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 Feb. 26, 2020
VIOLATION: LICENSURE OF PERSONNEL Tag No: A0023
Based on review of hospital policies/procedures, documents, personnel files, and interviews, it was determined that the hospital failed to require the following:

1. Personnel completed orientation as required prior to providing hospital services, and patient care. This deficient practice poses a risk to health and safety of the patients, when there is no documented evidence that newly hired personnel have been trained according to hospital policies/procedures, and verifying personnel competency according to the requirement of his/her job description; and

2. Personnel complete mandatory in-service training and/or education. This deficient practice poses a risk to the health, and safety of the patients, when hospital personnel fails to complete mandatory training and/or education, ensuring current knowledge/skills that impacts patient care, and that there is no administrative oversight to ensure the mandatory training and/or education is completed.

Findings include:

1. Policy titled "New Employee Orientation" (# 48; 08/2018), revealed: "...Haven provides orientation to all newly hired employees...provides the tools to ensure a safe and healthy working environment...comply with applicable regulatory standards, which require that new employees are oriented to Haven, their departments, and their positions...all full-time, part-time, and PRN employees must attend a New Employee Orientation session..required to perform the initial training for...Compliance & Ethics...HIPAA Compliance...receiving copies of the Haven's Code of Conduct, and Fraud Prevention...Supervisors are responsible for introducing all new employees and returning employees to their jobs, departments...departmental New Employee Orientation is critical and must be done...departmental orientations should include any additional issues that are specific to the department such as training, safety, and security...the employee and applicable supervisor(s) shall complete a Department Orientation Checklist for each employee, and place a copy of the form in the employee's personnel file...."

Policy titled "Nursing Services" (# 90; 02/2020), revealed: "...Nursing Department Staff is composed of licensed personnel...RN/LPN shall maintain a current state license...qualifications and performance expectations...outlined in hospital policies, job descriptions, and as applicable, state law...personnel assigned to patient care shall have completed competency documents for that unit...."

Document titled "Haven Behavioral Healthcare Employee Handbook" (Rev. 03/2019), revealed: "...Orientation & On-Boarding...you will participate in an orientation, and on-boarding process...will receive important information regarding the performance requirements for your position, basic policies, and practices...plus other information necessary to acquaint you with your job and the workplace...."

Review of twenty-six (26) personnel files, conducted 02/20/2020 - 02/26/2020, revealed, no documented evidence of hospital New Employee Orientation (NEO), and/or Department Specific Orientation (DSO) for the following twelve (12) personnel:

Personnel #9: No DSO for current job duties;
Personnel #10: No DSO;
Personnel #13: No NEO, no DSO;
Personnel #14: No DSO for current job duties;
Personnel #15: No NEO, no DSO;
Personnel #17: No NEO, DSO was documented on a RN Skills checklist (employee is not a RN);
Personnel #19: DSO not completed;
Personnel #25: No DSO for current job duties (completed on day of file review);
Personnel #32: No NEO, no DSO;
Personnel #33: No NEO, no DSO;
Personnel #35: No NEO, No DSO;
Personnel #37: No NEO, No DSO.

Personnel #4 confirmed during an interview conducted 02/26/2020 (0900), that Personnel #14 worked a total of sixty-one (61) shifts with no documented evidence of orientation to his/her job duties, and that Personnel #14 worked as a House Supervisor for the hospital.

Additionally, Personnel #4 revealed, that Personnel #9 worked a total of forty-eight (48) shifts with no documented evidence of orientation to his/her job duties, and that Personnel #9 worked as a House Supervisor for the hospital.

Personnel #24 confirmed during an interview conducted 02/26/2020 (0915), that Personnel #25 was hired [09/16/2019], into a House Supervisor position for the hospital, but had no documented evidence of orientation to his/her job duties. Additionally, Personnel #24 revealed that the orientation specific to Personnel #25 job duties was completed on 02/25/2020.

Personnel #3, Personnel #4, and Personnel #24, all confirmed during multiple interviews conducted 02/20/2020 -02/26/2020, that there was no documented evidence of orientation for the identified personnel.

2. Policy titled "Mandatory Training" (# 44; 08/2018), revealed: "...Haven is committed to providing high quality care to patients...all employees are required to attend relevant mandatory training...all employees receive annually selected mandatory classes...all employees...are to receive annual training in specific areas identified each year...to meet Federal and State regulations...Human Resources shall develop a list of mandatory training and distribute the list to all direct patient care providers...at the end of each year, mandatory training for the upcoming year will be determined by the facility's management team...certain mandatory training is specific to particular employee groups...is determined by the facility's policy...employees who do not attend mandatory training are subject to disciplinary action...."

Policy titled "Seclusion Policy" (# 02; 07/2019), revealed: "...Leadership Responsibility/Authority...leadership is responsible for assuring compliance with the specifications in this policy and procedure...leadership is accountable for...on-going staff orientation, and training...."

Policy titled "Falls Prevention & Monitoring" (# 04; 10/2019), revealed: "...Training...all clinical staff will be oriented to the falls prevention and monitoring program upon hire, and then at least annually...."

Policy titled "Infection Prevention & Control Plan 2020" (# 44; 02/2020), revealed: "...Staff Education...training of staff in infection preventions begins with orientation of new hires, and occurs at least annually...annual education is provided for all staff...education of the Medical Staff is provided with input from the DON/Infection Preventionist...."

Policy titled "Physical Restraint" (# 06; #01/2020), revealed: "...a trained registered nurse may initiate restraint...nurse in charge will assign trained staff...."

Policy titled "Chemical Restraint" (# 24; 01/2020), revealed: "...a trained registered nurse may initiate restraint...nurse in charge will assign trained staff....";

Review of twenty-six (26) personnel files, conducted 02/20/2020 - 02/26/2020, revealed, no documented evidence of annual training or required training for: Infection Prevention (IP), Falls, and/or Seclusion/Restraint (S/R), as required per hospital's policies/procedures for the following twelve (12) personnel:

Personnel #10: No IP, Falls, S/R;
Personnel #14: No IP, Falls, S/R;
Personnel #15: No IP, Falls, S/R;
Personnel #16: No IP, Falls, S/R;
Personnel #19: No IP, Falls, S/R;
Personnel #25: No IP, S/R;
Personnel #27: No IP, Falls, S/R;
Personnel #31: No IP, Falls, S/R;
Personnel #33: No IP, Falls, S/R;
Personnel #34: No IP, Falls, S/R;
Personnel #37: No IP;
Personnel #38: No IP, Falls, S/R;

Personnel #3, and Personnel #4 confirmed during an interview conducted 02/26/2020 (0900), that the above identified personnel had no documented evidence in their personnel file of training and/or annual training for Infection Prevention (IP), Falls, and/or Seclusion/Restraint).
VIOLATION: GOVERNING BODY Tag No: A0043
Based on review of the hospital's policies/procedures, documents, and staff interviews, it was determined that the Governing Body failed to approve the Governing Body By-Laws which determines how the Governing Board should conduct business as an organized body, and on behalf of the hospital; and

(A0048) failed to review, and approve the Medical Staff ByLaws, and Medical Staff Rules & Regulations;

(A0309) failed to require that the Performance Improvement (PI) Plan was submitted for review.

The cumulative effect of these systematic deficient practices resulted in the Governing Board's failure to meet the requirement for the Condition of Participation for Governing Body, which poses a potential risk to the health and safety of patients when the Governing Board fails to evaluate and/or determine the causes of these deficiencies, and to develop an action plan to correct the deficiencies.

Findings include:

1. Policy titled "TEMPLATE Governing Board ByLaws of Haven Behavioral Hospital of XXX" (# 3; 01/2020), revealed: "...The principal purposes of the Governing Board are to recommend Hospital policy to the Member, to implement Hospital policy approved by the Member, to promote performance improvement and quality patient care at Hosptial, to organize and oversee management and planning of Hospital...to organize and oversee the Medical Staff...functions and duties of the Governing Board shall be as directed from time to time by the Member, consistent with the standards of...the Centers for Medicare and Medicaid Services (CMS)...applicable State and federal laws and regulations...regular meetings of the Governing Board shall be held quarterly...no less frequently than that required by applicable federal, and State law...the Governing Board shall keep and maintain regular minutes of its proceedings...the Governing Board shall ensure that Medical Staff ByLaws are adopted and remain in effect...Medical Staff ByLaws...are subject to the ultimate approval of the Governing Board...Governing Board shall have responsibility for the business and affairs of the Hospital...Governing Board...shall support and participate in an institutional process to periodically review, evaluate and revise Hospital policies and procedures to enhance integrated patient care....Chief Executive Officer (CEO)...duties include...effective operation, organization, and management of Hospital and it's services, departments...and it's patients...ensure that all personnel providing hospital or volunteer services meet applicable State health requirements and receive orientation and documented in-services, education within the time frames required by State law...ensure that a personnel record is maintained for each such personnel as required by State law...On an annual basis, the Governing Board shall evaluate its own performance...Adoption and Execution...ByLaws shall not be effective until they have been approved by the Member and by the Governing Board...."

