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.

CORNERSTONE BEHAVIORAL HEALTH EL DORADO 1400 NORTH WILMOT ROAD TUCSON, AZ 85712 June 17, 2019
VIOLATION: NURSING SERVICES Tag No: A0385
Based on clinical record reviews, review of policies and procedures, hospital documents, observations, and staff interviews, it was determined the hospital's Registered Nurses (RN):

A-395: 1. failed to ensure all patients were observed every fifteen minutes including Patients #9, #10, and #16. 2. failed to document in the clinical record, a patient-to-patient altercation resulting in injuries (Patients #3 and #7). 3. failed to ensure the RN intervened in an altercation between Patient #1 and Staff #12 on 6/1/2019.

A-405: failed to ensure medications were administered following physician, Physician Assistant (PA), and/or Nurse Practitioners (NP) orders. (Patients #8, #10, and #16) This deficient practice poses the risk of medication errors causing potential patient harm.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment related to the provisions of nursing services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on clinical record reviews, policies and procedures documents, and staff interviews, it was determined the hospital's Registered Nurses (RN):

1. failed to ensure all patients were observed every fifteen minutes including Patients #9, #10, and #16. This deficient practice poses the risk of potential harm to patients or are at risk for harm to themselves or others and patients who are at risk for experiencing life threatening symptoms of alcohol withdrawal.

2. failed to document in the clinical record, a patient-to-patient altercation resulting in injuries (Patients #3 and #7). This deficient practice poses the potential risk of behaviors and injuries not identified in the record for continuity of care.

3. failed to ensure the RN intervened in an altercation between Patient #1 and Staff #12 on
6/1/2019. This deficient practice poses the potential risk of harm to patients when the care is not directed by an RN.

Findings include:

1. The hospital's policy and procedure titled "Rounds of Patient Observation" (Policy 1129) included: "An accurate record of the whereabouts and behavior of all patients will be maintained during each shift...Every patient must be seen by a staff member at a minimum of every fifteen minutes...A staff member will be assigned by the Charge Nurse each shift to be responsible for the Patient Observation Record...Responsibilities...Nurse oversight of patient observation rounds is evident per review/signature on Patient Observation rounds Checklist at a minimum of twice per shift...BHT...Observe each patient, a minimum of every 15 minutes and/or according to precaution level and document observation on the patient observation form..Observe patients on bed rest or when sleeping by: Looking for the rise and the fall of the chest...Counting at least three respirations, and... Making sure that the patient had moved (sic) from his/her sleeping position."

Security video footage of the East Wing (Rooms 301 through Room 333) was randomly selected for review for 3/9/2019 between approximately 2 a.m. to 7 a.m. There were 15 patients on the East Wing during that time. Staff #7 was observed looking into patient rooms between 2:13 a.m. and 2:15 a.m. There were no observation checks on the East Wing until 3:19 a.m., over one hour later, by Staff #17. At 5:16 a.m., almost two hours later, Staff #7 and Staff #17 entered five rooms with the vital signs equipment. There were no observation checks again on the East Wing until 7:07 a.m.

The clinical records for Patient #9 (Room 303), Patient #10 (Room 304), and Patient #16 (Room 305) were randomly selected for review.

Patient #9 was admitted with suicidal ideation. Patients #10 and #16 were admitted for acute alcohol detoxification and suicidal ideation.

All three patients had physician orders for "Observation q (every) 15 minutes every shift." Documentation dated 3/9/2019 between 2 a.m. and 7 a.m. for these patients revealed they were observed by Staff #7 every fifteen minutes in their rooms and each patient "Appears Asleep."

The CEO was present during the above security video footage and acknowledged observation rounds were not performed every fifteen minutes per the hospital's policies and procedures.

2. The hospital's policy and procedure titled, "Incident Report Protocol" (Policy 8005) included the following: "...document the incident in the patient's medical record including notification of the physician and physician response if applicable...The supervisor if notified of the incident ensures that the following has occurred...Patient was examined and received immediate medical attention as needed...Medical record is appropriate and has factual, complete information

Patient #3

A hospital occurrence report dated 2/23/2019 at 4:50 p.m. included details of a patient-to-patient altercation in which Patient #3 was held down on the floor and hit and choked by another patient. The report revealed the altercation resulted in the following injuries to Patient #3: scratches to the right shoulder, hand marks and redness on his neck, and redness on his lower back. A nursing note in the clinical record dated 2/23/2019 at 4 p.m. included: "...irritated with another patient who instigated a verbal altercation." There was no other documentation that referenced the physical altercation with another patient with resulting injuries and no documentation that the injuries were treated and followed up on.

The Chief Nursing Officer acknowledged during an interview that the incident and patient injuries were not documented in the clinical record.

