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

Cross reference A0117: Failure to ensure ensure a patient or patient's representative received a written copy of their patient rights for six (6) of 11 patients.

Cross reference A0131: Failure to inform patients that there was not an MD/DO present at the hospital 24/7.

Cross reference A-0144: Failure to ensure a patient bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk.

Cross reference A-0160: Failure to record and monitor as a restraint, the use of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition, and therefore did not follow proper procedures and protocols for a chemical 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 facility policy and procedure, medical record review and employee interview, the Department determined the administrator failed to ensure a patient or patient's representative received a written copy of their patient rights for six (6) of 11 patients. This deficient practice poses the potential risk that patients or patient representatives are not informed of their rights at the time of admission.

Findings include:

Facility policy titled "Patient Rights" revealed "...This facility informs each patient, patient's guardian, and/or patient's family when appropriate, of the patient's rights, in advance of furnishing or discounting patient care whenever possible. The rights are discussed during admission, a copy is furnished in the patient handbook, and they are posted throughout the hospital units..."

Facility policy titled "Intake Admission Process" revealed "...III. Protection of the Patient's rights at admission: ...a. Upon admission, each patient, or when appropriate, the patient's representative, is informed, [sic] of the patient's rights, in advance of furnishing or discounting patient care whenever possible...."

Medical records review conducted on August 28, 2024, revealed no evidence that patient rights were received by Patients #8. #18, #21, #22, #23, and #35.

Employee #3 confirmed during an interview conducted on August 28, 2024, that there was no documentation present in medical records that Patients #8. #18, #21, #22, #23, and #35 received a copy of their patient rights.

Based on the review of documents, observations on tour, and interviews, the Department determined the hospital failed to inform patients that there was not an MD/DO present at the hospital 24/7. The deficient practice poses a potential risk to patients that may compromise the quality and safety of patient care.

Findings include:

Hospital documents included a Patient Packet that is provided to patients upon admission. Review of the packet did not include notification to patients that there was not an MD/DO on-site 24/7. Review of patient medical records revealed no documentation of notification of provider coverage.

Observations on tour conducted on August 30, 2024 included the hospital lobby and intake area. Patient rights were posted in the hospital's intake area. There was no notice informing patients that there was not an MD/DO on-site 24/7.

Employee #2 and Employee #3 confirmed during an interview conducted on August 30, 2024, that the hospital does not have a hospital posting to notify patients that there is no MD/DO present on-site 24/7. The hospital does not provide patients with a written notification that there is no MD/DO present at the hospital 24/7.

Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bedroom and bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients.

Findings include:

Observation on August 28, 2024, revealed the facility's non-compliance with State licensing requirements for environmental standards and physical plant standards to protect the health and safety of patients receiving treatment at the facility. Ligature risks were identified during the facility tour that included;

1. Patient bedroom internal door knobs were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point.
2. Six patient bathroom mirrors were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point.
3. Three soap dishes in patient bathrooms were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point.
4. All patient bathroom shower heads were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point.
5. Patient bedroom and bathroom light switches (13) were not installed flush with the wall and did not have pick resistant caulk if not flush, creating a tie off point and possible access to electrical.

Document titled "EOC Safety and infection Control Minutes" for April 2024 to June 2024, did not identify the issues.

Interview with Employee #2, Employee #3 and Employee #4 confirmed in an interview on August 28, 2024, that the above identified ligaures were not addressed.

Based on facility policy and procedure, review of facility medical records, document request and employee interview, the Department determined the administrator failed to record and monitor as a restraint, the use of a drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition, and therefore did not follow proper procedures and protocols for a chemical restraint. This deficient practice poses a risk to patient health and safety including possible death if a patient is not properly monitored after a chemical restraint.

Findings include:

Facility policy titled "Seclusion and Restraint" revealed "...Procedure: ...E. The patient shall be monitored and reassessed through continuous in-person observation, documented on the restraint/seclusion checklist...."

Facility medical record review revealed the following:

Patient #23 - Document titled "RISK INCIDENT REPORT - CONFIDENTIAL REPORT OF OCCURRENCE" revealed "...Date of Occurrence: 3/1/2024...Patient was in therapy room with (unidentified employee). Patient seen through window throwing computer off desk...Follow up Action Taken: ...Psych provider notified and orders for B52 were given. Orders read back and verified with provider...." No documentation was provided confirming monitoring and assessment of Patient #23.

Patient #33 - Document titled "Progress Note 02/29/2024 15:44" revealed "...Pt was upset that he/she wasn't receiving pudding as his/her snack. BHT attempted to explain why there was no pudding and pt started yelling and showing staff his/her gums. Pt started yelling at BHT and head butt him/her on the head. Pt took PO B52 and told (Employee #21) that he/she would inform us if he/she started to get agitated with any peers or staff...." No documentation was provided confirming monitoring and assessment of Patient #33.