The Governing Body ByLaws provided to the State Department, and titled ""TEMPLATE Governing Board ByLaws of Haven Behavioral Hospital of XXX", with the last review date of 01/2020, have not been developed specifically for the hospital, and/or presented to the Governing Board for approval.

Personnel #6 confirmed during an interview conducted 02/24/2020 (1530), that the Governing Body ByLaws provided to the Department have not been developed specifically for the hospital, and/or presented to the Governing Board for approval.

Personnel #3, and Personnel #4 confirmed during a combined interview conducted 02/25/2020 (0730), that the Governing Body ByLaws have never been adopted or approved by the Governing Board.
VIOLATION: MEDICAL STAFF - BYLAWS AND RULES Tag No: A0048
Based on review of the hospital documents, and interviews, it was determined that the Governing Body failed to ensure that the Medical Staff ByLaws, and Medical Staff Rules & Regulations were reviewed, and approved. This deficient practice poses a risk to the health, and safety of the patients, when the Medical Staff ByLaws, and Medical Staff Rules & Regulations have not been reviewed, and approved, to ensure that competent, safe medical care is being provided to the patients.

Findings include:

Document titled "Medical Staff ByLaws-Phoenix" (# 81; 07/2018), revealed: "...Medical staff shall account to the Governing Board for the quality and appropriateness of patient care rendered by all practitioners authorized to provide patient care services...adoption and amendment of these ByLaws following recommendations...of the Medical Executive Committee, subject to the approval of the Governing Board...the adoption and amendment of the Rules and Regulations shall not become effective until approved by the Governing Board...."

Document titled "Medical Staff Rules & Regulations" (# 35; 07/2018), revealed: "...the Governing Board ByLaws shall have priority over the Medical Staff ByLaws, and these Rules & Regulations...."

Personnel #6 confirmed during an interview conducted 02/24/2020 (1530), that the Governing Board ByLaws provided to the Department, and titled "TEMPLATE Governing Board ByLaws of Haven Behavioral Hospital of XXX", with the last review date of 01/2020, has not been developed specifically for the hospital, and/or presented to the Governing Board for approval.

Personnel #3, and Personnel #4 confirmed during a combined interview conducted 02/25/2020 (0730), that there was no documented evidence in the Governing Board Meeting Minutes of the Governing Board's adoption, and voting approval of the Medical Staff ByLaws, and/or Medical Staff Rules & Regulations.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on review of the hospital's policies/procedures, documents, medical records, observations on tour, and staff interviews, it was determined that the facility failed to:

(A0144) require that one of one patient was not subjected to sexual assault, and ensure a patient was provided safe care. This deficient practice poses a risk to the health, and safety of the patients, when hospital personnel failed to complete patient observation rounds, at a minimum every fifteen (15) minutes, and failed to ensure the patient observation rounds were documented. ( Patient # 1)

(A0168) ensure that one of one patient's restraint and seclusion was performed according to policies and procedures. This deficient practice poses a potential risk of harm to a patient, staff, other patients, or visitors. (Patient #7)

(A0175) require that nursing personnel adhere to the requirements when administering chemical restraints for 1 of 1 patient ( Patient # 3). This deficient practice poses a risk to the health, and safety of the patient when nursing personnel did not follow the hospital's policies/procedures when assessing, administering, and evaluating chemical restraints.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights, which poses a potential risk to the health and safety of patients when the facility fails to ensure that patient observations are completed as ordered, and that physical and chemical restraints are performed according to policies/procedures.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on review of the hospital's policies/procedures, hospital document, the patient's medical record, and interviews, it was determined that the hospital failed to require that one of one patient was not subjected to sexual assault, and ensure a patient was provided safe care. This deficient practice poses a risk to the health, and safety of the patients, when hospital personnel failed to complete patient observation rounds, at a minimum every fifteen (15) minutes, and failed to ensure the patient observation rounds were documented. ( Patient # 1)

Findings include:

Policy titled "Patient Rights-Phoenix" (# 35; 10/2018), revealed: "...Each patient has the right to...be treated with dignity, respect, and consideration...to be free from...sexual assault...."

Policy titled "Abuse Reporting" (# 19; 10/2019), revealed: "...Patients have the right to be free from...sexual...abuse...it is the policy of this hospital to protect patients from real or perceived abuse...any healthcare worker having reasonable cause to believe that any person is in the state of abuse....shall report the information to the appropriate regulatory body...all allegations, observations or suspected cases of abuse...in the hospital will be investigated by the hospital...Definitions...Sexual Abuse...sexual contact...sexual conduct...sexual assault..inflected on...dependent adult...Procedure...Management of Suspected Abuse...will be investigated thoroughly...must be reported to the CEO or designee immediately...all cases of suspected abuse...must be reported to authorities...the physical or mental health or welfare of a patient of the hospital who is receiving medical services, has been, is or will be adversely affected by abuse...by any person, shall as soon as possible, report the information supporting the belief to the Department of Health, or the appropriate healthcare regulatory agency...the hospital CEO or designee, shall be notified immediately prior to making a report, with no delay in reporting...to protect the patient from real or suspected...sexual...abuse...staff will safeguard the patient from the offending individual(s)...."

Policy titled "Levels of Observation and Special Precautions" (# 93; 07/2019), revealed: "...It is the policy of the hospital to maintain safety and provide quality care to patients while maintaining their dignity...the physician may order one of four levels of observation at any time of assessment, and change the level based on the patient's condition...all patients will automatically receive every fifteen (15) minute observations for the duration of their hospital stay...the RN may increase the level of observation if the patient's condition changes...the physician will be notified...staff will complete the patient observation record as rounds are made...staff documentation will be complete, timely, and accurate...Levels of Observation...Every fifteen (15) minute checks...this is the minimum level of observation for any patient admitted ...staff will observe patient and document on the Patient Observation form every fifteen (15) minutes...assigned staff will make direct visual contact with patients and confirm they are in no danger or distress...staff will be vigilant for potential risk factors identified for specific patients....Observations while patient is asleep...observations may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping...it is expected that staff conducting fifteen (15) minute observations will enter the room, approach the patient, and check their identity, respirations, and to ensure that they are no in any distress...staff are required to observe the rise and fall of the chest at least two (2) times...staff are required to use a flashlight to adequately observe the patient in bed if the room is too dark to observe without one...Staff Training...as applicable to their duties, hospital staff involved with patient care will be trained and evaluated for competency before participating in any provision of levels of observation...."

Policy titled "Administrative Call (AOC)" (# 56; 10/2019), revealed: "...Immediate notification of the Administrator on Call (AOC) by the Charge Nurse is required for...Class 1 event (Incident Report)...any allegation of abuse...."

Policy titled "Nursing Services" (# 90; 02/2020), revealed: "...The goal of staffing each nursing unit is to ensure patient safety...direct nursing care is provided by a team of RN's, LPN's, and mental health technicians who have been trained to meet the needs of the population...."

Policy titled "Assignment of Nursing Staff" (# 66; 02/2020), revealed: "...To assure quality nursing care and a safe patient environment, nursing personnel staffing and assignments are based on at least the following...a RN plans, supervises, and evaluates the nursing care of each patient...."

Policy titled "Documentation Protocol" (# 55; 11/2019), revealed: "...All medical records are to be accurate...staff are to document accurately services provided...."

Policy titled "Camera Surveillance" (# 33; 11/2017), revealed: "...It is the hosptial's policy to utilize video monitoring as it deems appropriate to promote patient care, and overall safety of patients...video monitoring may...be used continuously in patient care areas to monitor both patient and staff safety...facilities may use security cameras on their premises...images of patients from such cameras will be considered part of health care operations...video records shall not be part of the patient's medical record...."

Document titled "HBH, Patient Rights" (06/2018), revealed: "...Each patient has the right to...be treated with dignity, respect, and consideration...to be free from...sexual assault...."

Medical record review for Patient # 1 conducted 02/13/2020 (1300), revealed the following:

i. 02/08/2020 Patient Observations: Box marked "Observations: Check every fifteen (15) minutes"; Observations recorded at the following times: [0400] Code-Room, sleeping , calm, initialed by Personnel #17; 0415 Code-Room, sleeping , calm, initialed by Personnel #17; 0430 Code-Room, sleeping, calm, initialed by Personnel #12; 0445 Code-Room, sleeping, calm, initialed by Personnel #12.