Patient #7

Documentation in a hospital's occurrence report dated 3/9/2019 at 9:45 a.m. revealed an altercation between Patient #7 and a Behavioral Health Technician (BHT), Staff #16. The patient yelled and threw a cup of water/ice at Staff #16. Staff #16 became upset and started swinging at and chasing the patient. Documentation in the occurrence report included: "Pt was found in his room having visual hallucinations, extremely anxious with tremors. States he fears for his life....Tech admitted that he was aggressive towards patient." The incident was confirmed by the CEO who reported during an interview that he reviewed security video of the incident. (Refer to Tag A-0145 for more details of the incident.)

There was no nursing documentation in the patient's clinical record that reflected the above incident, however, there were telephone orders from a Nurse Practitioner at 11:02 a.m. for the following medications to be administered "one time only" by mouth for "agitation": Zyprexa 10 mg, Diphenhydramine HCl (Benadryl) 50 mg, and Lorazepam 2 mg. The orders were received by and administered to the patient by the Charge Nurse (Staff #9) who was on duty at the time of the incident and who wrote and signed the occurrence report. There was no documentation that the patient was reassessed after the incident to determine the impact of the BHT's aggressive behavior directed at him.

The CNO acknowledged during interviews that the nursing documentation was not complete and did not reflect ongoing assessments and management of the complex psychiatric needs of the patient.

3. Video footage of an altercation between Staff #12 and Patient #1 on 6/1/2019 at 9:40 p.m. was reviewed on 6/5/2019. The video footage revealed Staff #12 forcefully pushing Patient #1 causing her to stumble. The Registered Nurse (RN) assigned to the patient's care was in the nurses station during this incident and appeared to observe the interaction but did not attempt to intervene and direct the situation. Refer to Tag A-145 for more details.

The CNO was present when the video footage was reviewed and acknowledged the RN should have intervened and managed the care to prevent the altercation.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews, hospital policies and procedures, observations, and staff interview, it was determined the hospital failed to ensure medications were administered following physician, Physician Assistant (PA), and/or Nurse Practitioners (NP) orders. (Patients #8, #10, and #16) This deficient practice poses the risk of medication errors causing patient harm.

Findings include:

The hospital was not able to locate and provide nursing policies and procedures for medication administration.

Documentation in the hospital's "Alcohol Withdrawal Assessment Scoring Guidelines (CIWA-Ar)" form included: "The CIWA-Ar scale is the most sensitive tool for assessment of the patient experiencing alcohol withdrawal. Nursing assessment is vitally important. Early intervention for CIWA-Ar score of 8 or greater provides the best means to prevent the progression of withdrawal." Documentation in the two CIWA Medication Order Sets attached to the assessment tool included: "Lorazepam NTE (not to exceed) 12 mg/24 hrs."

Patient #8

Patient #8 was admitted on [DATE], on or around 9:30 p.m. for alcohol detoxification. A physician's order at 10:40 p.m. included: "Monitor per CIWA Protocol." The CIWA-Ar form includes the key or description of the scores as follows:

-From 0 to 9 = Absent or Minimal Withdrawal
From 10 to 19 = Mild to Moderate Withdrawal
From 20 to 70 = Severe Withdrawal

Nursing documentation of CIWA scores and medication administration in Patient #8's clinical record included the following:

-The first documented CIWA assessment was done at 11:37 p.m., and the total score was "8" (absent or minimal withdrawal). Physician orders for a CIWA score between 8-10 were for Lorazepam 2 mg to be administered by mouth with reassessment in two hours. There was no documentation in the Medication Administration Records (MAR) that Lorazepam 2 mg was administered, however, a nursing note dated 2/25/2019 at 6:54 a.m. included: "Admission CIWA score was 9. Writer medicated him with Ativan 2 mgs."

-The next CIWA assessment documented was at 2:25 a.m. on 2/25/2019, and the total score was "12" (mild to moderate withdrawal). Physician orders for a CIWA score between 11-14 were for Lorazepam 3 mg to be administered by mouth with reassessment in one hour. The patient was given 3 mg of Lorazepam at 2:55 a.m. The RN documented in the MAR at 6:10 a.m. (3 hours later) that the Lorazepam 3 mg administered at 2:55 a.m. was "Not effective." There was no CIWA assessment documented with a score corresponding to that time.

-The next CIWA assessment documented was at 9:22 a.m., and the total score was "29" (severe withdrawal). The RN administered 3 mg of Lorazepam by mouth at 9:39 a.m. under the order for a CIWA score between 11-14. There was a physician's order for the dose of Lorazepam (4 mg) to be administered if the CIWA score was between 15 and 25, however, there was no physician's order for medication to be administered for a score over 25. The RN documented in the MAR at 10:19 a.m. that the medication was "effective," however there was no corresponding CIWA assessment and score documented.

