Arizona State Hospital

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45202 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 A-0144: Failure to ensure a patient bathrooms were 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 and other hazardous sharp object. The facility further failed to comply with the plan of correction and IJ process. The egregious nature of this deficient practice and the failure of the facility to comply with the survey process by following their mitigation plan 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.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 45202 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 and health and safety concerns by having areas in which a patient could cut themselves. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients that could result in self asphyxiation and death. Sharp mirrors can be used to inflict self-harm and result in patient death by exsanguination. Findings include: Policy titled “Patient Rights and Responsibilities” last revised April 4, 2022, revealed, “...8. Patients at ASH have the right to: a. Be safe in their surroundings...” Observations during an on-site tour in the Palo Verde North and East Units on October 8, 2024, revealed patient bathrooms with sink faucets not flush with sink allowing for a tie-off point and mirrors with excessively sharp corners. A second tour on October 15, 2024, revealed Patient toilet tanks not flush creating tie-off points and patient bathroom grab bars not flush, on tiles at grout points not caulked, creating tie-off points. Employee #3 and Employee #4 confirmed during a joint interview on October 8, 2024, that patient areas had not been maintained in a manner to decrease patient physical injury risk. Employee #3 and Employee #4 acknowledged the findings on tour on October 15, 2024.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 42929 Based on observation, interview, and document review, it was determined the facility staff failed to ensure patients receive care in a safe setting. Specifically, five (5) of five (5) seclusion or restraint rooms contained mirrors made of plexiglass, that had sharp edges, mounted on the interior wall of the rooms. Findings: On 02/27/2024 at 10:00 a.m., surveyors toured five (5) seclusion or restraint rooms on three (3) psychiatric units of the facility, with Staff Member (SM) 4 and SM2. Each of the five (5) rooms had two (2) long mirrors made of plexiglass, adhered horizontally on the back wall of each room. The mirrors were adhered to the walls with tamper-proof screws and the edges of the mirrors were lined with “anti-pick” caulk (caulk that is flexible yet hard-setting to resist picking apart or tampering - grainger.com). The top of the mirrors, which were within reach of patients, in all five (5) rooms, had sharp edges that were not beveled. When touching the edges of the mirror in the first restraint/seclusion room observed, one (1) surveyor was cut on the hand by the mirror. When asked about the mirrors, SM4 stated their deeming organization advised the mirrors’ edges should be beveled to ensure the patients would not be injured. On 02/28/2024 at 12:21 p.m., the surveyors discussed the sharp edged mirrors with SM2. SM2 agreed that the mirrors were unsafe, and the administration team was discussing their removal. A review of the facility policy titled “PATIENT RIGHTS AND RESPONSIBILITIES” (effective April 4, 2022) states in part: “Patients at ASH have the right to: Be safe in their surroundings...””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(1) Training intervals. Staff must be trained and able to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion- (i) Before performing any of the actions specified in this paragraph; (ii) As part of orientation; and (iii) Subsequently on a periodic basis consistent with hospital policy. This Standard is not met as evidenced by: 45736 Based on personnel record review, facility policy review and interview, it was determined the facility staff failed to ensure that nine (9) of twelve (12) staff members (SM) were trained according to facility policy in the application of restraints, implementation of seclusion and monitoring, assessment; and providing care for patients in restraint or seclusion. (SM15, SM18, SM19, SM26, SM27, SM28, SM29, SM30, SM31). The findings include: The surveyors conducted a review of personnel records on 2/28/24 at 8:55 a.m. The review revealed that nine (9) of twelve (12) facility personnel did not have up to date non-violent crisis intervention (NVCI) and restraint application training. The staff members who did not have up to date NVCI and restraint application training were required to have mandatory training based on their position at this facility and greater than ninety (90) days had passed since their due date. In an interview with Staff Member 2 (SM) on 2/28/24 at 12:20 p.m., SM2 told the surveyor that there was a policy change in July of 2023. Before the policy change, not all positions listed in the policy were required to have annual NVCI and restraint application training. There were some changes in staffing in this facility’s education and training department and this “just fell through the cracks.” A review of the facility policy titled “Staff Development and Training” (effective date July 28, 2023) states in part: “D. MANDATORY TRAINING: 1. All employees are responsible for completing the mandatory training (Attachment 1) applicable to their position....Attachment 1: Nonviolent Crisis Intervention (NVCI) and Restraint Application Training: Rehabilitation, Psychology, Social Work, Psychiatry and Medical Providers, Security, Quality, Nursing ...*****In the event that a staff member has not completed the Refresher course by his/her due date, and more than 90 days have passed since the due date, the staff member will need to complete the initial, full NVCI and Restraint Application course.””