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

HAVEN BEHAVIORAL HOSPITAL OF PHOENIX 1201 SOUTH 7TH AVENUE, SUITE 200 PHOENIX, AZ 85007 June 8, 2020
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure, review of patient #3's medical record and staff interviews, it was determined the hospital failed to recognize the patient was in labor resulting in the patient giving birth in the psychiatric hospital. This deficient practice poses a risk to patient health and safety when hospital staff fail to thoroughly assess the patient's medical condition.

Findings include:

The "Medical Staff Rules and Regulations, 3/2020, requires: "...The following shall be included in the H & P: ...prior medical history...Review of all systems...Rectal or pelvic exam, as indicated. It is not acceptable to document 'deferred' reason for deferral must be documented...Sexual function / reproductive organs...
The patient was hospitalized in 12/2019 and in 2/2020. Both medical records were reviewed.

Physician #1 documented the following on 12/10/2019: "Pt is pregnant 24 weeks".

Employee #10 documented the following on 12/11/2019: "she is currently 24 weeks pregnant".

The medical record, 12/10/2019, contained an ultrasound report from the sending hospital that contained the following: "...second trimester pregnancy with estimated gestational [AGE] weeks...based on ultrasound ...."

The Medical History and Physical, 2/18/2020, contained the following: " ...26 w pregnant...Review of Systems: unremarkable...Female Genitalia: Pregnancy: Yes...Patient wishes to have own physician perform exam ...."

Nursing staff documented the following on 2/27/2020: 04:44: "...pt screaming & crying of pain. Writer tried to touch abdomen but pt would not let. First request Tylenol she was given . Then asked for Mylanta she was given. Then she was given Benadryl 50mg po and MOM & Dulcolax suppository. Supervisor was informed in the middle of calling MD Pt started screaming that she is not going to the hospital. We will continue to monitor ...."

Nursing staff documented the following on 2/27/2020 at 4:45: "...Patient screaming...patient stated 'my stomach hurts, I'm constipated I need a laxative'. Patient continued to scream. This writer asked, 'Do you need to go to the hospital?' Patient stated, 'I don't need to go to the hospital.' Patient was given PRN Laxative per MD order ...0615: This writer was called to unit by BHT reporting that patient was delivering a baby. This writer and day supervisor entered room to see baby coming out of patient ...."

Employee #6 and employee #8 confirmed in an interview conducted on 6/4/2020, the patient was "very pregnant" during the hospital admission in 2/2020. Employee #6 reported that both hospital admissions identified the patient was 24 or 26 weeks pregnant in December 2019 and in February 2020.

Employee #2 confirmed in an interview conducted on 6/4/2020, she would have expected nursing staff to identify signs and symptoms of labor sooner, instead the staff was treating the patient for constipation.
VIOLATION: EMERGENCY SERVICES Tag No: A0093
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure, review of patient #3's medical record and staff interviews, it was determined the hospital failed to recognize the patient was in labor resulting in the patient giving birth in the psychiatric hospital. This deficient practice poses a risk to patient health and safety when hospital staff fail to thoroughly assess the patient's medical condition.

Findings include:

The "Medical Staff Rules and Regulations, 3/2020, requires: "...The following shall be included in the H & P: ...prior medical history...Review of all systems...Rectal or pelvic exam, as indicated. It is not acceptable to document 'deferred' reason for deferral must be documented...Sexual function / reproductive organs...
The patient was hospitalized in 12/2019 and in 2/2020. Both medical records were reviewed.

Physician #1 documented the following on 12/10/2019: "Pt is pregnant 24 weeks".

Employee #10 documented the following on 12/11/2019: "she is currently 24 weeks pregnant".

The medical record, 12/10/2019, contained an ultrasound report from the sending hospital that contained the following: "...second trimester pregnancy with estimated gestational [AGE] weeks...based on ultrasound ...."