-The last CIWA assessment documented was at 2 p.m., and the total score was "37" (severe withdrawal). The RN again administered 3 mg of Lorazepam at 2:03 p.m. under the physician's order for the 11-14 CIWA score. The RN documented on the MAR at 2:51 p.m. that the medication was "not effective," however there was no corresponding CIWA assessment and score documented.

The RN's nursing note at 3:15 p.m. included: "Patient hit behavioral health tech. Ativan 4 mg IM given." The RN documented the administration 4 mg of Lorazepam intramuscularly (IM) to the patient at 3:09 p.m. under the physician's order for a CIWA score of 15-25. There was no documentation that a CIWA assessment was performed resulting in a score to validate the administration of Lorazepam 4 mg. The nursing note indicated the medication was given because the patient hit a BHT.

Documentation in the MAR reflected a total of 13 mg of Lorazepam administered between 2:25 a.m. and 3:09 p.m., approximately 11 hours. That does not include the 2 mg the RN documented in a nursing note as being given at the time of the first CIWA assessment. The paper CIWA Medication order sets direct that the total Lorazepam dose is not to exceed 12 mg in 24 hours.

The patient was transferred to an acute care hospital at approximately 3:15 p.m. where he was admitted .

Patient #8's clinical record was reviewed with Staff #2 on 6/12/2019, who acknowledged there were discrepancies in the physician orders and what was administered as well as the frequency of CIWA assessments. Staff #2 also acknowledged there were discrepancies in their "paper" CIWA-Ar scoring guidelines, and what was entered into the electronic medical record.

Patient #10

Patient #10 was admitted for alcohol detoxification. The following documentation was located in the MAR's and CIWA-Ar scoring forms:

-A CIWA-Ar form dated 6/1/2019 at 12:55 p.m. revealed a score of "17." There was no documentation the patient received Lorazepam 4 mg for a CIWA-Ar score of 15-25 in accordance with physician's orders.

-The CIWA-Ar form dated 6/1/2019 at 3:15 p.m. revealed a score of "15." The patient was administered 2 mg of Lorazepam by mouth rather than 4 mg in accordance with the physician's order for that score (15-25).

-The CIWA-Ar form dated 6/1/2019 at 10:36 p.m. revealed a score of "18" and the patient was given the appropriate dose of Lorazepam following physician orders. However, documentation on the MAR revealed the patient was not reassessed until 3:57 a.m. on 6/2/2019, a period of over five hours later. The patient should have been reassessed within the hour according to physician orders.

-The patient scored "17" on a CIWA-Ar form dated 6/4/2019 at 10:36 a.m., however, there was no documentation that the patient was medicated following the physician's order for that score which was Lorazepam 4 mg. There was no documentation in the record that the patient was offered the medication but refused.

Patient #16

Patient #16 was admitted for alcohol detoxification. A review of the MAR's and CIWA-Ar scoring forms revealed the following:

-There were several instances where the RN documented in the MAR that the patient was reassessed after given Lorazepam with the documentation "Effective" rather than documentation that the CIWA-Ar form was completed and scored per the protocols and physician orders. For example, Lorazepam 2 mg was administered on 6/9/2019 at 6:02 p.m. for a CIWA-Ar Score completed at 6 p.m. of "8." The patient should have been reassessed within two hours, but not reassessed until 9:38 p.m., and the RN documented the Lorazepam was "Effective" rather than a CIWA-Ar score.

-The patient was given Lorazepam 2 mg at 9:19 p.m., however, there was no corresponding CIWA-Ar score documented to justify the administration. The patient was reassessed at 3:31 a.m. on 6/11/2019 over six hours later.

-The patient was given Lorazepam 2 mg on 6/11/2019 at 8:07 a.m. for a CIWA-Ar score of "8" and was reassessed at 8:43 a.m., "Effective." The patient was given another 4 mg of Lorazepam at 9 a.m., however there was no corresponding CIWA-Ar form with a score to justify the administration.

-The patient's CIWA-Ar score on 6/12/2019 at 12:51 p.m. was "18." Documentation in the MAR revealed the patient received Lorazepam 2 mg by mouth rather than the physician's order to administer Lorazepam 4 mg for a CIWA-Ar score between 15-25.

-The patient's CIWA-Ar score on 6/13/2019 at 5:39 a.m. was "12." The patient received Lorazepam 3 mg at 7:51 a.m., over two hours later. The patient should have been reassessed within an hour according to physician orders, however, the patient was not reassessed until 2:21 p.m., over six hours later.

The above clinical records were reviewed with the Chief Nursing Officer who acknowledged CIWA protocols including the frequency of assessments and reassessments and physician orders were not being followed.