Video review conducted 02/18/2020 (1325), with Personnel #2, revealed the following:

i. 02/08/2020 (0400) Patient #1's bedroom door was closed Room;
ii. 02/08/2020 (0404) Personnel #10 was standing at the Nurse's Station;
ii. 02/08/2020 (0408) Personnel #17 was standing at the Dining Room door talking;
iii. 02/08/2020 (0415) Personnel #10 walked out of the dining room, and walked to the Quiet Room;
v. 02/08/2020 (0416) Personnel #10 walked Patient #1 from the Quiet Room down the hallway, towards Patient #1's bedroom;
vi. 02/08/2020 (0417) Personnel #10 opened Patient #1's bedroom door, and walked Patient #1 inside the bedroom;
vii. 02/08/2020 (0418) Personnel #10 walked out of Patient #1's bedroom, closed the door, and walked back to the Dining Room;
viii. 02/08/2020 (0428) Patient #8 opened the door to Patient #1's bedroom, entered the bedroom, and closed the bedroom door;
ix. 02/08/2020 (0438) Personnel #10 walked out of the Dining Room, walked to Patient #1's bedroom, and opened the bedroom door.

Personnel #13 confirmed during an interview conducted 02/18/2020 (1445), that s/he was working when the incident regarding Patient #1 occurred. Personnel #13 revealed that when making rounds s/he saw Patient #1 sitting in the Quiet Room, and asked Personnel #10 to assist Patient #1 back to his/her bedroom. Personnel #13 confirmed that during this time that Personnel #17 was on a lunch break, and Personnel #18 was sitting in a patient's room at the end of the hall, with a patient on a 1:1 observation. Personnel #13 revealed that at approximately 0438, s/he went to talk with Personnel #18, and when returning to the nurse's station heard Patient #8 yelling/screaming. S/he was requested by Personnel #10 to come to Patient #1's room. Personnel #13 confirmed that upon arriving at Patient #1's bedroom, s/he was informed about the incident that had just occurred involving two (2) patients (Patient #1 and Patient #8). Personnel #13 revealed that s/he assessed Patient #1, texted the House Supervisor, and notified Physician #2. Personnel #13 confirmed that s/he did not see Personnel #10 making observation rounds, but that s/he was sitting at the nurse's station charting. Personnel #13 revealed that s/he participated in a Root-Cause-Analysis (RCA) meeting on 02/10/2020 (1100), to discuss the incident. Additionally, Personnel #13 confirmed that Patient #8 was immediately moved to another unit within the facility.

Personnel #10 confirmed during an interview conducted 02/18/2020 (1523), that s/he was working when the incident regarding Patient #1 occurred. Personnel #10 revealed that s/he was sitting in the dining room doing his/her charting, but went to the Quiet Room at approximately 0408-0410 to escort Patient #1 back to his/her room. Personnel #10 confirmed that after assisting Patient #1 to bed, s/he went back to the dining room to complete his/her charting; and then went to check on Patient #1 at approximately 0440 for the 0445 rounds. Personnel #10 revealed that when s/he opened Patient #1's bedroom door, s/he saw Patient #8 in the bedroom, on top of Patient #1, and that Patient #8 had his/her pants off. Personnel #10 yelled at Patient #8 to leave the room, and s/he called for Personnel #13 to come to the patient's room. Additionally, Personnel #10 revealed that s/he attended the RCA meeting on 02/10/2020, and was told to ensure that patient rounds are done on time, and that staff must have a clear view of the entire patient room.

Personnel #14 confirmed during an interview conducted 02/19/2020 (0950), that s/he was working when the incident regarding Patient #1 occurred. S/he received a secured text from the Juniper unit, and went immediately to the unit. Personnel #14 confirmed that s/he, along with Personnel #13 talked with, and assessed/examined Patient #1 prior to calling Provider #2. Personnel #14 revealed that s/he contacted Personnel #8 to inform him/her of the incident.

Personnel #8 confirmed during an interview conducted 02/19/2020 (1032), and 02/26/2020 (1133), that s/he received a call regarding an incident that involved Patient #1 who was on the Juniper unit. Personnel #8 revealed that s/he was not the administrator on call (AOC), but that Personnel #14 contacted her. Once notified, s/he also notified Personnel #1, and Personnel #2, and then informed Personnel #14, not to call the police, that administration would call the police. Personnel #8 revealed that s/he came to the facility, and after going to the Juniper unit, s/he talked with Patient #8. Personnel #8 confirmed that Physician #2 was made aware, and came to the hospital early to assess Patient #1. Personnel #8 revealed that s/he along with Personnel #2 contacted the patient's representative, and then the police were called at approximately 1000. Personnel #8 revealed that patient bedroom doors are never to be closed, and should be opened during the night, so that staff are able to view the patient(s). Additionally, Personnel #8 confirmed that s/he had viewed the video for the date, and time-frame of the incident which showed Patient #1's bedroom door was closed, and that the activities observed on the video did not match what was documented on the Patient Observation form, indicating that there was a discrepancy/falsification of documentation.

Personnel #26 confirmed during an interview conducted 02/19/2020 (1225), that any criminal nature, or allegation of sexual assault is to be called to the police immediately.

Personnel #18 confirmed during an interview conducted 02/19/2020 (1225), that when patients are in their bedrooms, that the doors cannot be closed. Additionally, Personnel #18 revealed that when patients are sleeping at night, the doors must be cracked so that staff can monitor the patients.

Personnel #2 confirmed during an interview conducted 02/20/2020 (1245), that s/he was called by Personnel #8 at 0458, the day of the incident, regarding what occurred on the Juniper unit. Personnel #2 revealed that there appeared to be confusion regarding the time-line of the incident among staff. Personnel #2 confirmed that s/he, along with Personnel #8, talked with Patient #8, the staff working on the unit, and Personnel #1. Personnel #2 confirmed, that at approximately 1030, s/he notified the police of the incident, and that s/he, along with Personnel #8 called and talked with the patient's representative. Personnel #2 revealed that when watching the video, it appeared that the time-stamp on the video did not match the documentation on Patient #1's Patient Observation form, and that Patient Observation rounds were not made at 0430. Additionally, Personnel #2 confirmed that the video showed Patient #1's bedroom door being closed, and that the patient's bedroom doors are not to be closed when the patients are sleeping.

Personnel #1 confirmed during an interview conducted 02/25/2020 (1409), that s/he was made aware of the incident involving Patient #1 at 0530, that same day, and that s/he spoke with Personnel #2, and Personnel #8, who both went to the facility after being notified of the incident. After receiving additional updates regarding the incident, Personnel #1, revealed that s/he asked Personnel #2 to notify the police. Personnel #1 confirmed that s/he viewed the video several days later, and it was determined that there was a discrepancy regarding what was on the video to the findings of the investigation, and that the statements from the staff involved were not consistent. Additionally, Personnel #1 revealed that observation rounds for Patient #1 were not completed as required, and that disciplinary action had been taken for those involved staff.

Provider #2 confirmed during an interview conducted 02/21/2020 (1150), that s/he was called regarding the incident involving Patient #1, and came to the facility to assess the patient. Provider #2 confirmed that s/he was made aware that the assigned facility personnel was not checking on Patient #1 according to the observation rounding schedule.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on review of hospital policies and procedures, hospital document, Patient #7's medical records, and staff interviews, it was determined that the facility failed to ensure that one of one patient's restraint and seclusion was performed according to policies and procedures. This deficient practice poses a potential risk of harm to a patient, staff, other patients, or visitors. (Patient #7)

Findings include:

Policy titled "Restraint, Physical" revealed: "...A restraint is any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely...Restraint may only be ordered by a practitioner (Physician or Nurse Practitioner)...Approved CPI holds are considered a physical restraint...."

Policy titled "Seclusion Policy" revealed: "...seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving...When clinically indicated, the seclusion procedure is implemented by the RN...Unless there is an immediate and overriding concern for safety, the seclusion procedure is utilized only after all alternative or less restrictive treatment interventions have been tried without success and a valid seclusion order has been obtained from the patient's physician or another LIP...."

Hospital document titled "Camera Review" revealed that at 1331, Employee #33 grabbed Patient #7's left upper bicep and moved the patient towards the seclusion room. Patient #7 walked in and out of seclusion room, however Employee #33 was noted at 1341:36, and 1347:11, to be blocking the patient from exiting the room.

Medical record dated 01/03/2020, revealed that there was no documentation of an order for a restraint or seclusion.

Medical record dated 01/03/2020, 1345, revealed: "...Psychiatric Progress Note...Interval History...Needs Isolation...."

Medical record dated 01/03/2020, 1515 revealed: "...Therapy Note...shared about being in isolation prior to the group...."

Medical record dated 01/04/2020, 0740, revealed: "...Psychiatric Progress Note...Had to be restrained for safety...."

Employee #7 confirmed during an interview conducted on 02/25/2020, at 1508-1511, that Employee #33 moved Patient #7 from the hall into the seclusion room. A BHT can take a patient to seclusion, however, there would be a seclusion order, and a seclusion restraint packet would be filled out.

Employee #38 confirmed during an interview conducted on 02/26/2020, at 0815-0821, that a hold and/or seclusion would require a physician order, and that s/he did not direct any staff member to place Patient #7 in a hold or seclusion.

