HospitalInspections.org

Based on review of documents and staff interview, it was determined the Administrator failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients.

Findings Include:
Document titled "Position Title: Chief Executive Officer," revealed: "...Establishes credibility throughout the organization and with the executive staff as an effective developer of solutions to business challenges. 2. Provides leadership and management to ensure that the mission and core values of the company are put into practice...Fosters a success-oriented, accountable environment within the organization...This position manages subordinate supervisors who supervise employees and is responsible for the overall direction, coordination and evaluation of these units. The CEO also directly supervises non-supervisory employees. This position's responsibilities include: interviewing, hiring and training employees...disciplining employees; addressing complaints and resolving problems...."

During the survey it was determined the CEO failed to perform the core functions of the CEO as demonstrated by the following:

Cross reference A-0145: A failure to protect patients from staff abuse;
Cross reference A-0159: The inability to recognize a physical hold for any length of time was a physical restraint;
Cross reference A-0167: There was a failure to ensure physical restraints were conducted safely, after a patient suffered a serious injury, to prevent further injuries to patients;
Cross reference A-0168: Failing to uphold patient rights by physically restraining patients only on the order of a licensed practitioner;
Cross reference A-0169: Failing to ensure patients were not subjected to restraints on an as needed basis;
Cross reference A- 0178: Ensuring patients received a face to face evaluation after receiving a physical restraint.

Based on review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by the hospital's failure to:

Cross reference A-0145: A failure to appropriately investigate and report potential abuse of a minor patient;

Cross reference A-0159: The inability to recognize a physical hold for any length of time was a physical restraint;

Cross reference A-0167: There was a failure to ensure physical restraints were conducted safely, after a patient suffered a serious injury, to prevent further injuries to patients;

Cross reference A-0168: Failing to uphold patient rights by physically restraining patients only on the order of a licensed practitioner;

Cross reference A-0169: Failing to ensure patients were not subjected to restraints on an as needed basis;

Cross reference A- 0178: Ensuring patients received a face to face evaluation after receiving a physical restraint.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on a review of hospital record and interview, it was determined the hospital failed:
1. to protect Patient #1 from potential abuse, when Patient #1 suffered a fractured humerus while under staff care.
2. to protect Patient #2 from potential abuse, when Patient #2 was physically assaulted by an employee.

This deficient practice poses the risk of further injury or death to patients while under the care of the facility.

Findings Include:

Policy titled, "Abuse, Assault or Neglect of a Patient," revealed: "...All staff members are expected to treat patients with the utmost respect and dignity. Any evidence to the contrary will not be tolerated and will be subject to disciplinary action ...An employee suspected to have physically, verbally, or sexually abused a patient shall be subject to disciplinary action up to, and including, the possibility of termination. The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report. The above listed administrators will be responsible for conducting the investigation ...At the conclusion of the investigation if the facility has reasonable suspicion that the employee, did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire. Any employee that is a professional licensed or eligible for licensure will be reported to their respective state professional Board. The hospital also reserves the right to contact local law enforcement ...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later than twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation. ..."

Policy titled, "Seclusion and Restraint," revealed: "...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient ' s body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...The nurse will assign trained staff to continuously monitor the patient during the restraint event. The staff member will visually monitor the patient ' s physical and psychological condition...The person monitoring the patient must be trained to respond to an emergency should one occur...An RN will conduct a patient debriefing following each use of seclusion or restraint. Documentation of the debriefing shall include the following information...Any injuries to patients or staff...All seclusion and restraints may be reviewed via video to help ensure that the patient ' s rights are respected as well as protecting the health and safety of the staff and patients...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints...."

Policy titled "Incident Reporting Policy," revealed: "...Incidents may include but are not limited to...a. injury to patient - accidental or intentional...i. Any unusual event that deviates from policy...Upon receipt, Quality Director or designee completes the investigation and notes any areas requiring follow-up...Events are analyzed for patterns and systems failures. However, if upon investigation, an adverse event appears to have been a result of intentional or neglectful action by staff, staff is subject to discipline...."