Observations of a medication pass on the East Unit were made on 6/13/2019 at approximately 9 a.m. The nurses station is located directly to the east and faced the open patient common area where patients from both the East and West units congregated because it was across from the dining room which also included a television. There were two RN's sitting down in the nurses station in front of computers, and patients lined up (in no order) on the other side of the counter in two columns. The nurses administered medications to their assigned patients. The nurses would ask each patient for their name and then go to the medication room located inside the nurses station and come out with their medication(s). The nurses used no other method to identify the patient to ensure they were administering the right medication to the right patient. One patient was observed to ask a nurse for a specific medication. The nurse explained why he could not have that medication at that time. The patient became upset and would not leave the nurses station but did step to the side so the next patient in line could get medications. However, both of those patients began to argue. Also observed during the medication pass was a patient walking rapidly throughout the common area, in and out of the dining room and around the nurses station talking in a loud voice and threatening staff, other patients, and the surveyor. There was not a sense of order or control to the medication pass.
VIOLATION: GOVERNING BODY Tag No: A0043
Based on clinical record reviews, review of hospital policies and procedures and other hospital documents, and staff interviews, it was determined the Governing Body was not effective in carrying out the functions of the hospital to ensure compliance with the following Conditions of Participation:

Patient Rights (A-115): The hospital failed to promote and protect each patient's rights as evidenced by:

(A-145): failure to to ensure two patients were free from abuse:

(A-168) failure to ensure physician orders were obtained for restraints on two patients;

(A-178) failure to ensure three patients were evaluated by a physician or other appropriately trained licensed individual Practitioner within one hour of being restrained; and

(A-196) failure to ensure all direct care staff received training on verbal de-escalation and restraints at least annually per their policy.

QAPI (A-263): The hospital failed to maintain an effective, ongoing data-drive quality assessment and performance improvement program as evidenced by:

(A-283) failure to analyze data and identify indicators and priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement;

(A-286) 1. failure to report, document, analyze and implement corrective actions for all medication administration errors and failure to investigate an incident of a patient found unresponsive with a bag of white powder near him; and
2. failed to investigate a patient found unresponsive with a bag of white powder near him. (Patient# 5) The failure to investigate patient events and implement corrective action if needed poses the risk of repeated incidents and risk of negative patient outcomes.

(A-309) failure of the Governing Body to actively reviewed the results of the hospital's quality improvement activities including data collection, analyses, and implementation of corrective actions for the provision of quality patient care and failed to ensure the performance improvement program was evaluated at least annually per their policy; and,

(A-315) failure of the Governing Board failed to provide resources to ensure the hospital's Quality Improvement Plan was fully functioning per their policies and procedures.

Nursing Services (A-385): The hospital failed to ensure nursing services were provided and supervised by Registered Nurses following hospital policies and procedures as evidenced by:

(A-395) failure to ensure all patients were observed every fifteen minutes; failure to document a patient to patient altercation with injuries in the clinical record; and failure to ensure the RN intervened in an altercation between a patient and a staff member; and
(A-405) failure to ensure medications were administered following physician orders.

The cumulative effect of these systemic problem resulted in the hospital's inability to provide quality health care in a safe environment.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of clinical records, review of policies and procedures, review of video footage, and staff interview, it was determined the hospital failed to:

A-145: ensure patients were free from all forms of abuse. (Patients #1 and #7). This deficient practice posed the risk of physical and/or psychological harm to vulnerable patients with psychiatric disorders.

A-168: ensure physician orders for restraints were obtained for two of two patients with documentation of being restrained. (Patients #2 and #8) This deficient practice poses the risk of physical and/or psychological harm to patient(s) restrained used without the knowledge and direction of the medical practitioner.

A-178: ensure three of three patients were evaluated by a physician or other appropriately trained licensed individual Practitioner within one hour of being restrained. (Patients #1, #2, and #8) This deficient practice poses the risk of physical and/or psychological harm not identified and treated after the restraint.

A-196: ensure all direct care staff received training on verbal de-escalation and restraints at least annually per their policy. One Registered Nurse (RN), four Behavioral Health Technicians (BHT), and one Clinical Services staff did not have documented training for over one year. This deficient practice posed the risk of patient harm if staff are not periodically trained using approved and safe techniques.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment that promotes and protects the rights of each patient.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of clinical records, policies and procedures, video footage, and staff interview, it was determined the hospital failed to ensure patients were free from all forms of abuse. (Patients #1 and #7). This deficient practice posed the risk of physical and/or psychological harm to vulnerable patients with psychiatric disorders.

Findings include:

The hospital's policy titled "Arizona Patient's Bill of Rights" (Policy ) included: "All patients shall have rights which include, but are not limited to, the following: 1. To be treated with dignity, respect, and consideration 2. Is not subjected to: Abuse...."

The hospital's policy titled "Recognizing and Reporting Suspected Child, Adult Disabled Person or Elderly Abuse, Neglect and Exploitation" (Policy 1020) included: "El Dorado Behavioral Medicine shall protect patients from real or perceived abuse, neglect or exploitation from any, including staff members, students, volunteers, other patients, visitors or family members. This hospital mandates that, under the guidance of applicable laws, any healthcare worker having reasonable cause to believe that any person is in the state of abuse, exploitation or neglect shall report the information to the appropriate regulatory agency."