Provider #2 confirmed during an interview conducted on 02/26/2020, at 0851-0858, that documentation of isolation could mean a lot of things, including isolating or removing a patient from a situation. Provider #2 would not enter an order for a restraint if the employee just grabbed the patient. Provider #2 witnessed Patient #7 yelling and banging on the wall. The BHT was trying to calm the patient down, and Provider #2 asked the staff if they needed anything, to let him/her know if they did.

Employee #8 confirmed during an interview conducted on 02/26/2020, at 1115-1133, that s/he recalled viewing the video and that Patient #7 was walking towards the quiet room, then turned around to go back down the hall, and Employee #33 and Employee #29 blocked the hall. Employee #33 grabbed the patient's arm, Employee #29 opened the door to the quiet room, and Patient #7 went into the room.

Employee #4 confirmed during an interview conducted on 02/26/2020, at 0900, that there was no order for a hold or seclusion for Patient #7.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
Based on review of the hospital's policies/procedures, patient's medical record, and interview, it was determined that the facility failed to require that nursing personnel adhere to the requirements when administering chemical restraints for 1 of 1 patient ( Patient # 3). This deficient practice poses a risk to the health, and safety of the patient when nursing personnel did not follow the hospital's policies/procedures when assessing, administering, and evaluating chemical restraints.

Findings include:

Policy titled "Restraint, Chemical" (# 24; 01/2020), revealed: "...Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner...when medication categorized as a chemical restraint is ordered the following actions will be taken...the registered nurse (RN) will document behaviors when led to the need for the use of chemical restraints in the Restraint/Seclusion Progress Note, and the RN Restraint/Seclusion Assessment...the patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained RN the chemical restraint has ended...the nurse in charge will assign trained staff to continuously monitor the patient during the duration of the chemical restraint...a practitioner or trained RN shall conduct an in-person evaluation of the patient within one (1) hour of the medication...if the in-person evaluation is conducted by a trained RN, the RN must consult with the attending/covering practitioner as soon as possible, but not to exceed one 91) hour after completion of the in-person evaluation...the legal representative...shall be promptly notified of the chemical restraint...the treatment plan shall be reviewed, and revised following the first episode of [chemical] restraint to include measures to prevent recurrence...."

Policy titled "Documentation Protocol" (# 55; 11/2019), revealed: "...All medical records are to be accurate...staff to to document accurately services provided..."

Policy titled "Adherence to Documentation and Record Retention Policies" (# 87; #06/2019), revealed: "...All persons who engage in documentation, or whose job duties require documentation, of behaviors, activities, events, communications, results...shall comply with the applicable documentation protocols and policies pertaining to the subject matter area they are, or are required to, document...includes...but not limited to, documentation that law, policies, or procedures require to be part of: medical records...any person who fails to adhere to the applicable documentation policies shall be subject to possible discipline...."

Medical record review for Patient # 3 conducted 02/20/2020 (1030), revealed the following:

i. 10/02/2019 (1500) Restraint/Seclusion Practitioner Order: Documentation incomplete. Order for 10/02/2019 (1500), chemical restraint box checked, Physician #2 signed the order 10/03/2019 (0600);
ii. RN Restraint Assessment: Document with no date, no time, no RN signature; document not completed for "Release from Restraint/Seclusion";
iii. 10/03/2019 (1530) Restraint Progress Note RN/Practitioner: Documentation of patient assessment, and interventions, signed by Licensed Practical Nurse (LPN), no RN signature;
iv. 10/02/2019 Restraint Flowsheet: Documentation reads "Intervention - Other - Chemical Restraint", Time In/Time Out -1510/1515; Patient Monitoring documented "refused, signed by LPN, no RN signature;
v. 10/03/2019 (1400) Restraint Patient Debriefing: Form completed, and signed by LPN, approximately twenty-three (23) hours after the patient received the [chemical] restraint].

Personnel #3 confirmed during an interview conducted 02/25/2020 (1120), that the following required restraint documents/forms dated 10/02/2019 - 10/03/2019, and titled: Restraint/Seclusion Practitioner Order, RN Restraint Assessment, Restraint Progress Note RN/Practitioner, Restraint Flowsheet, and Restraint Patient Debriefing, was not completed per the facilities policies/procedures.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on review of hospital policy/procedure, and interview, it was determined that the Governing Body failed to require that the Performance Improvement (PI) Plan was submitted for review. This deficient practice poses a risk to the health and safety of the patients, when the Governing Board has no oversight of hospital services, and environmental services, and does not know what performance measures are being evaluated, to determine compliance.

Findings include:

Policy titled "Performance Improvement Plan" (# 80; #09/2019), revealed: "...The purpose of the PI Plan is to...maintain a mechanism by which the Governing Board remain knowledgeable about the quality of services being delivered, the competency of the staff who provide care, and the efficient and effective management of the hospital...Governing Board and Leadership decisions are based on the PI Plan...Governing Board delegates responsibility of the implementation of the PI Plan...to the Chief Executive Officer, and the Medical Staff...Governing Board has the ultimate responsibility for adopting an organization-wide plan to assess and improve the quality of care provided...An annual review of performance activities shall be conducted...the PI Risk Director shall facilitate the annual review with hospital leadership and summarize the findings for presentation to the Governing Board...."

The facility Quality Plan that requires an annual review was requested related to quality improvement and patient safety initiatives involoving patient falls.

Personnel #3 confirmed during an interview conducted 02/26/2020 (0855), that the hospital has no documented evidence that the PI Plan, which requires annual review, was approved by the Governing Board.
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
Based on review of hospital policy/procedure, hospital documents, the patient's medical record, and interviews, it was determined that the governing body failed to require that the physician contact one of one patient's representative as requested, to discuss the patient's treatment plan. This deficient practices poses a risk to the health, and safety of the patients, when the physician directing patient care, does not adhere to the patient's rights for treatment planning. (Patient # 2)

Findings include:

Policy titled "Patient Rights-Phoenix" (# 35;10/2018), revealed: "...Each patient has the right to...receive assistance from a family member, designated representative...in understanding, protecting, or exercising the patient's rights...participate or...have the patient's...guardian...participate in treatment decisions, and in the development and periodic review and revision of the patient's written treatment plan...to be informed of the requirements necessary for the patient's discharge or transfer to a less restrictive physical environment...."

Document titled: "Medical Staff Rules & Regulations" (# 35; 07/2018), revealed: "...all patients admitted to the hospital shall be attended by an Attending Physician...the Attending Physician has the ultimate responsibility for...supervising the care of the patient...each Attending Physician agrees to adhere to the design of the Hosptial's treatment programs, and agrees to practice in accordance with the program model...Each clinic practitioner will adhere to all written hospital policies, procedures, protocols, and guidelines...all practitioners shall participate in the education of patients and families...."

Document titled "HBH, Patient Rights" (06/2018), revealed: "...each patient, and if applicable, the patient's parent, guardian...is entitled to...a written list, and verbal explanation of the following patient rights...for inpatient psychiatric services for...persons diagnosed with a severe mental illness...the opportunity to acknowledge, in writing, receipt of a written list...assistance with understanding the rights...each patient has the right to...to receive assistance from a family member, designated representative...in understanding, protecting, or exercising the patient's rights...to receive a verbal explanation of the patient's condition and a proposed treatment, including the intended outcome, the nature of the proposed treatment...to participate or...to have the patient's parent, guardian...participate in treatment decisions...."

Medical record review for Patient # 2 conducted 02/13/2020 (1400), revealed the following:

i. 12/26/2019 Progress Note: Documentation by Personnel #16, of the patient's representative (legal guardian) request to speak with the patient's physician;

ii. 12/10/2019 - 12/30/2019 Psychiatric Progress Notes: No documented evidence of the physician's call to speak with the patient's representative;

Personnel #16 confirmed during an interview conducted 02/20/2020 (1155), that if a patient's representative and/or legal guardian requests to speak with the patient's physician, then the request is shared with the physician that day, or next day at the treatment team meeting. Personnel #16 revealed that s/he remembered the patient's representative (legal guardian) request to speak with the physician, and that the physician was informed.

Personnel #19 confirmed during an interview conducted 02/20/2020 (1205), that most legal guardians want to be called by the physician to discuss the patient's treatment plan. Personnel #19 remembered the patient's representative's request to speak with the physician. Additionally, Personnel #19 remembered that s/he informed the physician of the request.

Personnel #15 confirmed during an interview conducted 02/21/2020 (0720), that s/he remembered the patient, and the patient's representative. Personnel #15 revealed that the patient's representative called frequently, requesting updates regarding the patient, and the patient's treatment plans.

