Sonora Behavioral Health 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 A0117: Failure to ensure a patient or patient’s representative received a written copy of their patient rights. Cross reference A-0144: Failure to ensure a patient bathroom, bedroom and seclusion room 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. The egregious nature 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.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a)(1) A hospital must inform each patient, or when appropriate, the patient’s representative (as allowed under State law), of the patient’s rights, in advance of furnishing or discontinuing patient care whenever possible. This Standard is not met as evidenced by: 45202 Based on review of policies and procedures, medical records, and staff interview, the Department determined the administrator failed to ensure consents were completed for two patients in advance of furnishing or discontinuing patient care. This deficient practice poses the potential risk of patients receiving services they did not consent to. Findings include: Review of policy #RI 01, titled “Patient Rights and Responsibilities” last revised December 2023, revealed “...2. The Patient Rights and Responsibilities acknowledgment form shall be signed and placed in the patient ’ s medical record...Each patient has the right to...18. To give general consent and, if applicable, informed consent to treatment....” Review of Patient #1’s medical record revealed Patient #1 was admitted to the licensed facility involuntarily on August 6, 2024. Further review revealed Patient #1 was granted a voluntary status at the licensed facility on August 8, 2024 at 9:46am. A request was made for evidence of Patient #1’s Patient Rights and General Consent upon Patient #1’s voluntary status. None was provided. Review of policy #RI 23b, titled “Overflow Patients” last reviewed December 2023, revealed “...1. Patient may be placed in overflow space in the event of...clinical emergency. This will also require patient of (sic) guardian consent....” Review of Patient #3’s medical record on September 10, 2024 and September 11, 2024 revealed a “Progress Note” dated August 12, 2024, that states “...Patient was punched in the face and then slammed into the wall...A sleepout order was placed to prevent any further incidences....” Employee #1 confirmed the term “sleepout order” does not indicate an order is needed by a physician. A request was made for evidence that Patient #3 gave consent for the sleepout, per policies and procedures. None was provided. Employee #1 confirmed an interview conducted on September 10, 2024 and September 11, 2024, that Patient #1’s medical record did not contain evidence of signed Patient Rights or General Consent. Employee #1 also confirmed that Patient #3’s medical record did not contain evidence of consent for the sleepout that occurred on August 12, 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: 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. 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 as well as ingesting potentially hazardous materials or using items to inflict self harm. Findings include: Observation on September 10, 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 and/or health and safety conditions were identified during the facility tour that included; 1. Patient bathroom sinks (Approximately 40) not flush with the wall creating a tie-off point. 2. Seclusion bathroom sinks (6) not flush with the wall creating a tie-off point. 3. Patient bedroom wall racks and door frames with non tamper resistant screws creating a self harm hazard. 4. Patient bathroom caulking not flush with the wall and shower wall panel and easily able to be removed creating a ligature and opportunity for patients to ingest potentially hazardous substances. Document titled “Environmental rounds” for June, July and August 2024, did not identify the issues with bathrooms ligatures and the form does not address ligatures. Interview with Employee #1, Employee #3 and Employee #26 confirmed in an interview on September 10, 2024, that the above identified ligatures and health and safety conditions were not addressed.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 45202 Based on facility policy, medical record review and staff interview, the Department determined that the Director of Nursing failed to ensure nursing services were provided as ordered for observation status for sexually acting out. This deficient practice can result in a patient not being properly observed and can result in patient harm, sexual assault or death. Findings include: Sexually acting out precautions: Facility policy #PC 30, titled “Precautions,” last reviewed and approved December 2023, states “ ...when a patient is placed on precautions, the Observations Rounds Forms ...will be revised to reflect the precautions ordered ....” Patient # 13 was placed on Sexually Acting Out (SAO) precautions on August 2, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 4, 2024. Patient # 14 was placed on SAO precautions on August 2, 2024. Observations Rounds Form did not reflect that SAO precautions were implemented at any time until the time of survey exit on August 12, 2024. Patient # 15 was placed on SAO precautions on August 7, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 8, 2024. Patient # 16 was placed on SAO precautions on August 7, 2024. Observations Rounds Form indicated that SAO precautions were not implemented until August 8, 2024. Employee # 8 confirmed in an interview on September 10, 2024, that Sexually Acting Out precautions were ordered for patient # 13, patient # 14, patient # 15, and patient # 16 by a physician and were not implemented as ordered timely.