Patient #1:
Patient #1's medical record contained a note titled "Seclusion and Restraint Individual," dated 06/22/2024, which revealed: "...Pt did not take meds willingly required personal restraint. Meds given in room...Personal Restraint...Start time: 1924 End time: 1924...Name/Credentials/Title of Primary Individual involved in the Restraint: (Employee #5, Employee #7, Employee #12, Employee #14)...Description of Member Condition...Patient stated that [her] "f**king arm hurts.", {sic} sat on [her] bed, tearful and allowed RN to assess [her] arm...Information discussed during the debriefing: Prevention of escalating behaviors, unit activities, safety planning...."

Employee #7's written statement dated 06/22/2024, revealed: "...Staff had to put [her] in a personal hold to safely administer the medication. Patient started to kick at staff...and then kicked off the wall and twisted [her] body. Staff reported that they heard a "pop" sound. Patient yelled that, "you hurt my f**king arm!"...The medication was administered, patient was released and [she] sat on [her] bed. TW assessed [her] left arm. No redness, swelling, or protrusion noted at this time. TW called the IM provider on call and requested to send patient to the ED for an x-ray...Maricopa Transport arrived at 2009 and escorted patient to [Del Webb] at 2011...."

Employee #8's written statement dated 06/22/2024, revealed: "...At approx 19:30 staffs were asked to assist Patient to receiving [her] shots due to patient refusing to taking them. While assisting the patient to the east wall of [her] room. Patient jumped up and kicked the causing [her] to hyperextend [her] left shoulder. Medical attention where {sic} given to patient no further incident...."

Employee #5's written statement dated 06/22/2024, revealed: "...Pt refused to go to exam room for medication administration but was willing to go into [her] room. This nurse, second RN and to{sic}BHT staff members went into pt room to administer medications. Pt sat on [her] bed and then refused to take ordered meds. Pt was informed that [she] would be placed in a hold while medications were given and pt became extremely agitated...Pt used [her] feet to push against the wall and continued kicking. Once pt was facing the wall and continued kicking. Once pt was facing the wall [she] yelled "you f**king hurt my arm" and BHT stated [he] heard a "pop." Medication administration was completed and pt was released. Pt sat on [her] bed and was tearful stating [her] arm hurt. Pts arm was assessed by [her] RN and provider notified. Pt was sent to ED for xray and exam...."

Employee #12's written statement dated 06/22/2024, revealed: "...Once pt was put in a hold to receive shots. Once pt was put in a hold [she] began to jerk [her] body around and kicking. As we moved out way towards the wall pt kicked [her] legs up and tried to push off wall. Once the pt did that you could hear a pop, immediately after the popping noise pt screamed "you hurt my arm". Pt then received shots and sat back down on bed as the nurses examined [her] arm...."

Patient #1's medical record contained a note titled "Nursing Note," dated 06/23/2024, which revealed: "...This writer called [Banner Del E. Webb] ER to get an update on this patient...an employee of [Banner] informed this writer that patient sustained left Humerus Fracture, and that the Social Workers will be investigating how [she] sustained this injury, that for the mean time, they were not comfortable send this patient back to Destiny Springs...."

Patient #1's medical record from [Banner Del E. Webb], contained a note titled "ED Pertinent Report," which revealed: "...Patient was then restrained by staff which caused sudden onset of pain of [her] left arm...I feel that the patient's presentation is most consistent with left midshaft spiral humerus fracture with angulation and shortening...I spoke with [Dr. Vu], [Banner Pediatric] Orthopedic Surgery, regarding the patient's case...States the patient will require plating but recommends following up in the clinic in 2 weeks...."

Patient #1's medical record from [Banner Del E. Webb], contained a note titled "Diagnostic Radiology," which revealed: "...Elbow 3 or More Views Lt...Impression: Acute, spiral-type fracture of the left distal humeral diaphysis with medial angulation and posterior displacement...."