Provider #1 confirmed during an interview conducted 02/21/2020 (0730), that s/he remembered the patient. Provider #1 revealed that if the patient's representative was contacted by phone, then a note referencing the call would be documented in the Psychiatric Progress Note. Additionally, Provider #1 confirmed that the box checked on the Psychiatric Progress Note that reads "Management Plan: current progress reviewed with patient/guardian" marked "Yes", and "Medication Risks/Benefits/Alternatives: discussed with patient/guardian marked "Yes", does not specify if it was the patient or guardian whom the physician spoke with.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on review of the hospital's policies/procedures, documents, medical records, observations on tour, and staff interviews, it was determined that the facility failed to require:

(A0392) the nurse executive ensure that the Juniper unit was staffed according to acuity. This deficient practice poses a risk to the health, and safety of the patient, when the Registered Nurse (RN) assigned to the unit, and having oversight of the Licensed Practical Nurse (LPN), and Behavioral Health Technicians (BHT's), is unaware of the staffing assignment, or that the staffing assignment is made according to the patient's acuity scores.

(A0395) nursing staff ensured Activities of Daily Living (ADL's) were provided to one of one patient. (Patient # 1). This deficient practice poses a risk to the health, and safety of the patient, when the Registered Nurse (RN) fails to oversee the care being provided to patients, specifically, that the patient receives, and or is assisted with basic hygiene care (shower/bath/pericare/oral care); and

2. nursing staff monitored 5 patients according to policy and procedures. (Patient's # 7, #9, #10, #11, and # 12) This deficient practice poses a potential danger to the patient and/or others when observations are not completed to assess a patient's change in condition and/or location. This deficient practice poses a potential danger to the patient and/or others when observations are not completed to assess a patient's change in condition and/or location.

(A0396) that three patient Multidisciplinary Treatment Plans were updated per hospital requirements. This deficient practice poses a risk to the health, and safety of the patients, when the medical, nursing, and social service's staff fail to maintain a current treatment plan, not addressing the goals, and/or response to treatment.(Patient # 1, # 2, and # 3); and

(A0397) require RN staff complete clinical oversight of the Behavioral Health Technicians (BHT's) duties to ensure needs of the patients were met. This deficient practice poses a risk to the health, and safety of the patients, when the BHT's who are conducting physician ordered patient observations, have no clinical oversight ensuring that patient observations, or any other patient care assignments by the BHT's are done correctly, and according to policy.

The cumulative effect of these systematic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Nursing Services, which poses a risk to the health and safety of patients when the facility fails to staff according to patient acuity, provide ADL's for patients who are unable to care for him/herself, maintain Treatment Plans per policy/procedure, complete patient observations as required per physician order, and provide clinical oversight to BHT's.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on review of hospital policies/procedures, staffing assignment sheets, and interviews, it was determined that the facility failed to require that the nurse executive ensure that the Juniper unit was staffed according to acuity. This deficient practice poses a risk to the health, and safety of the patient, when the Registered Nurse (RN) assigned to the unit, and having oversight of the Licensed Practical Nurse (LPN), and Behavioral Health Technicians (BHT's), is unaware of the staffing assignment, or that the staffing assignment is made according to the patient's acuity scores.

Findings include:

Policy titled "Acuity Based Staffing" (# 92; 01/2018), revealed: "...The Nursing Department has established a classification system that provides a basis for assigning nursing personnel according to patient needs...It is the responsibility of nursing leadership t ensure that the patient acuity level is consistently utilized in order to provide the staffing required for patient care...the patient acuity score will reset...at midnight...nursing leaders will need to reassess patient acuity to determine the overall acuity for the milieu daily...."

Policy titled "Nursing Acuity and Staffing Plan-Phoenix" (# 15; 02/2020), revealed: "...Nursing Department defines, implements and maintains a system for determining patient requirements for nursing care on the basis of demonstrated patient needs, appropriate nursing intervention and priority for care...based on patient acuity...nursing staff personnel consists of the RN, LPN, and BHT's...to assure quality nursing care and a safe patient environment, nursing personnel staffing, and assignments are based on...patient care assignment is commensurate with the qualifications of each nursing staff member and identified nursing need of the patient according to acuity...patient care assignments are based on patient acuity, and equally distributed among staff...."

Policy titled "Nursing Services" (# 90; 02/2020), revealed: "...Core Coverage...minimum staffing needed for each skill level (RN, LPN) is determined by the nurse-patient ratio guidelines, and patient care needs...minimum staffing levels may be adjusted up or down based on workload assignment, which may include patient acuity...staffing is planned on average daily census, and average patient acuity...."

Document titled "Haven Acuity Staffing Tool" for 02/13/2020 (Day Shift), listed the following:

Based on current acuity:
i. Morning/Afternoon - Suggested # of RN Resources: 2.00;
ii. Morning/Afternoon - Suggested # of BHT Resources: 1.00;

Based on current acuity + anticipated admissions:
i. Morning/Afternoon - Suggested # of RN Resources: 2.00;
ii. Morning/Afternoon - Suggested # of BHT Resources: 1.00;

Reason for Variance: 2 RN's and 2 BHT's. Actual staffing for 02/13/2020 (Day Shift) included: RN (1), LPN (1), and BHT's (2).

Document titled "House Supervisor-Staff Assignment Sheet, Unit: Juniper, Date: 02/07/2020, Night HS: Camille, RN (Charge)", showed a census of fifteen (15) patients, with one (1) vacant bed. The "House Supervisor-Staff Assignment sheet" listed the following:

i. Column 1- Not Titled: #1 - #16 (listed in numerical order), no room #'s listed;
ii. Column 2- Titled: Patient Full Name - Patient's first name, and initial only of last name listed;
iii. Column 3- Titled: Night Nurse- All sixteen (16) rows listed the same information; Personnel #13's first name and job title/Personnel #17's first name and job title;
iv. Column 4- Titled: Acuity- No acuity score/number listed;
v. Column 5- Titled: Night BHT- Personnel #18's first name and job title (in row's #1-8), and Personnel #10's first name and no job title (in rows #9-16);

Document titled "Registered Nurse, Job Description" (05/2017), revealed: "...Shift Administration...Complete Charge Nurse duties when assigned including assignment sheet, verification that staff assignments are completed, and providing on-going supervision as needed to the assigned nursing staff...."

Document titled "Registered Nurse (RN) House Supervisor, Job Description" (05/2017), revealed: "...Essential Job Functions...Administrative Management...maintain and adjust appropriate staffing patterns using patient acuity...ensure staffing sheets...are completed accurately and timely by each unit...."

Observations on tour of the Juniper unit conducted 02/13/2020 (1149), with Personnel #2, revealed the following patient census, and staffing assignment:

The maximum co-ed census allowed is sixteen (16). On the day of tour census was fifteen (15). Staffing consisted of the following: RN (1), LPN (1), and BHT's (2).

Observations on tour of the staff break room, located near the Palo Verde unit conducted 02/19/2020 (1315), with Personnel #8, revealed the following:

There is an ADP time clock that is used for staff to clock in and clock out. There was no evidence of a daily Shift Assignment sheet posted.

Personnel #11 confirmed during an interview conducted 02/13/2020 (1155), that the staffing assignment for the day shift, is made by the night shift. Personnel #11 revealed that there is usually a daily House Supervisor Staff Assignment Sheet on the clipboard which hangs on the wall in the unit, but that currently there was not a House Supervisor Staff Assignment Sheet on the unit for that day. Personnel #11 confirmed that the staffing assignment for this day, was that the hall was divided in the middle, front hallway and back hallway) for the RN, and LPN, and that the staffing assignment for the BHT's was the same, with the hallway and patient rooms being divided in the middle (front hallway and back hallway). Additionally, Personnel #11 revealed that if a nurse (RN/LPN) has been working consecutive days, and a nurse who has been off is scheduled, then the nurse (RN/LPN) who has been previously working keeps the patients that s/he had been assigned to.

Personnel #9 confirmed during an interview conducted 02/13/2020 (1152), that usually there is a House Supervisor Staff Assignment Sheet on the clip board on the unit, but that there was an overnight staffing issue, and that the House Supervisor Staff Assignment Sheet did not get automatically faxed/printed to the unit for posting. Additionally, Personnel #9 revealed that there is a daily Shift Assignment sheet that is posted by the ADP time clocks where staff clock in and clock, and that staff can look at the daily Shift Assignment sheet to know where they are working.

Personnel #4, and Personnel #8 both confirmed during an interview conducted 02/13/2020 (1230), that the ADP time clock machine located in the Administration office area, had a daily Shift Assignment sheet posted for the the following dates: 02/11/2020, 02/12/2020, and that the daily Shift Assignment sheet for 02/13/2020 was posted after the start of the day shift.

Personnel #12 confirmed during an interview conducted 02/18/2020 (1445), that for the night shift [02/07/2020], Personnel #18 was in a patient room for a 1:1 observation until approximately 0430, and that Personnel #10 was assigned to complete the patient observation rounds for the remaining thirteen (13) patients.

Personnel #8 confirmed during an interview conducted 02/19/2020 (1208), that there was no evidence of a daily Shift Assignment sheet posted by the ADP time clock located in the staff lounge, located near the Palo Verde unit. Additionally, Personnel #8 revealed that the document titled House Supervisor-Staff Assignment sheet dated [02/07/2020 (Night Shift), listed the staff assignment with the RN and LPN both assigned to all patients, and that the BHT's assignment was divided by rooms #1-#8, and #9-#16.