Patient #1

Nursing documentation in the clinical record dated 6/2/2019 at 4:20 a.m. included: "At approximately 2230 (10:30 p.m.) on 6-1-19 just after med pass, the patient began to escalate. She became aggressive with staff and tried to find something lying about to injure herself with. She also attempted to force her way into the nurses station which is off limits to patients. She was not easily deterred by staff intervention to deter this."

Video footage of the above incident was reviewed on 6/5/2019, with the CNO to determine how the above incident was handled by staff. The video footage revealed that at approximately 9:42 p.m., Patient #1 approached the nurses station on the West Unit. The half-door into and out of the station was half-way open and the patient started towards the door. Staff # 10, a female Behavioral Health Technician (BHT) was inside of the nurses station and tried to close and secure the door before the patient got there, however, the patient was able to position herself so the BHT could not engage the latch. Staff #11, a male BHT, then approached the patient from behind and right and positioned himself between the patient and the door facing the patient. The patient was trying to disengage the latch when Staff #11 pushed her backwards with both hands. The patient stumbled but was able to regain her balance. She went back to the door and continued to try and get in. Staff #11 got behind the patient, placed his right hand under the patient's right arm pit and left hand under the patient's left arm pit and pulled her backwards and twisted her to the left which caused the patient's scrub top to pop open revealing her bra, abdomen and stomach. The patient turned around and continued to try to get into the nurses station. A third male BHT (Staff #12) arrived who appeared to talk to the patient while Staff #10 buttoned/snapped the scrub top closed. Staff #11 was at the patient's front right and then with his left side, he again pushed the patient causing her to stumble sideways. Staff #12 caught the patient and was able to redirect her away from the nurses station.

The Chief Nursing Officer was present during the review of the video and identified the incident and actions of BHT #11 had not been reported to her.

Patient #7

Documentation in a hospital's internal report dated 3/9/2019 at 9:45 a.m., revealed an altercation between Patient #7 and a Behavioral Health Technician (BHT), Staff #16. Staff #16 was trying to get the patient to change his socks, and Patient #7 reacted by yelling and throwing a cup of water on Staff #16. Another patient grabbed Patient #7 trying to hold him back. Staff #16 swung at Patient #7 but missed, and Patient #7 ran to his room. The documentation included: "Pt was found in his room having visual hallucinations, extremely anxious with tremors. States he fears for his life....Tech admitted that he was aggressive towards patient. Tech was discharged from hospital."

There was no documentation in the patient's clinical record that reflected the above incident, however, there were telephone orders from a Nurse Practitioner at 11:02 a.m. for the following medications to be administered "one time only" by mouth for "agitation": Zyprexa 10 mg, Diphenhydramine HCl (Benadryl) 50 mg, and Lorazepam 2 mg. The orders were received by and administered to the patient by the RN who wrote and signed the above occurrence report.

Documentation in Staff #16's personnel record included: "On 3/9/2019 at 10:53 a.m., a patient threw a cup of ice at (Staff #16). (Staff #16) responded by attempting to punch the patient but missed only because the patient ran away. (Staff #16) then pursued the patient (who was trying to escape) down the hall, throwing 3 more punches, and connecting with the final punch." The employee was terminated the same day.

The CEO reported during an interview on 6/10/2019, that he was notified of the incident and reviewed the security video which confirmed Staff #16 chased and swung at Patient #7. The CEO confirmed Staff #16's final punch "grazed" the patient's face. The CEO interviewed Staff #16 who acknowledged the incident and stated he "snapped."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on clinical record reviews, review of hospital policies and procedures, and staff interview, it was determined for two of two patients with documentation of being restrained, the hospital failed to ensure the use of the restraint(s) was in accordance with an order from a physician or other credentialed Licensed Independent Practitioner (LIP). (Patients #2 and #8) This deficient practice poses the risk of physical and/or psychological harm to patient(s) restrained, that restraintsn were used without the knowledge and direction of the medical practitioner.

Findings include:

The hospital's policies and procedures titled, "Restraint or Seclusion," (Policy 1201) included:
"Restraint or seclusion shall be used in emergency situations only and requires an order from a physician or Nurse Practitioner...For emergencies, in the absence of a physician/NP, the registered nurse may authorize the initiation of restraint or seclusion...The physician/AHP must be contacted by the RN for an order for the restraint or seclusion as soon as possible after initiating the restraint or seclusion, not longer than one hour."

Patient #2

Nursing documentation dated 12/30/2018 at 1:25 a.m. included: "...Patient later became very aggressive and psychotic throwing things posturing and hitting on doors and windows...also entering into the peers room. IM (intramuscular) lorazepam given and patient held and given medication." The Registered Nurse (RN) documented the provider on call was notified who ordered more medication as well as 1:1 observation. There was no order for the use of a physical hold restraint.