Employee #2 confirmed in an interview on 06/25/2024, Patient #1 was placed in a physical hold to receive an IM medication, and was injured during the hold and sent to the ED. Employee #2 further confirmed, the hold took place in the patient bedroom where there is no video footage. Employee #2 further confirmed there were no actions taken by the hospital as a result of the event, and Employees #5, 7, 8, and 12, were not placed on administrative leave while an investigation took place. Employee #2 also confirmed the facility determined the patient suffered a broken arm due to their own actions.

Patient #2:
Video footage from the Intake Department, dated 06/15/2024, revealed:
13:25:44 - Employee #11 and Patient #2 seen walking down hallway
13:26:24 - Patient #2 picks up mop from unattended EVS cart and throws mop at Employee #11
13:26:25 - Employee #11 tackles Patient #2 to the floor, holding Patient #2 between the wall and EVS cart, on his back. Patient #2 is observed hitting left side of head on EVS cart. Employee #11 is on top of Patient #2. Employee #11 is seen extending their legs while shifting their upper body onto Patient #2 ' s upper body.
13:26:33 - Patient #2 observed with legs twitching, still under Employee #11. No change in restraint
13:27:06 - Patient #2 observed with legs/body not moving. Employee #11 shifted weight back, and Patient #2 positioned on left side. Employee #11 is holding Patient #2 ' s arms with their right hand, and Employee #11 ' s left hand was on Patient #2 ' s right shoulder.
13:28:15 - Employee #11 releases Patient #2 from hold and stands up. Patient #2 is observed struggling to stand up from floor. Blood observed on floor from where Patient #2 ' s head was.
13:33:12 Code team arrives.

Document titled, "Daily Assignment," revealed Employee #11 was on duty 06/19/2024, 06/20/2024, 06/21/2024, and 06/22/2024.

Document titled, "Incident Report 6/15/24", written by Employee #16 revealed: "...(Patient #2) turned to swing stick at (Employee #11). Staff proceeded to block stick and leaped at patient, knocking patient onto floor ...."

Document titled, "Incident Report 6/15/24", written by Employee #17 revealed: "...I saw (Patient #2) arguing grabing {sic} [his] belongings and (Employee #11) walking arguing with the patient to have a seat. (Patient #2) got upset [he] could not go out for a smoke pointed at (Employee #11) ' s face told [him] to ' leave [him] alone liar ' . (Employee #11) continued to tell (Patient #2) to sit down don ' t be pointing in [his] face. (Patient #2) then grabed {sic} a mop stick from housekeeping cart and swung it at (Employee #11) saying ' I said to back tf up man leave me alone ' (Employee #11) tackled (Patient #2) onto house keeping cart. (Patient #2) head hit the cart and rib on [his] left side ..."

Document titled, "Written Warning Form," revealed: "...Final Written Warning ...(Employee #11) attempted a 1-person restraint, and the patient was injured in the process. Pt had laceration to left brow and shoulder. When reviewing camera footage, it is observed, (Employee #11) used excessive force when attempting to restrain the pt ... Plan for Improvement (be specific): (Employee #11) will be required to complete CPI to help re-train and re-educate [him] on proper holds and de-escalation techniques ...."

Restraint documentation and orders were requested and none provided.

Employee #1 confirmed during an interview conducted on 7/2/2024, Employee #11 was not placed on administrative leave or terminated following this incident. Employee #1 also confirmed they did not follow policy due to Employee #11 not having any other incidents similar to this.

Employee # 2 confirmed during an interview conducted on 07/03/2024, Employee #11 was given a final written warning, retraining, and weekly monitoring and oversight from the Intake Director.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients who were restrained in a personal hold by staff were recognized as being under a physical restraint. This deficient practice poses the risk of a patient being physically restrained unnecessarily, and proper restraint procedures, such as de-escalation, and appropriate monitoring, not being performed.

Findings include:
Policy titled, "Seclusion and Restraint," revealed: "...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints....."

Video footage from the Monarch Unit, dated 06/22/2024, revealed:
19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14.

