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 Dec. 30, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of polices and procedures, hospital documents, and staff interviews, it was determined the facility failed to:

(A0142) ensure that 1 of 1 patients ( Patient # 8) was not pulled by their arms into his/her bedroom by a Behavioral Health Technician (BHT) and failed to require hospital staff utilize a hospital approved "Handle with Care" technique, when placing the patient in a physical hold. This deficient practice posed a potential risk of patient injury and harm when hospital staff failed to adhere to approved "Handle with Care" techniques; and

(A0286) require hospital staff follow the incident reporting policy as evidenced by:

1. staff failed to complete an incident report when a staff member pulled a patient by the arms into the hallway; and

2. hospital staff failed to complete an incident report when placing a patient in a physical hold

The cumulative effect of these systemic practices resulted in the Governing Body's inability to ensure the provision of the Condition of Patient Rights was maintained to ensure patient health and safety within the hospital arena when hospital staff fail to adhere to established policies.
VIOLATION: PATIENT RIGHTS: PRIVACY AND SAFETY Tag No: A0142
Based on review of polices and procedures, hospital documents, and staff interviews, it was determined the facility failed to ensure that 1 of 1 patients ( Patient # 8) was not pulled by their arms into his/her bedroom by a Behavioral Health Technician (BHT) and failed to require hospital staff utilize a hospital approved "Handle with Care" technique, when placing the patient in a physical hold. This deficient practice posed a potential risk of patient injury and harm when hospital staff failed to adhere to approved "Handle with Care" techniques.

Findings include:

The undated "Patient Rights and Responsibilities" document requires the following: "...An administrator shall ensure that: ...A patient is treated with dignity, respect, and consideration ...A patient is not subjected to: ...Abuse...."

The "Restraint" policy, reviewed 5/30/2019, requires the following: "...Physical restraint includes manual measures approved by Handle With Care (HWC) to limit or restrict body movement...All direct care staff shall be required to, participate in and show evidence of, initial Handle With Care training...Any direct care staff who are identified to be out of compliance with HWC training requirements will be immediately removed from the schedule until such time as he/she can show evidence of training completion...."

Employee #15 confirmed in an interview conducted on 10/21/2019, that s/he witnessed a BHT pulling a patient by the arms into his/her room. S/he confirmed that an incident report was not completed.

Employee #7 confirmed in an interview conducted on 10/29/2019, that s/he witnessed an unidentified Behavioral Health Technician pulling patient #8 by the arms into the seclusion room. Employee #7 confirmed that s/he assisted the staff member to perform a correct "Handle with Care" hold. Employee #7 confirmed that the BHT was not performing a proper handle with care hold, and reported it to the BHT's supervisors. Employee #7 did not complete an incident report and stated: "the nurses usually complete the report".

Employee #8 confirmed in an interview, conducted on 10/29/2019, s/he received a report of a BHT (on the Tortolita unit) performing an incorrect physical hold. S/he confirmed that the BHT was pulling or dragging the patient by the arms in the hall. Employee #8 confirmed s/he did not receive an incident report, therefore did not conduct an investigation. S/he confirmed that additional education or training was not provided to the BHT.

Employee #11 confirmed in an interview conducted on 10/30/2019, that s/he remembered an incident regarding a BHT and an improper hold. The BHT was moved off the adolescent unit to an adult unit. Employee #11 confirmed that s/he did not complete an incident report or address the improper hold with the BHT.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of polices and procedures, hospital documents, patient #2's medical record and staff interviews, it was determined the facility failed to require hospital staff follow the incident reporting policy as evidenced by:

1. staff failed to complete an incident report when a staff member pulled a patient by the arms into the hallway; and

2. hospital staff failed to complete an incident report when placing a patient in a physical hold

These deficient practices posed a potential risk to patient health and safety when hospital staff fail to report, document, track and evaluate unanticipated events.

Findings include:

The "Incident Reporting - Risk Management Program" policy, reviewed 1/01/2019, requires the following: "...An "incident" is an unanticipated event which was not consistent with the standard of care and / or operation of the facility and may have occurred due to a violation of policy and procedure...Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day. If the incident involves a patient, staff must chart relevant information in the patient's medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an "error" or that an Incident Report was completed...."

The "Restraint" policy, reviewed 5/30/2019, requires the following: "...Patients will be physically restrained in the supine position...Approved Handle with Care holds are considered a physical restraint...Copy of Restraint documentation will be completed and turned in to the Director of Nursing...no later than the end of shift with the following information: ...Completed Incident Report...."

#1 Employee #15 confirmed in an interview conducted on 10/21/2019, s/he witnessed a BHT pulling a patient by the arms into his/her room. S/he confirmed that an incident report was not completed because s/he was advised that it was "not a restraint" by Employee #7.

Employee #7 confirmed in an interview conducted on 10/29/2019, s/he witnessed a BHT pulling a patient by the arms across the floor. Employee #7 confirmed that s/he did not complete an incident report, but did report the situation to the BHT's supervisors.

Employee #8 confirmed in an interview conducted on 10/29/2019, employee #7 reported an incident involving a BHT pulling the patient across the floor by the arms. S/he did not receive an incident report, and therefore an investigation was not completed.

Employee #11 confirmed in an interview conducted on 10/30/2019, employee #7 and employee #8 reported that a BHT pulled a patient across the floor by the arms. The employee was moved to a different unit, no education was provided to the BHT and an investigation was not completed.

Hospital staff were unable to provide documentation related to the circumstances surrounding this incident.

#2 Patient #2's medical record contained the following documentation: "...10/07/2019: taken to quiet room secondary to not following BHT request to calm down. Placed in safe hold by bht and this RN until he agreed to calm down and follow rules...."

Patient #2's medical record did not contain a restraint packet.

The Incident Report log, 10/2019, did not contain an incident report for the physical hold applied to patient #2 on 10/07/2019.

Employee #10 confirmed in an interview conducted on 10/30/2019, that hospital employees are required to complete an incident report and restraint packet when placing a patient in a physical hold. Employee #10 confirmed that s/he did not receive an incident report related to the physical hold for patient #2 on 10/07/2019.

Hospital staff failed to provide documentation that these adverse events were measured, evaluated and tracked. No implemented preventative actions were provided that included hospital training, retraining and/or re-education to staff.