The Medical History and Physical, 2/18/2020, contained the following: " ...26 w pregnant...Review of Systems: unremarkable...Female Genitalia: Pregnancy: Yes...Patient wishes to have own physician perform exam ...."

Nursing staff documented the following on 2/27/2020: 04:44: "...pt screaming & crying of pain. Writer tried to touch abdomen but pt would not let. First request Tylenol she was given . Then asked for Mylanta she was given. Then she was given Benadryl 50mg po and MOM & Dulcolax suppository. Supervisor was informed in the middle of calling MD Pt started screaming that she is not going to the hospital. We will continue to monitor ...."

Nursing staff documented the following on 2/27/2020 at 4:45: "...Patient screaming...patient stated 'my stomach hurts, I'm constipated I need a laxative'. Patient continued to scream. This writer asked, 'Do you need to go to the hospital?' Patient stated, 'I don't need to go to the hospital.' Patient was given PRN Laxative per MD order ...0615: This writer was called to unit by BHT reporting that patient was delivering a baby. This writer and day supervisor entered room to see baby coming out of patient ...."

Employee #6 and employee #8 confirmed in an interview conducted on 6/4/2020, the patient was "very pregnant" during the hospital admission in 2/2020. Employee #6 reported that both hospital admissions identified the patient was 24 or 26 weeks pregnant in December 2019 and in February 2020.

Employee #2 confirmed in an interview conducted on 6/4/2020, she would have expected nursing staff to identify signs and symptoms of labor sooner, instead the staff was treating the patient for constipation.
VIOLATION: CONTENT OF RECORD - DISCHARGE SUMMARY Tag No: A0468
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of hospital policies and procedures, medical record review, and staff interviews, it was determined the administrator failed to require patient #3's discharge summary to include an accurate account of the patient's medical condition upon transfer to the medical hospital. This deficient practice poses a potential risk to patient health and safety when future providers do not have a complete/accurate discharge summary.

Findings include:

The "Medical Staff Rules & Regulations, 4/2020, requires: "...The discharge summary must also include the reason for hospitalization , significant findings, procedures performed and treatments rendered ...."

Physician #1 documented the following on 12/10/2019: "Pt is pregnant 24 weeks".

Employee #10 documented the following on 12/11/2019: "she is currently 24 weeks pregnant".

The medical record from the admission on 12/10/2019 contained an ultrasound report from the sending hospital that contained the following: "...second trimester pregnancy with estimated gestational [AGE] weeks...based on ultrasound ...."

Physician #1 documented the following on 2/27/2020: "Discharge Summary: ...Patient apparently is 26 weeks pregnant ... Reason for Discharge (blank)...Follow Up: In the post hospital care plan, patient needs to follow up with (name of health plan). Patient needs to follow with the primary care physician ...."

The Discharge Order 2/27/2020, contained the following: "...26 weeks pregnant / s/p labor...Discharge Patient to home / group home / shelter ...."

The "Practitioner Order" 2/27/2020, 06:20, contained the following: "...send patient to ER for post-natal care ...."

Nursing staff documented the following on 2/27/2020: 04:44: "...pt screaming & crying of pain. Writer tried to touch abdomen but pt would not let. First request Tylenol she was given. Then asked for Mylanta she was given. Then she was given Benadryl 50mg po and MOM & Dulcolax suppository. Supervisor was informed in the middle of calling MD Pt started screaming that she is not going to the hospital. We will continue to monitor ...."

The discharge summary did not contain information related to the patient giving birth at the hospital. The follow sections of the discharge summary were left blank: "...Past Psychiatric History, Admission Diagnosis(ES), Medications on Admission, Reason for Discharge...."

Employee #2 confirmed in an interview conducted on 6/4/2020, the discharge summary did not identify that the patient delivered a baby while at the psychiatric hospital and was therefore transferred to a medical hospital.
VIOLATION: CRITERIA FOR DISCHARGE EVALUATIONS Tag No: A0800
Based on hospital policies and procedures, patient #2's medical record, and staff interviews, it was determined the hospital failed to provide patient #2 with an appropriate discharge plan. This deficient practice poses a risk to patient health and safety when the hospital does not make appropriate arrangements upon discharge.