Restraint packet documentation for Patients #23 and #33 for the aforementioned incidents was requested, none was provided.

Employee #3 confirmed in interviews conducted on August 28, 2024 and August 29, 2024, that no restraint packet documentation including documentation of monitoring and assessment was completed for Patient #23 and Patient #33.

Based on the review of records and staff interviews, it was determined that the Medical Staff failed to provide quality patient care as stated in the by-laws as evidenced by:

0340: Failed to periodically conduct appraisals of its members.

0358: Failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations.

0454: Failed to ensure practitioner orders were completed and signed as determined by medical staff rules and regulations.


The cumulative effect of these systemic problems resulted in the medical staff's inability to ensure the provision of quality patient care.

Based on review of Medical Staff Bylaws, credential files and staff interviews, it was determined the medical staff failed to periodically conduct appraisals of its members. This deficient practice can result in practitioners not being provided oversight resulting in inappropriate patient care and operating outside their scope.

Findings include:

Review of the Medical Staff Bylaws revealed: "...Develop criteria to be used for evaluating the performance of Practitioners when issues affecting the provision of safe, high quality patient care are identified and develop criteria that determine the type of performance monitoring to be conducted...."

Policy titled "OPPE/FPPE" states "...Ongoing professional practice evaluation is conducted continuously and reported to the Medical Executive Committee for review and action...The Medical Executive Committee meets quarterly. The frequency of ongoing professional practice evaluations at ABHC is three eight month periods in order to accrue 3 OPP'E reports for review at the two-year approval period...."

Interview with Employee #10 confirmed that he conducts "quarterly reviews of all providers."

Review of credential files for 5 of 5 providers (Employee #11, 12, 13, 14, & 15) revealed one written appraisals in their files during a 2 year period for titled "Q3 2023 Peer Review."

Employee #10 & #16 confirmed in an interview on August 29, 2024, that no other appraisals were available to review.

Based on facility policy and procedure, facility documents and employee interview, the Department determined the administrator failed to ensure a History and Physical examination was completed within the timeframe determined by medical staff rules and regulations. This deficient practice poses the risk that patients will not receive timely healthcare services, leading to potential injury or death.

Findings include:

Facility policy titled "Medical Staff Bylaws, Rules and Regulations" revealed "...History & Physical Examination: ...A complete admission History and Physical examination shall be written or dictated within twenty-four (24) hours of the patient's admission to the Hospital and signed within 48-hours or next visit, whichever comes first...."

Review of facility patient medical records revealed the following:

The medical record for Patient #17 documented an admission date and time of March 30, 2024 at 15:28. Review of document titled "History and Physical Exam 03/31/2024 12:38" revealed an electronic signature by Employee #17 at "...03/31/2024 19:54..."

The medical record for Patient #16 documented an admission date and time of June 14, 2024 at 01:33. Review of document titled "History and Physical Exam 06/14/2024 23:47" revealed an electronic signature by Employee #18 at "...06/16/2024 09:05..."

Employee #3 confirmed during an interview conducted on August 29, 2024, that the History and Physical examinations for Patients #16 and #17 were electronically signed by the completing providers after 24 hours of both patient admissions.

Based on facility policy and procedure, facility documents and employee interview, the Department determined the administrator failed to ensure practitioner orders were completed and signed as determined by medical staff rules and regulations. This deficient practice poses the risk that the person authenticating another practitioners' orders will not know if the correct infomarmation was taken down by the transcribing RN for verbal orders.

Findings include:

Facility policy titled "Medical Staff Bylaws, Rules and Regulations" revealed "...All orders, either verbal or dictated over the telephone, shall be signed by the duly authorized person, to whom it was dictated, indicating the name of the Practitioner per his or her own name. These orders shall be read back to the Practitioner. The responsible Practitioner shall authenticate oral orders within 48 hours or the next visit, whichever occurs first...."

The medical record for Patient #11 revealed the following:

Document titled "Order to Admit, once, until further notice" that states "...Duration: Until further notice, start date: 03/21/2024 20:30...Ordered by (Employee #10)...Entered by (Employee #23)...Order Review (Employee #19)...03/22/2024 10:09..." The Order Review by Employee #19 contained an electronic signature.

The medical record for Patient #12 revealed the following:

Document titled "Order to Admit, once, until further notice" that states "...Duration: Until further notice, start date: 03/11/2024 12:00...Ordered by (Employee #19)...Entered by (Employee #24)...Order Review (Employee #11)...03/12/2024 11:08..." The Order Review by Employee #11 contained an electronic signature.

The medical record for Patient #33 revealed the following:

Document titled "Order to Admit, once, until further notice" that states: "...Duration: Until further notice, start date: 02/20/2024 14:30...Ordered by (Employee #19)...Entered by (Employee #20)...Order Review (Employee #11)...02/21/2024 18:10..." The Order Review by Employee #11 contained an electronic signature.

