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Based on record reviews, observations, and staff interviews, it was determined the administrator failed to ensure the seclusion of a patient (Patient #16) occurred in a seclusion room approved by the Department. This deficient practice poses the risk of patients being confined and secluded in a room that is not safe and designed for seclusion, and causes confusion to patients whether they are allowed to leave the room.

Findings include:

Review of the hospital's Arizona Department of Health Services (AZDHS) licensing file revealed no documentation that the Department approved the small day room in the Cholla unit as a seclusion room.

Patient #16's medical record dated 04/16/2024 identified a nursing note, and it revealed: " ...Patient came out of [her] room to engage with peers in hallway refusing redirection by staff. Patient began to hit [her] head against the wall. Staff restrained patient and transferred [her] to Cholla ....Patient secluded to stay in small day room at 2106 and [she] proceeded to pick at scabs making [herself] bleed and threaten staff when preventing [her] from continuing ...."

Patient #16's medical record dated 04/16/2024 revealed a seclusion order for two hours.

Patient #16's medical record dated 04/16/2024 identified a behavioral seclusion restraint flowsheet, and it revealed Patient #16 was placed in seclusion in the small day room of the Cholla unit at 2106 hours, and released at 2118 hours.

Observations on tour of the Cholla unit on 06/03/2024 revealed the small day room required key access to enter. The room had three non-reclining chairs, glass window across the room from the door, and walls that were not padded.

Employee #1 confirmed during an interview on 06/03/2024 that Cholla unit was empty with no inpatients on 04/16/2024. Employee #1 also confirmed Patient #16 would get agitated surrounded by peers, and often times need time alone away from their peers. Employee #1 and Employee #4 confirmed Patient #16 was removed from their peers, and secluded in the small day room of the Cholla unit.

Based on record reviews and staff interview, it was determined the hospital failed to ensure trained registered nurses, who conducted the face-to-face evaluation after two restraint/seclusion episodes, consulted with the attending physician as soon as possible for a patient (Patient #16). This deficient practice poses a risk to the health and safety of patients when the attending physician is not consulted of the patient's medical and behavioral condition after a restraint/seclusion episode.

Findings include:

Policy titled, "Restraint", revealed: " ...Procedure ...8. A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status ...."

Policy titled, "Seclusion", revealed: " ...Procedure ...7. A practitioner or registered nurse shall conduct an in-person evaluation of the patient within one hour of initiation of seclusion to assess physical and psychological status ...."

Document titled, "Rules and Regulations of the Medical Staff", revealed: " ...9.2 Restraints or Seclusion Used for Emergency Behavior Management Reasons ...A Practitioner or specifically trained registered nurse must see and evaluation the need for the Restraints or Seclusion within one (1) hour after initiation of the Restraints or Seclusion and upon being released from Restraints or Seclusion ....In the event that a registered nurse conducts the evaluation required by this section, the Attending Physician must be consulted as soon as possible ...."

Patient #16's medical record dated 04/16/2024 revealed they were placed in physical restraint at 2104 hours, and seclusion from 2106 to 2118 hours. Review of the face-to-face evaluation revealed it was performed on 04/16/2024 at 2118 hours by a registered nurse. Further review of the face-to-face evaluation revealed no documentation that the attending physician was consulted after the evaluation was completed.

Patient #16's medical record dated 04/17/2024 revealed they were placed in physical restraint at 2024 hours, and seclusion from 2025 to 2220 hours. Review of the face-to-face evaluation revealed it was performed on 04/17/2024 at 2124 hours by a registered nurse. Further review of the face-to-face evaluation revealed no documentation that the attending physician was consulted after the evaluation was completed.

Employee #4 confirmed during an interview conducted on 05/31/2024 that there was no documentation the registered nurses, who performed the face-to-face evaluations on Patient #16, consulted with the attending physician after the completion of the evaluations.