The "Medical Staff Rules & Regulations" 03/2020, requires: "...Patients shall be discharged on ly on a written order of the Attending Physician...The The record of each patient must have a discharge summary...of the patient's hospitalization and recommendations concerning follow-up or aftercare, developed in conjunction with the community treatment agency as appropriate...."

The "Discharge Planning Process - After Care Plan" policy, reviewed 12/2019, requires: "...The discharge/aftercare plan is a multidisciplinary form and defines the following: ...where the patient will live following discharge based on patient/family needs and or wants. The level of care which the patient will be discharged to...All professionals who will follow-up with the patient, including medical follow-up to monitor medications...."

The medical record contained documentation confirming the patient was on an amended court ordered treatment plan upon admission to the hospital.

The Psychiatric Progress Note, 3/25/2020, contained the following: "...Pt with agitation & mood swings needs redirection, gets upset & tries to hit head on wall...pt taken to ER loss of vision. Has appt w/eye specialist today...Expected discharge plan: Group Home...Reason to Continue Inpatient Level of care: Behavior which is life threatening, destructive or disabling to self or others, requires change in psychopharmacology, requires 24 hr care for monitoring of medication effectiveness ....".

Employee #11 provided the following e-mail communications:

SW Network emailed the following to Employee #11: " ...3/25/2020 at 12:05 pm: I would like to request that the attending BHMP conduct a Doc/Doc with our San Tan OP BHMP. We would like Haven to clarify if this member meets inpatient criteria today. Our plan is to assist in transporting him to an appointment needs to have better clarity and communication about his need for inpatient. We would like Haven team to clarify if this is a PASS for a needed appointment or a DISCHARGE...We do not feel it is appropriate for us to bring him back and have him "assessed" for inpatient ...."

Haven employee #12 emailed the following to the outpatient care team and employee #11: " ...3/25/2020 at 12:35 pm: Haven does not do passes. The ER set up this apt for David as he may have a possible detached retina which will require immediate surgery, not sure if they will reschedule. He currently reports no vision in his left eye hence the urgency and why [name of employee #11] was trying desperately to coordinate with the team this morning

SW Network emailed the following to Haven staff: " ...3/25/2020 at 12:48: ...[Name of Physician #3] just talked to [name of physician #4]. We were informed that he is not being DC and will need to return back to Haven after his appointment today ...."

SW Network emailed the following to Haven staff: " ...3/25/2020 at 2:34 pm: ...[name of patient] is done with his appointment. He is on his way back to Haven now ...."

Employee #11 documented the following: "...3/25/2020 at 3:22 pm: ...[name of patient] arrived at Haven, but declined readmission. He was offered services from two different people, including the director of social services...I just received a call from the eye doctor and they reported that [name of patient] has ischemic optic neuropathy. They reported that it is a serious condition and he has a follow up appointment tomorrow...He was provided a bus pass from the inpatient team. He reports that he is planning on going to his mother's home. This is not the inpatient team's recommendation as his mother states that he is unable to return home ...."

Patient #2's medical record contained the following physician's order: " ...3/25/2020...please send pt for eye appt at noon today ...."

The medical record did not contain a discharge order on 3/25/2020.

Nursing staff documented the following on 3/25/2020 at 23:58: " ...[name of patient] was readmitted ...after he was discharged during the day shift for a follow up appointment for his eyes...Pt stated he got picked up by police after he tried to escape to his mom's house...Provider notified at 2300 & pt was continued on q 5 minute observations & suicide precautions ...."

Employee #2 confirmed in an interview conducted on 6/4/2020, the medical record did not contain an order to discharge the patient on 3/25/2020.