Video footage from the Lotus Unit, dated 06/25/2024, revealed:
Patient #8 was placed in a physical restraint at 19:48, by an employee, who was then relieved by Employee #18 and #21.
Patient #8 was placed in a physical restraint at 19:53, by Employee #18 for an undetermined amount of time as both exit the video field of view at 19:56 with physical hold still in place.
Patient #10 was placed in a physical restraint at 19:53 until 19:54, by Employee #7 and Employee #21.
Patient #11 was placed in a physical restraint at 19:53 until 19:54, by Employee #22 and Employee #23.

Restraint documentation and orders were requested for Patient #3, #4, #6, #8, #10 and #11, and none were provided.

Employee #2 confirmed in an interview conducted on 06/27/2024, Patient's #4, #6, and #3, were in a physical restraint for less than five minutes, therefore they are not required to have orders or restraint documentation.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure restraints were conducted safely, resulting in Patient #1 suffering a fractured humerus. This deficient practice poses the risk of further injury or death to patients.

Findings include:
Policy titled, "Seclusion and Restraint," revealed: "...It is the intent of Destiny Springs Healthcare to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body...Following the initiation of restraint or seclusion the RN shall...Determine the person's current physical, emotional and mental status...The nurse will assign trained staff to continuously monitor the patient during the restraint event. The staff member will visually monitor the patient's physical and psychological condition. If the patient is observed to be in physical or psychological distress, the monitoring staff member will immediately alert an RN...The person monitoring the patient must be trained to respond to an emergency should one occur...An RN will conduct a patient debriefing following each use of seclusion or restraint. Documentation of the debriefing shall include the following information...Any injuries to patients or staff...All seclusion and restraints may be reviewed via video to help ensure that the patient's rights are respected as well as protecting the health and safety of the staff and patients...The Chief Quality Officer, or designee, will report any incidents of Seclusion and Restraint that result in an injury or complication requiring medical attention to the Health Plan within 24 hours through the AHCCCS IAD portal...."

Patient #1's medical record contained a note titled "Seclusion and Restraint Individual," dated 06/22/2024, which revealed: "...Pt did not take meds willingly required personal restraint. Meds given in room...Personal Restraint...Start time: 1924 End time: 1924...Name/Credentials/Title of Primary Individual involved in the Restraint: (Employee #5, Employee #7, Employee #8, Employee #12)...Description of Member Condition...Patient stated that [her] "fucking arm hurts.", {sic} sat on [her] bed, tearful and allowed RN to assess [her] arm...Information discussed during the debriefing: Prevention of escalating behaviors, unit activities, safety planning...."

Employee #7's written statement dated 06/22/2024, revealed: "...Staff had to put [her] in a personal hold to safely administer the medication. Patient started to kick at staff...and then kicked off the wall and twisted [her] body. Staff reported that they heard a "pop" sound. Patient yelled that, "you hurt my f***ing arm!"...The medication was administered, patient was released and [she] sat on [her] bed. TW assessed [her] left arm. No redness, swelling, or protrusion noted at this time. TW called the IM provider on call and requested to send patient to the ED for an x-ray...Maricopa Transport arrived at 2009 and escorted patient to Del Webb at 2011...."

Employee #8's written statement dated 06/22/2024, revealed: "...At approx 19:30 staffs were asked to assist Patient to receiving [her] shots due to patient refusing to taking them. While assisting the patient to the east wall of [her] room. Patient jumped up and kicked the causing [her] to hyperextend [her] left shoulder. Medical attention where {sic} given to patient no further incident...."

Employee #5's written statement dated 06/22/2024, revealed: "...Pt refused to go to exam room for medication administration but was willing to go into [her] room. This nurse, second RN and to{sic}BHT staff members went into pt room to administer medications. Pt sat on [her] bed and then refused to take ordered meds. Pt was informed that [she] would be placed in a hold while medications were given and pt became extremely agitated...Pt used [her] feet to push against the wall and continued kicking. Once pt was facing the wall and continued kicking. Once pt was facing the wall [she] yelled "you f***ing hurt my arm" and BHT stated [he] heard a "pop." Medication administration was completed and pt was released. Pt sat on [her] bed and was tearful stating [her] arm hurt. Pts arm was assessed by [her] RN and provider notified. Pt was sent to ED for xray and exam...."