Personnel #20 confirmed during an interview conducted 02/19/2020 (1215), that the day's RN assignment was split (front hallway and back hallway), and that the BHT's assignment was also split (front hallway and back hallway).
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of the hospital's policies/procedures, patient's medical record, and interviews, it was determined that the facility failed to require that:

1. nursing staff ensured Activities of Daily Living (ADL's) were provided to the patient. This deficient practice poses a risk to the health, and safety of the patient, when the Registered Nurse (RN) fails to oversee the care being provided to patients, specifically, that the patient receives, and or is assisted with basic hygiene care (shower/bath/pericare/oral care); and

2. nursing staff monitored 5 patients according to policy and procedures. (Patient's # 7, #9, #10, #11, and # 12) This deficient practice poses a potential danger to the patient and/or others when observations are not completed to assess a patient's change in condition and/or location. This deficient practice poses a potential danger to the patient and/or others when observations are not completed to assess a patient's change in condition and/or location.

Findings include:

1. Policy titled "Patient Rights-Phoenix" (# 35; 10/2018), revealed: "...Each patient has the right to...be treated with dignity, respect, and consideration...to receive treatment that...supports and respects the patient's...abilities...to be free from neglect...to privacy in...personal hygiene...."

Policy titled "Treatment Plan" (# 04; 09/2019), revealed: "...to provide a process and guidelines for implementation of comprehensive, individualized treatment planning for every inpatient...each patient shall have a written, individual comprehensive treatment plan...the plan must be based on an inventory of the patient's strengths and disabilities...must include...problem statement...long-term goals...short-term goals...treatment interventions...is reviewed and revised within seven (7) days of the Master Treatment Plan, and every seven (7) days thereafter...progress/lack of progress toward achieving goals, and any changes, additions or deletions to the plan are recorded...changes are discussed...."

Medical record review for Patient # 1 conducted 02/13/2020 (1430), revealed the following:

i. 02/07/2020 (0050)- Nursing Assessment-Initial Treatment Plan: Medical Needs - impaired mobility, and high fall risk; Interventions - assist with toileting, use of assistive devices; Patient Safety/High Risk Needs - [altered mental status];
ii. 02/08/2020 (0830)- Multidisciplinary Master Treatment Plan: Problem #2 - [description of the Mood], Short-term goal - participation in ADL's including bathing, eating, toileting; Type/Modality - monitoring of safety and completion of ADL's; Frequency - every shift; Duration - as needed throughout 24/7 support; Time frame - seven (7) days;
iii. 02/12/2020 (0800)- Multidisciplinary Master Treatment Plan Update: No documented evidence of addressing ADL's;
iv. 02/20/2020 (0845)- Multidisciplinary Master Treatment Plan Update: Problem #2 - [name of specific psychiatric diagnosis], Short-term goal - participation in ADL's including bathing, eating, toileting; Type/Modality - work with patient to engage in ADL's; Frequency - daily; Duration - no documentation; Time frame - no documentation;
v. 02/19/2020- Daily Graphics Sheet: No documented evidence that a shower, bath, pericare, or oral care was provided;
vi. 02/20/2020- Daily Graphics Sheet: No documented evidence of a form used on this date;
vii. 02/21/2020- Daily Graphics Sheet: No documented evidence that a shower, bath, or pericare was provided;
viii. 02/22/2020- Daily Graphics Sheet: No documented evidence that a shower, bath, or oral care was provided;
ix. 02/07/2020 -02/25/2020- Patient Observations: Documented evidence that only one (1) shower was given to the patient during this time.

Personnel #8 confirmed during an interview conducted 02/21/2020 (0946), that his/her name was on the Multidisciplinary Master Treatment Plan Update dated 02/20/2020, but that s/he did not attend. Additionally, Personnel #8 revealed that s/he does attend some of the multidisciplinary team meetings, but does not attend all of them.

Personnel #3, and Personnel #4 both confirmed during an interview conducted 02/21/2020 (1020), that the Patient Observation forms, and Daily Graphic Sheets, showed no documented evidence that ADL's for Patient #1 were provided.

2. Policy titled "Documentation Protocol" revealed: "...All medical records are to be accurate, truthful and complete...Purpose ...To assure accurate and timely documentation ...."

Policy titled "Levels of Observation and Special Precautions" revealed: "...The physician may order one of four levels of observation...The presence of natural or non-Haven professional supports does not eliminate the need for observation by clinical staff. Clinical staff must carry out the ordered level of supervision, despite presence of others...Levels of Observation Q 15 Minute Checks...This is the minimum level of observation for any patient admitted ...Staff will observe patient and document on the Patient Observation Record Q 15 minutes...Observations may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that staff conducting 15 minute observations will enter the room...."

Hospital document titled "Camera Review" revealed that on 01/03/2020, at 1331, Employee #33 grabbed and held on to the left upper bicep of Patient #7, while Employee #29 unlocked the door. At 1332, Patient #7 was talking to Employee #33, while Employee #29 was writing on the board. At 1352:20 both BHT's exited the seclusion ante room and went back to observing the rest of the unit.

Hospital document titled "House Supervisor - Staff Assignment Sheet, Unit Palo Verde" revealed that on 01/03/2020, the day shift had two (2) BHTs, Employee #29 and Employee #33.

Medical record dated, 01/03/2020, revealed that the Patient Observation sheets for Patient #7, Patient #9, Patient #10, and Patient #11 listed the patients as observation "Check every 15 minutes". Time period on the observation sheet for 1330, 1345, and 1400, were initialed by Employee #29. Additionally, Patient #12's observation sheet was documented as "Patient Observations - Q5" and for the time periods 1330, 1335, 1340, and 1345, were initialed by Employee #29.

Employee #7 confirmed during an interview conducted on 2/24/2020, at 1353, that his/her expectation was that a patient on Q 15 minute observation was seen anytime during that 15 minute block of time, and it could be about 30 minutes before a patient is seen again.

Employee #32 confirmed during an interview conducted on 2/24/2020, at 1450-1501, that the BHT's start their rounding observations a few minutes prior to the 15 minute mark, and are done within a few minutes after the 15 minute mark. When doing room to room observations s/he would only do an assessment from the door if s/he could see the patient, and if s/he could not see the patient, s/he would step in the room.

Employee #7 confirmed during an interview conducted on 02/25/2020, at 1508-1511, that there are only two (2) BHTs on the floor.

Employee #38 confirmed during an interview conducted 02/26/2020, at 0815-0821, that Q15 minute means that the patient would be checked on every 15 minutes.

Employee #7 and Employee #8 confirmed during a combined interview conducted on 02/26/20, at 1244-1245, that the medical record dated 01/03/2020, for Patient #7, Patient #9, Patient #10, and Patient #11 revealed that their Q 15 minute observations for the time period of 1330, 1345, and 1400, were initialed by Employee #29. Patient #12's medical record dated 01/03/2020, revealed that the Q 5 minute observations for the time period of 1330, 1335, 1340, and 1345, were initialed by Employee #29. It was also confirmed that Employee #29 was with Patient #7 for the time period of 1331-1352.





Based on review of hospital policies and procedures, hospital documents, medical records, and staff interviews, it was determined that the facility failed to ensure that patient's were monitored according to policy and procedures. This deficient practice poses a potential danger to the patient and/or others when observations are not completed to assess a patient's change in condition and/or location.

Findings include:

Policy titled "Documentation Protocol" revealed: "...All medical records are to be accurate, truthful and complete...Purpose ...To assure accurate and timely documentation ...."

Policy titled "Levels of Observation and Special Precautions" revealed: "...The physician may order one of four levels of observation...The presence of natural or non-Haven professional supports does not eliminate the need for observation by clinical staff. Clinical staff must carry out the ordered level of supervision, despite presence of others...Levels of Observation Q 15 Minute Checks...This is the minimum level of observation for any patient admitted ...Staff will observe patient and document on the Patient Observation Record Q 15 minutes...Observations may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping. It is expected that staff conducting 15 minute observations will enter the room ...."

Hospital document titled "Camera Review" revealed that on 01/03/2020, at 1331, Employee #33 grabs and holds on to the left upper bicep of Patient #7, while Employee #29 unlocks the door. At 1332, Patient #7 is talking to Employee #33, while Employee #29 is writing on the board. At 1352:20 both BHT's exit the seclusion ante room and go back to observing the rest of the unit.

Hospital document titled "House Supervisor - Staff Assignment Sheet, Unit Palo Verde" revealed that on 01/03/2020, the day shift had two (2) BHTs, Employee #29 and Employee #33.

Medical record dated, 01/03/2020, revealed that the Patient Observation sheets for Patient #7, Patient #9, Patient #10, and Patient #11 listed the patients as observation "Check every 15 minutes". Time period on the observation sheet for 1330, 1345, and 1400, were initialed by Employee #29. Additionally, Patient #12's observation sheet was documented as "Patient Observations - Q5" and for the time periods 1330, 1335, 1340, and 1345, were initialed by Employee #29.