Patient #8

A hospital occurrence report dated 2/25/2019, revealed Patient #8 went into another patient's room and attempted to eat a sock. A BHT took away the garbage, and the patient punched him on the chin. The BHT's documentation included: "I handled (Patient #8) with care to a seated position and held for a few minutes until paramedics took to hospital."

There was no documentation that a provider order was obtained for the use of a physical hold restraint.

The Chief Nursing Officer acknowledged during interviews that there were no physician orders for the use of the physical hold restraints on Patients #2 and #8.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on clinical record review, review of hospital policies and procedures, and staff interview, it was determined for three of three patients who were restrained, the hospital failed to ensure the patients were evaluated (seen face to face) by a physician or other appropriately trained licensed individual Practitioner within one hour of the restraint. (Patients #1, #2, and #8) This deficient practice poses the risk of physical and/or psychological harm not identified and treated after the restraint.

Findings include:

The hospital's policy and procedure titled, "Restraint or Seclusion" (Policy 1201) included: "Within one hour of the initiation of restraint or seclusion, the patient shall be evaluated in person by a physician, Nurse Practitioner or trained RN...The evaluation will be documented in the medical record...."

Patient #1

Nursing documentation in Patient #1's clinical record dated 5/31/2019 at 6:20 p.m. revealed the patient was placed in a physical hold by two Behavioral Health Technicians (BHT) after she threatened to harm herself with a crumpled plastic medication cup. The provider on-call, a Nurse Practitioner (NP), was notified and an order received for the restraint. The NP's documentation of the face-to-face evaluation was at 9:35 p.m., over three hours after the physical hold.

Patient #2

Nursing documentation in Patient #2's clinical record revealed the patient was "held" in order to administer medication for aggressive and threatening behaviors. There was no physician's order for the physical hold, nor was there documentation that a face-to-face evaluation by qualified staff was performed within an hour of the hold. The patient reported after discharge that he was injured by staff during a physical hold.

Patient #8

Documentation in a hospital occurrence report dated 2/25/2019, revealed Patient #8 was "held" by a BHT for an unknown amount of time. There was no documentation that a medical provider ordered the physical hold, nor was there documentation that a one hour face-to-face assessment was completed.

The Chief Nursing Office acknowledged during an interview that the face-to-face evaluations were not performed within one hour for Patient #1 and were not performed at all for Patients #2 and #8.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0196
Based on document reviews and staff interview, it was determined the hospital failed to ensure all direct care staff received training on verbal de-escalation and restraints at least annually per their policy. One Registered Nurse (RN), four Behavioral Health Technicians (BHT), and one Clinical Services staff did not have documented training for over one year. This deficient practice posed the risk of patient harm if staff are not periodically trained using approved and safe techniques.

Findings include:

The hospital's policy titled "Restraint or Seclusion" (Policy 1201) included the following: "Medical staff, direct care staff, and RNs are oriented to the standards for the use of restraint/seclusion. Direct care staff and RNs are required to attend aggression management training and show evidence of competency related to participating in a code situation, application of restraints, or the monitoring, assessment and care of a patient in restraints or seclusion...As part of orientation, before performing any of the actions outlined in this policy, and at least annually, training occurs...."

A list of employees with documentation of de-escalation and restraint training revealed the following direct care staff were outside of the 12 month renewal window:

Staff # (BHT) / Last Completed Date
6 2/27/2018
18 12/2017
22 3/26/2018
23 1/29/2018
(RN)
19 7/20/2017
(Clinical Services)
20 9/01/2017

The Chief Nursing Officer acknowledged during interviews that not all employees were current with de-escalation and restraint training.
VIOLATION: QAPI Tag No: A0263
Based on review the hospital's quality improvement plan, review of quality meeting minutes and hospital documents, and interviews, it was determined :

A-283: the hospital failed to analyze data and identify indicators and priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement This deficient practice poses the risk of patient harm if data collected is not analyzed and opportunities for improvement not identified and action taken to reduce and prevent medical errors.

A-286: the hospital failed to 1. ensure all medication administration errors were reported, documented and analyzed with corrective actions implemented to decrease and prevent recurrences.
2. investigate a patient found unresponsive with a bag of white powder near him. (Patient# 5) The failure to investigate patient events and implement corrective action if needed poses the risk of repeated incidents and risk of negative patient outcomes.

A-309: the Governing Body failed to actively review the results of the hospital's quality improvement activities including data collection, analyses, and implementation of corrective actions for the provision of quality patient care and failed to ensure the performance improvement program was evaluated at least annually per their policy.