Document titled "Lorazepam, 2mg x 1 tablet, oral, tablet, once, for 1 day" that states "...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58..." The Order Review by Employee #19 contained an electronic signature.

Document titled "Diphenhydramine Hcl, 25mg x 2 tablet, oral, tablet, once, for 1 day" that states "...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58..." The Order Review by Employee #19 contained an electronic signature.

Document titled "Haloperidol, 5mg x 1 tablet, oral, tablet, once, for 1 day" that states "...Duration: 1 day, start date: 02/29/2024 15:30, end date: 03/01/2024...Ordered by (Employee #10)...Entered by (Employee #21)...Order Review (Employee #19)...03/01/2024 08:58..." The Order Review by Employee #19 contained an electronic signature.

The medical record for Patient #34 revealed the following:

Document titled "Order to Admit, once, until further notice" that states "...Duration: Until further notice, start date: 03/18/2024 06:45...Ordered by (Employee #10)...Entered by (Employee #22)...Order Review (Employee #18)...03/18/2024 23:40..." The Order Review by Employee #18 contained an electronic signature.

Employee #3 confirmed during an interview conducted on August 29, 2024, that the aforementioned practitioner orders for Patients #11, #12, #33 and #34 were given verbally by practitioners who did not authenticate their own verbal orders.

Based on policy and procedure, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, observation, and interview, the Department determined that the hospital failed to ensure:

1. The kitchen was maintained and cleaned without leading pipes
2. Food was not kept past it's expiration
3. Food was not cross contaminated
4. Spills were cleaned
5. Food removed from its original container was dated and labeled
6. Temperatures logs were not being kept daily

The cumulative effect of these deficient practices poses a high potential risk of harm to patients and other individuals who may consume food that was stored and prepared in the facility kitchen in unsanitary equipment and environment if the facility does not follow guidelines set forth in dietary guidelines.

Findings include:

The Arizona Administrative Code (9 A.A.C. 8, Article 1) requires: "...ARTICLE 1. FOOD ESTABLISHMENTS...R9-8-101. Purpose and Definitions...A. The Department incorporates by reference the United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration and shall comply with the 2017 Food Code (FC) as specified in this Article. This incorporation by reference contains no future editions or amendments. The incorporated material is on file with the Department and is available for order at:
https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm239035.htm, refer to publication number IFS17...."

The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: "...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris...."

Facility policy titled "Food and Nutrition Services" revealed "...Policy: ...It is the policy of the facility to ensure safe and sanitary food service operations, including storage, handling, preparation, and distribution of food...Procedure: ...4. All food preparation areas, equipment, dishes, and utensils are appropriately cleaned and sanitized after use in accordance with local health guidelines...5. All perishable food and drinks for patient use will be stored in kitchen or unit refrigerators and labeled with the date of delivery to the unit. Staff shall monitor the unit refrigerators and remove any item that is not dated, labeled with a patient name if open, or appearing unfit for patient consumption...."

Observation of kitchen area during on-site tour conducted on August 27, 2024, revealed the following:

General kitchen preparation area:
Metal drainage pipe underneath sink with blue-green discoloration leaking at the L-joint, dripping water into a metal food service pan sitting on the floor.

Dry food storage area containing:
1. One can of El Pato Salsa de Chile Fresco with a date stamp of "Best By 02/23/24."
2. Three cans Embasa Chipotle Peppers with a date stamp of "Best By May 2022."
3. A bin of Flour dated "10/03/23 3:36 PM" Employee #4 confirmed that the shelf life of Flour outside its original container is not more than 30 days.
4. A bin of Sugar dated "10/03/2023 3:36 PM" Employee #4 confirmed that the shelf life of Sugar outside its original container is not more than 30 days.

Walk-in cooler revealed:
1. Multiple individually wrapped foods, removed from their original packaging, that did not have expiration dates and were without attached or posted dates when food items were removed from their original packaging.
2. A metal sheet pan with multiple food containers on it and an unidentified red-colored liquid pooled on the sheet pan surface.
3. Another sheet pan in the walk-in cooler had a partially used tube of hamburger meat wrapped in cellophane on it and a red-colored liquid coming from the wrapped meat and pooling in one corner of the pan.

Temperatures:
1. Daily Kitchen Dishwasher Temperature Log was not completed since 8/22/2024.
2. Daily Holding Refrigerator Temperature Log was not completed since 8/25/2024.
3. Daily Freezer Temperature Log was not completed since 8/25/2024.

Employee #4 confirmed in an interview conducted during the on-site tour conducted on August 27, 2024, that the metal drainage pipe was leaking and in need of repair, that the aforementioned food items were either expired or not stored according to policy, temperatures logs were not completed daily, and that sheet pans used for food storage had not been cleaned and that food for patient use was exposed to potentially contaminated liquid.