Employee #12's written statement dated 06/22/2024, revealed: "...Once pt was put in a hold to receive shots. Once pt was put in a hold [she] began to jerk [her] body around and kicking. As we moved out way towards the wall pt kicked [her] legs up and tried to push off wall. Once the pt did that you could hear a pop, immediately after the popping noise pt screamed "you hurt my arm". Pt then received shots and sat back down on bed as the nurses examined [her] arm...."

Patient #1's medical record contained a note titled "Nursing Note," dated 06/23/2024, which revealed: "...This writer called [Banner Del E. Webb] ER to get an update on this patient...an employee of [Banner] informed this writer that patient sustained left Humerus Fracture, and that the Social Workers will be investigating how [she] sustained this injury, that for the mean time, they were not comfortable send this patient back to Destiny Springs...."

Patient #1's medical record from [Banner Del E. Webb], contained a note titled "ED Pertinent Report," which revealed: "...Patient was then restrained by staff which caused sudden onset of pain of [her] left arm...I feel that the patient's presentation is most consistent with left midshaft spiral humerus fracture with angulation and shortening...I spoke with [Dr. Vu], [Banner Pediatric] Orthopedic Surgery, regarding the patient's case...States the patient will require plating but recommends following up in the clinic in 2 weeks...."

Patient #1's medical record from Banner Del E. Webb, contained a note titled "Diagnostic Radiology," which revealed: "...Elbow 3 or More Views Lt...Impression: Acute, spiral-type fracture of the left distal humeral diaphysis with medial angulation and posterior displacement...."

Employee #2 confirmed in an interview on 06/25/2024, Patient #1 was placed in a physical hold to receive an IM medication, and was injured during the hold and sent to the ED. Employee #2 also confirmed the injury was not included in the debriefing. Employee #2 further confirmed there were no actions taken by the hospital as a result of the event, and Employees #5, 7, 8, and 12, were not placed on administrative leave while an investigation took place. Employee #2 confirmed it was determined by the hospital the patient caused the injury by their actions during the restraint.

Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients were only placed in a physical restraint with an order from a licensed provider. This deficient practice poses the risk of a patient being physically restrained unnecessarily and a violation of patient rights.

Findings include:
Policy titled, "Seclusion and Restraint," revealed: "...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints....."

Video footage from the Monarch Unit, dated 06/22/2024, revealed:
19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14.

Video footage from the Lotus Unit, dated 06/25/2024, revealed:
Patient #8 was placed in a physical restraint at 19:48, by an employee, who was then relieved by Employee #18 and #21.
Patient #8 was placed in a physical restraint at 19:53, by Employee #18 for an undetermined amount of time as both exit the video field of view at 19:56 with physical hold still in place.
Patient #10 was placed in a physical restraint at 19:53 until 19:54, by Employee #7 and Employee #21.
Patient #11 was placed in a physical restraint at 19:53 until 19:54, by Employee #22 and Employee #23.

Restraint documentation and orders were requested for Patient #3, #4, #6, #8, #10, and #11 for these episodes, and none were provided.

Employee #2 confirmed in an interview conducted on 06/27/2024, Patient's #4, #6, and #3 were in a physical restraint for less than five minutes, therefore they are not required to have orders or restraint documentation.

Based on a review of hospital record and interview, it was determined the hospital failed to ensure restraint and seclusion orders were time limited and not used for a second episode of restraint and seclusion. This deficient practice poses the risk of a restraint and seclusion order being used as a PRN order or on an as needed basis.

Findings include:
Policy titled "Seclusion and Restraint," revealed: "... Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...If restraint or seclusion use needs to be continued beyond the expiration of the time-limited order, a new order for restraint or seclusion is obtained....."

Patient #7's medical record contained a note titled "Seclusion and Restraint Individual Reporting Form," dated 06/25/2024, which revealed: "...Personal Restraint...Start time: 1947 1st hold End time: 1948/ 2nd hold 2036-2037 1 minute...Seclusion...1st Seclusion...Start time: 1950 End time: 2027...Minutes: 37 minutes/2nd seclusion 2037-2122 55 minutes...Pt refused to follow directions and started to throw books at staff. Patient was taken to seclusion 2nd time...."