Employee #7 confirmed during an interview conducted on 2/24/2020, at 1353, that his/her expectation is that a patient on Q 15 minute observation is seen anytime during that 15 minute block of time and it could be about 30 minutes before a patient is seen again.

Employee #32 confirmed during an interview conducted on 2/24/2020, at 1450-1501, that the BHT's start their rounding observations a few minutes prior to the 15 minute mark and are done within a few minutes after the 15 minute mark. When doing room to room observations s/he would only do an assessment from the door if s/he could see the patient, and if s/he could not see the patient, s/he would step in the room.

Employee #7 confirmed during an interview conducted on 02/25/2020, at 1508-1511, that there are only two (2) BHTs on the floor.

Employee #38 confirmed during an interview conducted 02/26/2020, at 0815-0821, that Q15 minute means that the patient would be checked on every 15 minutes.

Employee #7 and Employee #8 confirmed during a combined interview conducted on 02/26/20, at 1244-1245, that the medical record dated 01/03/2020, for Patient #7, Patient #9, Patient #10, and Patient #11 revealed that their Q 15 minute observations for the time period of 1330, 1345, and 1400, were initialed by Employee #29. Patient #12's medical record dated 01/03/2020, revealed that the Q 5 minute observations for the time period of 1330, 1335, 1340, and 1345, were initialed by Employee #29. It was also confirmed that Employee #29 was with Patient #7 for the time period of 1331-1352.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on review of hospital's policies/procedures, documents, medical records, and interviews, it was determined that the facility failed to require that three patient Multidisciplinary Treatment Plans were updated per hospital requirements. This deficient practice poses a risk to the health, and safety of the patients, when the medical, nursing, and social service's staff fail to maintain a current treatment plan, not addressing the goals, and/or response to treatment.(Patient # 1, # 2, and # 3)

Findings include:

Policy titled "Treatment Plan" (# 04; 09/2019), revealed: "...Each patient shall have a written, individual comprehensive treatment plan within seventy-two (72) hours of inpatient admission...must include...problem statements...long term goals...short-term goals...multidisciplinary treatment interventions...team members responsible...date, signatures, and professional titles of each person in attendance...treatment and discharge plan is reviewed and revised within seven (7) days of the Master Treatment Plan...and every seven (7) days thereafter...."

Policy titled "Social Work Scope of Services" (# 64; 02/2020), revealed: "...Every patient is provided with Social Services...specific functions...include...psychosocial assessments...assessing the patient's goals, as well as the concerns of family and/or legal representative...interventions are identified on the Interdisciplinary Treatment Plan, and social services staff actively participates in the interdisciplinary treatment planning process...."

Policy titled "Patient Rights" (# 35; 10/2018), revealed: "...Each patient has the right to...be offered or referred for the treatment specified in the patient's treatment plan...to participate or, if applicable to have the patient's parent, guardian, custodian or agent participate in treatment decisions, and in the development and periodic review and revision of the patient's written treatment plan....:

Policy titled "Falls Prevention and Monitoring" (# 04; #10/2019), revealed: "...Post Fall Procedure...Following a fall, nursing will complete the following...the Treatment Plan will be updated with new intervention to prevent further injury...."

Policy titled "Chemical Restraint" (# 24; 01/2020), revealed: "...Procedure...the treatment plan shall be reviewed, and revised following the first episode of chemical restraint to include measure to prevent recurrent...additional review of the treatment plan with revisions as indicated, will occur if the patient is chemically restrained on more than one occasion...

Document titled "Medical Staff Rules & Regulations" (# 35l 07/2018), revealed: "...Attending Physician is responsible for ensuring that each of his patients has an individualized comprehensive treatment plan, developed with the involvement of the patient or his legal representative...Attending Physician is expected to be present at treatment team meetings on all of his patients as scheduled, and to participate in, review, and approve all treatment plans formulated by the treatment team...."

Medical record review conducted 02/19/2020 - 02/20/2020, of the Multidisciplinary Master Treatment Plans, for the following patients revealed:

Patient #1 - admitted [specific date identified], and discharged [specific date identified]. Fall Risk identified on Treatment Plan, with no date of when it was added, reviewed, and/or revised.
i. [specific date and time identified]: Initial - Impaired mobility & high fall risk identified;
ii. 02/08/2020: Updated. No documented evidence of patient and/or patient's representative's signature;
iii. 02/11/2020 & 12/2020: Updated. No evidence of patient and/or patient's representative's signature;
iv. 02/20/2020: Updated eight (8) days later;
v. 02/16/2020: Incident Report completed for a fall, no documented evidence that the Treatment Plan was updated after this incident;
vi. 02/10/2020: Medical Nutrition Therapy Initial Assessment completed to include identified problems, but no update to Treatment Plan until 02/19/2020.

Patient #2 - admitted [specific date identified], and discharged [specific date identified].
i. [specific date identified]: Initial;
ii. 12/16/2019: Treatment Plan updated, and signed by only the RN on 12/24/2019, no documented evidence of any other Treatment Plan updates/reviews/revisions.

Patient #3 - admitted [specific date identified], and discharged [specific date identified].
i. 09/24/2019 - 10/01/2019: No documented evidence that the Treatment Plan was signed by the multidisciplinary team until [10/16/2019];
ii. 09/29/2019, 10/12/2019, 10/15/2019, 10/23/2019: Incident Reports completed for patient [falls], no documented evidence that the Treatment Plan was updated after each incident;
iii. 09/29/2019, 10/02/2019: Incident Reports completed for the use of restraints, no documented evidence that the Treatment Plan was updated after each incident.

Personnel #4 confirmed during an interview conducted 02/20/2020 (1428), that there were no additional Treatment Plans for Patient #2, and that evidence of a Treatment Team meeting is required every seven (7) days.

Personnel #15 confirmed during an interview conducted 02/21/2020 (0720), that a representative from social services is required to attend the patient's Multidisciplinary Treatment Team meeting weekly, and after review, sign the Treatment Plan. Additionally, Personnel #15 revealed that if the patient has a legal guardian/representative, and that person is unable to attend the weekly Treatment Team meeting in person, than the legal guardian/representative can call in for the meeting, and the legal guardian/representative's participation is documented on the weekly Treatment Plan.

Personnel #3, Personnel #4, and Personnel #8, all confirmed during a combined interview conducted 02/21/2020 (1020), that the Treatment Plan for Patient #1 was not updated per the hospitals required time frame of every seven (7) days. Personnel #8 revealed the patient had a [fall], and [nutritional] needs were identified, but that these were not added to the Treatment Plan after the incident/identification. Personnel #3, Personnel #4, and Personnel #8 revealed that the Treatment Plan for Patient #1 was confusing, and that it was difficult to determine when problems were added/reviewed/updated. Additionally, Personnel #3 confirmed that with the exception of one (1) Treatment Team meeting, there was no documented evidence of the patient, and/or patient's representative signature, indicating his/her participation in the other two (2) Treatment Team meetings.

Personnel #3 confirmed during an interview conducted 02/25/2020 (1205), that the Treatment Plan for Patient #3 was not updated per the hospitals required time frame of every seven (7) days. Additionally, Personnel #3 revealed that the patient had multiple [falls], and several ordered [restraints], but that the Treatment Plan was not updated to include these.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on review of hospital policies/procedures, personnel files, and interviews, it was determined that the facility failed to require RN staff complete clinical oversight of the Behavioral Health Technicians (BHT's) duties to ensure needs of the patients were met. This deficient practice poses a risk to the health, and safety of the patients, when the BHT's who are conducting physician ordered patient observations, have no clinical oversight ensuring that patient observations, or any other patient care assignments by the BHT's are done correctly, and according to policy.

Findings include:

Policy titled "Nursing Services" (# 90; 02/2020), revealed: "...Staff Qualificiations...personnel assigned to patient care shall have completed competency documents for that unit, or be under the supervision of a preceptor...direct nursing care is provided by a team of registered nurses...and mental health technicians who have been trained to meet the needs of the population served...."

Policy titled "Nursing Acuity & Staffing Plan-Phoenix" (# 15; 02/2020), revealed: "...to assure quality nursing care, and a safe patient environment, nursing personnel staffing, and assignments are based on...a registered nurse plans, supervises, and evaluates the nursing care of each patient...."

Document titled "Registered Nurse, Job Description" (05/2017), revealed: "...Position Summary...Provides supervision to the BHT's...assumes role of Charge Nurse when assigned...providing on-going supervision as needed to the assigned nursing staff..."

Personnel file reviews conducted 02/20/2020 - 02/26/2020, revealed no documented evidence of clinical oversight for the following BHT's:

Personnel #10
Personnel #18
Personnel #23
Personnel #29
Personnel #30
Personnel #31
Personnel #32
Personnel #33
Personnel #35

Personnel #8 confirmed during an interview conducted 02/25/2020 (0930), that the Registered Nurse (RN) on the unit, has oversight of the BHT's, but that s/he is unaware of any documented evidence specific to the clinical oversight.

