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HAVEN BEHAVIORAL HOSPITAL OF PHOENIX 1201 SOUTH 7TH AVENUE, SUITE 200 PHOENIX, AZ 85007 April 12, 2019
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of policies and procedures, facility documents, and staff interviews, it was determined the registered nurse failed to ensure patient assignments were based on the individual needs of each patient 54 out of 78 times, by not assessing patients' acuity level. Failure to do so poses the risk that nursing personnel assignments are not based upon the acuity and needs of the patients, therefore potentially jeopardizing the quality of care delivered to the patients.

Findings include:

Review of the policy titled, "Acuity Based Staffing" revealed: "...Procedure: 1. The Nursing Department has established a classification system that provides a basis for assigning nursing personnel according to patient needs. The Nursing Department uses an acuity based staffing tool to: To provide a framework for nursing staff to evaluate the nurse-to-patient ration and nursing level of care needed. To provide for adequate coverage and ensure a safe and therapeutic environment. It is the responsibility of nursing leadership to ensure that the patient acuity is consistently utilized in order to provide the staffing required for patient care....2. The acuity tool provides a framework for the nursing department to adjust staffing based on whether patients on the unit appear to be exceeding average acuity or reducing the acuity on the unit...."

Review of Staff Assignment sheets revealed: "...Only RN's can make assignments...."

Review of nursing assignment sheets and acuity reports from the Mesquite Unit, Juniper Unit, and Palo Verde Unit for 2/15/2019 through 2/19/2019, 3/19/2019, 4/6/2019 through 4/10/2019, and 9/25/2018, and 11/18/2018 revealed that patients' acuity assessments were only completed 54 times out of 78 times.

Review of 39 patient assignment sheets, or 78 shifts, from the same dates revealed:

34 patient assignment sheets out of 39 failed to document RN patient assignments and/or BHT patient assignments.
18 day shift assignment sheets out of 39 failed to document RN patient assignments and/or BHT patient assignments.
32 night shift assignment sheets out of 39 failed to document RN patient assignments and/or BHT patient assignments.
39 assignment sheets out of 39 with no documented evidence that an RN assigned the nursing care to other nursing personnel, as individual staff members write their own names on the assignment sheets.

The CNO verified, in an interview conducted on 4/12/2019, that the assignment sheets were not complete.

The CNO and Director of PI/Risk Management confirmed, in an interview conducted on 4/10/2019, patients' acuity assessments are to be completed twice a day.

RN #4 confirmed, in an interview conducted on 4/10/2019 at 1000 hours, patients' acuity assessments are to be completed twice a day.

RN #3 confirmed, in an interview conducted on 4/11/2019 at 1100 hours, patients' acuity assessments are to be completed twice a day but that they are not always completed as they should be.

RN #14 confirmed, in an interview conducted on 4/12/2019 at 1215 hours, patients' acuity assessments are to be completed twice a day.

The CNO verified, in an interview conducted on 4/12/2019, patients' acuity assessments were not completed consistently for the selected dates listed.