A-315: the Governing Board failed to provide resources to ensure the hospital's Quality Improvement Plan was fully functioning per their policies and procedures. This deficient practice poses the risk of quality improvement activities not implemented and sustained.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment by on-going quality assurance and quality improvement activities.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on review of the hospital's quality improvement plan, review of quality meeting minutes and hospital documents, and interviews, it was determined the hospital failed to analyze data and identify indicators and priorities for performance improvement activities that focused on high-risk, high-volume, or problem-prone areas and take actions for performance improvement This deficient practice poses the risk of patient harm if data collected is not analyzed and opportunities for improvement not identified and action taken to reduce and prevent medical errors.

Findings include:

The hospital's policy titled, "Organizational Quality Improvement Plan" (Policy 8001), included the following: "The Governing Board is responsible for the quality of patient care provided...The Governing Board provides for resources and support systems for the quality improvement functions and risk management functions related to patient care and safety...The primary goals of the organizational Quality Improvement Plan are to continually and systematically plan, design, measure, assess and improve performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors...."

The Quality Committee meeting minutes were provided for 1/31/2019 and 3/28/2019. Documentation in the minutes dated 1/31/2019, revealed discussion of the incidents for December 2018 included the following:

-Falls x 3
-Contraband x 2
-AMA's x 3
-Property loss x 1
-Patient complaints regarding care x 4

There was no documentation of medication errors reported.

There was an attachment to the meeting minutes that included the following:
"1. Only 1 Master Treatment Plan done for January...
2. In regards to discharge summaries 81% completed for December.
3. Biopsychosocial Assessments 54% completed for December. Biopsychosocial Assessments 1 completed for January
4. Recreational Assessments are not being done routinely."

There was no documentation of any analysis, causes and corrective action plans developed to address quality deficiencies in an effort to improve performance.

The Quality Committee meeting documentation dated 3/28/2019, included an Agenda, the meeting minutes for 1/31/2019, and Quality Metrics for Risk Management, Dietary, Pharmacy/Medication Management, Medical Records, Nursing, Infection Prevention, and Employee Incident Reports. Documentation in the individual departmental Quality Metrics included the following:

Medical Records:
January 2019:
Indicator: Master Treatment Plans - 2 completed
Discharge summary: 58% completion
Biopsychosocial: 13% completion
February 2019:
Master Treatment Plans: 35 completed
Discharge summary: 57% completed
Biopsychosocial: 25% completed, 8.9% compliance
Recreation assessments: 8 completed
Admission consents: 2 missing

The Target was documented to be 90% compliance.

Risk Management: There were three patient falls without injury in January and February and one fall with injury in both January and February.

Dietary: There was 0% compliance with the Inventory of disaster food monitored routinely for expiration for both January and February.

Pharmacy: There were two Medication Variances in January and six in February.

Infection Prevention: There was no data presented in January or February for: "% of staff observed washing/sanitizing hands per guidelines."

There were no meeting minutes that included documentation of discussion that the above data collected was analyzed to identify opportunities for improvement that would lead to improvement in patient care and services.

The Chief Nursing Officer (CNO) and Chief Executive Officer (CEO)/Administrator reported during an interview on 6/17/2019, that there was no documented evidence of consistent and on-going quality improvement activities.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on clinical record review, review of hospital policies and procedures and documents, and staff interview, it was determined the hospital:

1. failed to ensure all medication administration errors were reported, documented and analyzed with corrective actions implemented to decrease and prevent recurrences.

2. failed to investigate a patient found unresponsive with a bag of white powder near him. (Patient# 5) The failure to investigate patient events and implement corrective action if needed poses the risk of repeated incidents and risk of negative patient outcomes.

Findings include:

1. The hospital's policy titled, "Organizational Quality Improvement Plan" (Policy 8001), included: The primary goals of the organizational Quality Improvement Plan are to continually and systematically plan, design, measure, assess and improve performance of critical focus areas, improve healthcare outcomes and reduce and prevent medical/health care errors...The Plan, Do, Check, Act (PDCA) methodology is utilized to plan, design, measure, assess and improve functions and processes related to patient care and safety throughout the organization...Performance measure for processes that are known to jeopardize the safety of patients or associated with sentinel events will be routinely monitored. At a minimum performance measure related to the following processes, as appropriate to care and services provided, are monitored with the approval and the suggested frequency of the Quality Improvement Committee...Medication management...Benchmarks or thresholds that trigger intensive assessment and evaluation are established. Undesirable patterns or trends in performance are analyzed for all of the above; however, an in-depth analysis is conducted for the following when the levels of performance, patterns or trends vary substantially from those expected...All significant medication errors."

A review of The Quality Committee meeting minutes dated 1/31/2019, revealed there was no medication errors reported for December 2018. A review of the Quality Committee reports dated 3/28/2019 revealed there were two "Medication Variances" in January 2019 and six Medication Variances in February 2019. A review of occurrence reports for March 2019 revealed there were 35 medication errors. There were 19 occurrence reports for medications errors in April 2019; 28 occurrence reports for medication errors in May 2019; and 16 reports of medication errors from 6/1/2019 to 6/12/2019.