Personnel #32 confirmed during an interview conducted 02/24/2020 (1450), that s/he does not think that the RN has clinical oversight over the BHT's, as no one is watching over the BHT's.

Personnel #24 confirmed during an interview conducted 02/25/2020 (1000), that s/he had no documentation in the BHT's personnel files specific to clinical oversight.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of hospital policies/procedures, medical records, video, and interviews, it was determined that the facility failed to require that for 8 patient records reviewed documentation specific to patient observations was accurate, and authenticated by personnel assigned to do patient observations . This deficient practice poses a risk to the health and safety of the patients, when personnel assigned to complete patient observations, does not complete patient observations, and then falsifies the patient's medical record, indicating that the patient observations were completed. (Patients # 1, #8, #13, #14, #15, # 16, # 17, and #18)

Findings include:

Policy titled "Documentation Protocol" (# 55; 11/2019), revealed: "...All medical records are to be accurate, truthful, and complete...staff are to document accurately service provided, patient interactions...every staff who creates...reviews...in a medical record, ensures that the medical record complies with this Documentation Protocol...Authentication...the process that ensures that users are who they say they are...medical record entries are to be authenticated by the author of the entry...never engage in back dating any document in the medical record...never record any inaccurate, false or misleading information in a medical record...if staff find that records, reports, chart, and documents are not accurate, truthful and complete or documentation protocols are not implemented appropriately, staff is to follow the chain of command in communication with their supervisor...."

Policy titled "Adherence to Documentation and Record Retention Policies" (# 87; 06/2019), revealed: "...All persons who engage in documentation...whose job duties require documentation...shall comply with...documentation protocols and policies pertaining to the subject matter area they are, or are required to document...includes...patient medical records...any person who fails to adhere to the applicable documentation policies shall be subject to possible discipline...."

Policy titled "Levels of Observation & Special Precautions" (# 93; 07/2019), revealed: "...Q 15 minute checks...staff will observe patient and document on the Patient Observation record every 15 minutes...assigned staff will make direct visual contact with patients and confirm they are in no danger or distress...observations may not be completed standing in the doorway, or at a distance, particularly for patients who are sleeping...expected that staff conducting 15 minute observations will enter the room...."

Video review conducted 02/18/2020 (1325) with Personnel #2, confirmed the following activities on the Juniper Unit on 02/08/2020 (0400-0445):

i. Personnel #10: No direct patient observations of patients at 0410 through 0435.

The following patient's on the Juniper Unit were ordered every 15 minute Patient Observations: Patient's #1, #8, #13, #14, #15, #16, and #17. All Patient Observation forms dated 02/08/2020 for 0415, and 0430 were initialed by Personnel #10, indicating direct Patient Observation.

The following patient on the Juniper Unit was ordered every 5 minute Patient Observations: Patient #18. Patient Observation form dated 02/08/2020 for 0410, 0415, 0420, 0425, 0430, 0435, were initialed by Personnel #10, indicating direct Patient Observation.

Personnel #2 confirmed during an interview conducted 02/18/2020 (1415), that Personnel #10 did not complete the required Patient Observations as evidence by the video.

Personnel #8 confirmed during an interview conducted 02/20/2020 (1410), that s/he reviewed the video, and it was determined that Personnel #10 did not complete the required Patient Observation rounds, but that the Patient Observation forms for the above patients were intiated by Personnel #10 as having been completed.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
Based on review of hospital policies/procedures, documents, medical records, and interviews, it was determined that the facility failed to require that for 6 medical records reviewed, verbal/telephone orders given by a medical provider, were not authenticated by the medical provider within the required twenty-four (24) hours. This deficient practice poses a risk to the health, and safety of the patients when the medical provider fails to authenticate an order, validating that the order was correct. (Patients # 1, #2, #3, #5, #6, and #7)

Findings include:

Policy titled "Written and Verbal Orders" (# 31; 02/2020), revealed: "...Telephone Orders/Read Back and Verification...only telephone orders from an approved licensed independent practitioner (LIP) will be taken...order will be written on the physician order sheet, represented as a telephone order...the prescriber shall co-sign the order within twenty-four (24) hours...."

Policy titled "Documentation Protocol" (# 55; 11/2019), revealed: "...all medical records are to be accurate...medical record entries are to be authenticated by the author of the entry...confirmed by written signature, date, time, and credentials...."

Document titled "Medical Staff Rules & Regulations" (# 35; 07/2018), revealed: "...Medical Records...Orders...an order shall be considered to be written if dictated by telephone to a registered nurse...and signed promptly...the order may be signed either by the attending physician or by any designee...orders dictated over the telephone shall be signed, dated, and timed by the person who took the order, and shall include the name of the practitioner giving the order...orders will be read-back...."

Medical record review conducted 02/18/2020 - 02/25/2020, revealed a total of one-hundred-twenty (120), physician verbal/telephone orders were not authenticated within the twenty-four (24) hour time requirement for the following patients:

Patient #1: A total of three (3) ancillary orders;
Patient #2: A total of twenty-one (21) ancillary, and medication orders;
Patient #3: A total of forty-four (44) ancillary, and medication orders;
Patient #5: A total of thirty-six (36) ancillary, and medication orders;
Patient #6: A total of fourteen (14) ancillary, and medication orders;
Patient #7: A total of two (2) medication orders.

Personnel #3, and Personnel #4 confirmed during an interview conducted 02/26/2020 (0930), that the ancillary, and medication verbal/telephone orders for Patient's #1, #2, #3, #5, #6, and #7, were not authenticated by the medical provider within twenty-four (24) hours as required per policies/procedures.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on review of hospital policies and procedures, hospital documents, medical records, observations on tour, and staff interviews, it was determined that the facility failed to:

(A0724) ensure that the hospital's premises were maintained to prevent injury and harm and keep 1 of 1 patient safe, (Patient #4), when an unsecured countertop was used to break the window in this patient's room and then allowed the patient to elope onto a second floor roof and cause injury to their arm

The cumulative effect of this systematic deficient practice resulted in the facility's failure to meet the requirement for the Condition of Participation for Physical Environment, which poses a potential risk to the health and safety of patients when the facility premises have not been inspected, ensuring that the countertops in the patient rooms were secured, and could not be removed/used to cause harm.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on review of hospital policies and procedures, hospital documents, medical records, observations on tour, and staff interviews, it was determined that the facility failed to ensure that the hospital's premises were maintained to prevent injury and harm and keep 1 of 1 patient safe, (Patient #4), when an unsecured countertop was used to break the window in this patient's room and then allowed the patient to elope onto a second floor roof and cause injury to their arm

Findings include:

Policy titled "Emergency Operations Plan" revealed: "...The hospital attempts to mitigate any event by participating in activities that help prevent emergency or reduce the chance of an emergency happening...Regular monthly, quarterly and annual systems inspections and checks to pro-actively identify areas of improvement...Structural Damage...Conduct monthly EOC rounds, reporting all deficiencies...."

Hospital document titled "Approximate Timeline" revealed the steps the facility has taken on 02/21/2020, 02/22/2020, and 02/23/2020, to fix any safety issues related to the incident and protect the safety of patients.

Hospital document titled "Facility Proactive Patient Safety Risk Assessment" revealed that the initial review was initiated on 02/21/2020, to assess and identify and risks, action plan in place, and that assessment was ongoing.

Hospital document dated "02/21/2020," revealed that a patient eloped from the facility. Notifications were made to the State, family, DON, shift supervisor, practitioner, police, and fire. Patient refused to return to facility. Patient was medically cleared by fire, taken to UPC by police, and discharged from Haven.

Hospital document titled "Safety/Environment of Care/Infection Control Committee Meeting" revealed that the status of report of environmental tours, findings, and plans of correction were reported for the months of October 2019, through January 2020.

Medical record for Patient #4 dated, 02/21/2020, revealed: "...Progress Notes...0620...BHT...yelled out code green. Both RNs went to patient room 226 and noticed the room window had been shattered. The BHT informed RN that patient had jumped out the window on to the roof. Patient utilized the top portion of the room shelf to break the window. The psych doctor was notified and ordered staff to call 911. BHT called 911 while staff RN secured room 226 and assisted the other patient in room 226 in to the hallway. Security and administrative staff were notified of the incident. Room 226 was locked to prevent others from entering room...."

Observation conducted on 02/21/2020, revealed that Room #226, was locked and no patient's were in the room. The room was assessed, the countertop was missing from the shelving unit, and the window directly above it was broken. There were additional staff noted observing rooms #204, #206, #208, and #218 that were identified by the facility that required repairs to the countertops. The countertops identified were loose or could be jiggled.

Employee #5 confirmed during an interview conducted on 02/24/2020, at 0951-1004, that on 02/21/2020, the facility contacted the landlord and completed an assessment of patient rooms. Rooms were identified that had loose countertops on the wardrobes.