Patient #7's medical record contained a form titled "Physician Orders Seclusion and Restraint Order," dated 06/25/24, which revealed: "...Date and time order obtained: 6/25/24 1945...Order for: Seclusion; Personal Restraint; Chemical Restraint; Seclusion/Restraint start time 1947 for max 2 hours...."

An order for the second seclusion and restraint episode that began at 20:36 was requested and could not be provided.

Employee #4 confirmed in an interview conducted on 07/05/2024, there was not a provider order for the second seclusion and restraint episode. Employee #4 further confirmed that patient restraint and seclusion orders are good for two hours, so if the patient gets released from one restraint or seclusion incident, and need another one within the two hour time frame, a second order is not needed, they can still use the first order.

Based on a review of hospital record and interview, it was determined the hospital failed to ensure patients undergoing restraint, had a face to face evaluation. This deficient practice poses the risk of physical or psychological injury to the patient going unreported after a restraint is used.

Findings include:
Policy titled, "Seclusion and Restraint," revealed: "...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient's body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints....."

Video footage from the Monarch Unit, dated 06/22/2024, revealed:
19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14.

Restraint documentation and orders were requested for Patient #3, #4, and #6, and none were provided.

Employee #2 confirmed in an interview conducted on 06/27/2024, Patient's #4, #6, and #3, were in a physical restraint for less than five minutes, therefore they are not required to have the documentation required for a restraint.

Based on record reviews and staff interviews, it was determined the hospital failed to ensure there were sufficient numbers of nursing staff to provide patient care according to hospital policies and procedures for 13 shifts in the past 2 months. This deficient practice poses a risk to the health and safety of patients when there is insufficient staff on the units to meet patient needs, and resulting in inadequate monitoring of patients.

Findings include:
Policy titled, "Staffing/Acuity Plan," revealed: "...Determination of staffing needs based on scoring as follows: a. Review the Core Staffing Matrix which identifies the number of RN's and BHT's needed without acuity per unit per shift...RN assess each patient under the 5 categories...on a scale of 1 to 4 per the acuity plan...Each category is calculated and averaged to come up with the average score which equals acuity for the unit...The supervisor will reference the key below the average score on the acuity form in identify the next step in adding, deleting staffing...."

Document titled, "Core Staffing Nursing," revealed on night shifts, defined as 23:00 to 07:00, by the facility, each unit should have one RN and two BHTs, without factoring in acuity, if there are nine or more patients in the unit. The document also revealed four of the units, with the exception of the Monarch unit, should have two RNs and two BHTs for a census of six patients or more, for the afternoon shift, defined by the facility as 15:00 to 23:00, without factoring in the patient acuity.

Documents titled "Daily Assignment," were reviewed for 06/16/2024, through 06/25/2024, which revealed the following:
06/16/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift
06/17/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift
06/18/2024: 3 out of 5 units (excluding Lotus and Cicada), were staffed with one RN and one BHT, for night shift
06/19/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift
06/20/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift
06/21/2024: 4 out of 5 units (excluding Phoenix and Cicada), were staffed with one RN and one BHT, for night shift
06/22/2024: 4 out of 5 units (excluding Phoenix), were staffed with one RN and one BHT, for night shift
06/23/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift
06/24/2024: 2 out of 5 units (excluding Cicada, Phoenix, and Koi), were staffed with one RN and one BHT, for night shift
06/25/2024: 2 out of 5 units (excluding Cicada, Phoenix, and Koi), were staffed with one RN and one BHT, for night shift

Documents titled "Cicada Acuity," "Lotus Acuity," " Koi Acuity," Monarch Acuity," and "Phoenix Acuity," were reviewed for 06/16/2024, through 06/25/2024, which revealed "...Plan; Drop Staff: N...."

Employee #4 confirmed during an interview conducted on 07/02/2024, night shift staffing was not done according to the Core Staffing Nursing chart, and was short on staff.