after) 1 (hr) if medicated SSWD (Signs/Symptoms of Withdrawal)...Ativan 1 mg po/IM Q 4 (hrs) SSWD, BP 150/90 P>100...."

An RN documented, on the Medication Administration Record (MAR), clarification of SSWD from the physician: "Ativan 1 mg po Q 4 hr S/S (Signs/Symptoms) of withdrawl (sic)-diaphorsis (sic) tremors...Prn BP >150/90 P >100".

On 5/3/16, at 1455, an RN documented administration of Ativan 1 mg po for Reason: "Anxiety 10/10" and Response: "Anxiety 5/10" at 1530.

Pt # 28's medical record did not contain an order for Ativan for anxiety.

Patient # 29

Review of Pt # 29's medical record revealed:

On 5/3/16, at 0920, an RN recorded a telephone order from MD # 1: "...Vital Signs:...Q 4 (hrs) VS (Vital Signs) and 1 (hr) (after) each W/D (Withdrawal) medication...Ativan 1 mg po or IM prn (as needed) Q 4 (hrs) if BP (Blood Pressure) above 150/90 P (Pulse) above 100...Ativan 1 mg IM Q (hr) prn SZ (Seizure) for 5 days Q 1 (hr)...."

An RN documented, on the Medication Administration Record (MAR), clarification from the physician: "Ativan 1 mg po Q 4 hr prn S/S (Signs/Symptoms) of W/D symptoms DBP (Diastolic Blood Pressure) >90, SBP (Systolic Blood Pressure >150 T (Temperature) >101 (degrees) & tremors, diaphorsis, visual disturbances"

On 5/3/16, at 2100, an RN documented administration of Ativan "1" for Reason: "Anxiety 6/10" and Response: "2/10" at 2200.

Pt # 29's medical record did not contain an order for Ativan for anxiety.

The Acting Director of Nursing confirmed, during interview conducted on 5/4/16, that Ativan was ordered for Pt # 28 and 29 for elevated vital signs and other S/S due to alcohol withdrawal. S/he confirmed that nursing administered the Ativan for "anxiety" and the medical records of Pt #s 28 and 29 did not contain orders for administration of Ativan for anxiety.
VIOLATION: CODING AND INDEXING OF MEDICAL RECORDS Tag No: A0440
Based on review of hospital policy/procedure, Intake assessment records and interviews, it was determined that the hospital failed to implement a system of coding and indexing the medical records of patients who received an assessment in the Intake Department and referral to an outside hospital and/or agency without being admitted to an inpatient unit of the hospital for 5 of 6 patients (Pt #s 16, 18, 20, 21 and 22).

Findings include:

Review of hospital policy/procedure titled Medical Record Content, revealed: "Policy: the medical record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers. The medical record must be complete for the purposes of facilitation of patient care, to serve as a financial and legal record, aid in clinical research, support decision analysis, and guide professional and organizational performance improvement. Purpose:...To provide continuity in the evaluation of the patient's condition...To document communication between the patient care providers...To assist in protecting the legal interest of the patient, facility, and health care providers...To provide data for use in continuing education and research...A medical record is maintained for every individual assessed or treated...The medical record must address the presence, accuracy, timeliness, legibility, and authentication of the following data and information:...The record and findings of the patient's assessment and health screen...the diagnosis or diagnostic impression, including a statement on the course of action planned for the patient for this episode of care...the reasons for admission or treatment...evidence of informed consent and patient rights...."

Cross reference Tag 0438 for information regarding the Intake Department assessment records for Pt #s 16, 18, 20, 21 and 22.

The Director of Performance Improvement and Risk Management confirmed, during interview conducted on 5/11/16, that the Intake records of Pt #s 16, 18, 20, 21 and 22 were stored in a locked file cabinet in her office. S/he stated that these records and records of other patients who were seen in the Intake Department but not admitted to the hospital, are not maintained in the medical records department/system. They are not coded and/or indexed by the Medical Records Department as required for other medical records of patients assessed and/or treated in the hospital.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the Rules and Regulations of the Medical Staff, record review, and interview, it was determined that all patient records were not authenticated by the person providing the service, when 3 of 3 outpatient records reviewed for authentication, did not have medical staff signatures (Patients #20, 21, and 22). The potential risk is to the health and safety of patients, who may not have been safe for discharge or transfer, without authentication from the medical staff that they were in agreement with the Qualified Medical Person's (QMP's) assessment of the patient.

Findings include:

The Rules and Regulations of the Medical Staff revealed: "...7.13 Completion of Medical Records-All discharge summaries and other medical record documentation shall be completed within thirty (30) days following the patient's discharge...."

Patient # 20

Patient #20 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-05-16. A Medical Screening Examination (MSE) was conducted by a Qualified Medical Person (QMP), and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff
#4, did not sign the telephone consultation.

Patient # 21

Patient #21 presented on [DATE] as a "Scheduled Assessment." A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #15, a Psychiatric Nurse Practitioner (NP). Medical Staff #15, did not sign the telephone consultation.

Patient # 22

Patient #22 presented as a "Walk In" to the Intake (emergency unit) of the hospital on 04-10-16. A Medical Screening Examination (MSE) was conducted by a QMP, and a telephone consultation was documented with Medical Staff #4, a psychiatrist. Medical Staff # 4, did not sign the telephone consultation.

Medical Staff #15 acknowledged, during interview conducted on 05-10-16 at 12:30 P.M., that the medical staff should sign the telephone consultation, and that within the telephone consultation, the communication between the QMP and the Medical Staff member should be clearly documented.