The majority of the medication errors were reported and documented by Pharmacy staff. Many patients had multiple medication errors. The types of errors included pulling and administering the wrong form of medication. For example, Venlaxafine SR was ordered for a patient but the nurse pulled and administered Venlaxafine ER. There were numerous reports of medications pulled for patients with no physician orders for the medications pulled and numerous reports of the wrong dose of medications pulled.

The Chief Nursing Officer reported during interviews that medication errors were not consistently report, analyzed or tracked prior to her arrival on 4/1/2019.

2. The hospital's policy and procedure titled, "Incident Report Protocol" (Policy 8005), did not include details on how individual incidents were to be investigated.

Patient #5

A nurse's note dated 3/19/2019 at 8:06 a.m. included: "During morning shift report BHT alerted this RN to patient lying in his emesis with inability to wake patient. Instructed BHT to phone 911 for medical emergency and upon assessment of patient, found his breathing to be shallow with O2 level of 35% and BP (sic)."

The Physician Assistant's documentation in the Discharge Summary dated 3/19/2019, included: "...(Patient #5) was found unresponsive in his bed, potentially aspirating his own vomit in an apparent overdose. Another patient on the floor pointed out a small plastic baggie with some residue in it. Paramedics were called, and (Patient #5) was given Narcan to reverse potential opiate overdose. (Patient #5) was transported to (name of hospital) and admitted to the ICU for further evaluation."

The hospital's report dated 3/19/2019 at 7:15 a.m. included: "Patient found unresponsive, BP 72/30, O2 sats (oxygen saturation level) 30% P 133. Team responded found patient with vomit possible aspiration. Patient was bagged with O2 15 L once sats increased a non rebreather was initiated. 911 called arriving within 10 minutes BP 72/30 ...HR 133, RR 6 ...BFG 158."

A review of the Emergency Department clinical records from the hospital where the patient was transferred revealed documentation that Emergency Medical Services (EMS) personnel referenced the patient being found unresponsive at Cornerstone: "...with a bag of white powder found on his person."

The hospital was not able to provide documented evidence that an investigation was conducted to determine what the "residue" or "white powder" was or how the patient obtained it in order to prevent a recurrence.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on a review of the quality program, meeting minutes, and interview, it was determined the hospital's Governing Body:

1. failed to document the board actively reviewed the results of the hospital's quality improvement activities including data collection, analyses, and implementation of corrective actions for the provision of quality patient care.

2. failed to ensure the performance improvement program was evaluated at least annually per their policy.

Findings include:

1. The hospital's policy and procedure titled, "Organizational Quality Improvement Plan" (Policy 8001) included: "The Governing Board is responsible for the quality of patient care provided...The Governing Board requires the detail and frequency of data collection for all indicators and performance processes as outlined in this plan...The Governing Board has a responsibility to evaluate the effectiveness of the quality improvement activities performed throughout Cornerstone Behavioral Health - El Dorado and the organizational quality improvement program as a whole...The Quality Improvement Committee will provide the Governing Board with a report of the relevant finds from all performance improvement activities performed throughout the institution at least on a quarterly basis."

There was documentation of nine Governing Board Meetings between 5/1/2018 to 5/17/2019. A review of the minutes of those meetings revealed no documented review and discussion of quality improvement activities except during the meeting on 5/1/2018.

2. The above policy also included: "To assure that the appropriate approach to planning processes of improvement, setting priorities for improvement; assessing performance systematically; implementing improvement activities on the basis of assessment; and maintaining achieved improvements, the organizational performance improvement program is evaluated for effectiveness at least annually and revised as necessary."

Documentation on the above policy revealed an effective dated of 5/1/2016. There was no documentation that the quality improvement plan had been reviewed since that date.

The CEO stated during an interview on 6/17/2019, that he did not know if the quality improvement plan had been reviewed annually.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on review of hospital policies and procedures, hospital documents, and staff interviews, it was determined the Governing Board failed to provide resources to ensure the hospital's Quality Improvement Plan was fully functioning per their policies and procedures. This deficient practice poses the risk of quality improvement activities not implemented and sustained.

Findings include:

The hospital's policy titled, "Organizational Quality Improvement Plan" (Policy 8001), included: "The Governing Board provides for resources and support systems for the quality improvement functions and risk management functions related to patient care and safety."

The Chief Nursing Officer (CNO) and Chief Executive Officer (CEO)/Administrator reported during interviews that the CNO was also responsible for the hospital's QAPI program. The CEO reported he had concerns with the prior Director of Quality and her employment was terminated shortly after the CNO was hired (4/1/2019), and the CNO was given the additional responsibility of managing the hospital's QAPI program.

The CNO reported she has primarily focused on nursing issues since she started, and has not been able to focus on what the current status is of the Quality Improvement program.