The Discharge Summary, 3/26/2020, contained the following: scheduled to have an ophthalmology examination the next morning. On 3/26, he was discharged to the Ophthalmology appointment where he was found to have AION. He was returned to the hospital after his discharge and left the next day for follow up appointment. After follow up appointment, it was determined the patient needed to be sent for emergent surgery and therefore, he was discharged from Haven Behavioral Healthcare as he was transferred to another hospital for further care ...."

The "Discharge / Aftercare Instructions", 3/26/2020, contained: "...Disposition: Other: Medical Appt ...."

The medical record did not contain documentation regarding coordination of care. The Discharge location had the address of an outpatient eye surgery center.

Employee #1 confirmed in an interview conducted on 6/4/2020, the patient was discharged to "the outpatient clinical team". Employee #1 was unable to provide information related to where the patient would be residing following the outpatient surgery.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on hospital policies and procedures, medical record review and staff interviews, it was determined the hospital failed to develop and implement a transport policy for two of two patients (patient #2 and patient #3). This deficient practice poses the risk to patient health and safety when the hospital fails to transport the patients to obtain services ordered by the physician and are not provided by the psychiatric hospital.

Findings include:

9 A.A.C. 10, Article 1, effective 10/01/2019 identifies the following: "Transport means a licensed health care institution: a. Sending a patient to a receiving licensed health care institution for outpatient services with the intent of the patient returning to the sending licensed health care institution, or b. Discharging a patient to return to a sending licensed health care institution after the patient received outpatient services from the receiving licensed health care institution".

Patient #2

Patient #2's medical record contained the following physician's order: " ...4/25/2020...please send pt for eye appt at noon today ...."

Employee #11 documented the following on 3/25/2020: " ...8:30 am ...[name of patient] was taken to medical hospital yesterday due to not being able to see out of his eye. He was brought back to [name of hospital] and informed that he needs to attend an appointment with the specialist today at 12:00 pm...DCS was informed that [name of patient] will need to discharge from the facility and be taken to his appointment. He can be reassessed for readmission following his appointment...met with [name of patient] to complete his discharge paper. He reported that he has SI without a plan or intent to harm himself. He was unable to sign his discharge paperwork due to his vision...SW and [name of patient] called his mother...She reported that [name of patient] has been verbally aggressive towards her and he is not authorized to return to her home without ACT services being in lace...If the clinical team is unable to take [name of patient] to the appointment a cab will be scheduled for him. SW later received email confirmation that the clinical team will be scheduling a cab for [name of patient] to go to his medical appointment ...."

Nursing staff documented the following on 3/25/2020 at 23:58: " ...[name of patient] was readmitted ...after he was discharged during the dayshift for a follow up appointment for his eyes...Pt stated he got picked up by police after he tried to escape to his mom's house...Provider notified at 2300 & pt was continued on q 5 minute observations & suicide precautions ...."

The medical record did not contain an order to discharge the patient.

Employee #2 confirmed in an interview conducted on 6/4/2020, the medical record did not contain an order to discharge the patient on 3/25/2020, but did contain an order to send the patient to the eye appointment scheduled at noon on 3/25/2020.

Patient #3

The medical record contained the following physician's order on 12/12/2019: "...Social worker - pt needs to see OBGYN on 12/16/19 needs transport arranged ...."

Employee #10 documented the following on 12/16/2019 at 12:25: "...met with [name of patient] to inform her of getting an ultra sound today. [name of patient] reports that she had an ultra sound appointment today with her primary OBGYN. SW will assist her with re-scheduling her an OBGYN. [name of patient] will discharge to a shelter per her choice ...."

The medical record did not contain documentation that staff notified the physician regarding the patient not attending the OBGYN appointment per physician order on 12/12/2019.

Employee #2 confirmed in an interview conducted on 6/4/2020, the hospital does not have the ability to transport a patient to an appointment to receive services the hospital does not offer.

Employee #9 confirmed in an interview conducted on 6/4/2020, the hospital does not have a policy or procedure related to the "transport" of a patient.