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 45202 Based on review of facility policies and procedures, medical records, and employee interview the Department determined the Administrator failed to ensure that patient care plans were updated with any changes to the patient’s care plan and accurately reflected the patient’s status and current goals. This deficient practice poses a potential risk to the health and safety of the patient when the patient’s treatment plan is not re-evaluated and updated accurately after a qualifying event to determine whether the current treatment plan is effective or needs to be modified per facility policy. Findings include: Policy titled “Treatment planning” policy #PC 01, reviewed January 2024, states “...Modifications or additions made to goals and interventions, as appropriate, and whenever a significant event or change in condition arises...at a minimum every 7 calendar days...Significant change in medical, cognitive or behavioral status that requires changes in the interventions....” Patient #13’s Care Plan dated August 5, 2024 was updated after the patient was placed on Sexually Acting Out (SAO) precautions. However, the care plan was not marked as “Yes” for SAO precautions. Patient #14’s Care Plan dated August 2, 2024 was not updated after the patient was placed on Sexually Acting Out (SAO) precautions on August 2, 2024. A care plan update was completed on August 7, 2024 while Patient #14 remained on SAO precautions however, the care plan was marked as “No” for SAO precautions. Patient #16’s Care Plan dated August 7, 2024 was not updated after the patient was placed on Sexually Acting Out (SAO) precautions on August 7, 2024. A care plan update was completed on August 12, 2024 while Patient #16 remained on SAO precautions however, the care plan was marked as “No” for SAO precautions. Interview with Employee #8 on September 11, 2024, confirmed that the care plan for Patient #13 did not reflect an accurate update of the SAO precautions, and the care plan for Patient #14 & #15 were not updated when the patient was placed on SAO precautions and when an update was completed they did not accurately reflect the SAO precautions.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 43788 Based on review of documents, observations and interviews, it was determined the Governing Body failed to ensure that hospital operations, functions, and responsibilities were monitored and evaluated to be able to provide a safe and healthy environment for the patient population. This deficient practice poses the risk of the Governing Body being unaware of the overall function and management of the hospital and the inability to improve patient care services. Findings include: Cross reference: A0021: Failure to ensure staff notified law enforcement of a sexual assault of a minor patient A0022: Failure to ensure the facility did not admit patients to units in excess of their licensed capacity for the service offered in that unit A0049: Failure to ensure that medical staff recognized and responded to a patient’s suicide attempt (Patient #38). A0057: Failure to ensure failed the Chief Executive Officer managed the daily operation of the hospital. A0144: Failure to ensure: 1. a patient was provided a medical examination and treatment after a suicide attempt. (Patient #38) 2. 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. A0145: Failure to ensure staff notified law enforcement of a sexual assault of a minor patient. A0213: Failure to notify CMS of a death of a patient who died within a half hour after receiving a chemical restraint (Patient #9). A0395: Failure to ensure: 1. staff conducted complete observational rounding of patients on the Santa Rita unit which poses a risk to the health and safety of patients if staff are not thoroughly monitoring sleeping patients. 2. a patient was assessed and monitored after being placed in a physical restraint and receiving a chemical restraint (Patient #9). This failure poses the risk of a patient suffering injury or death without the proper assessments performed, or being restrained unnecessarily. The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for the Condition of Participation for Governing Body.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 43788 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: 1. a patient was provided a medical examination and treatment after a suicide attempt. (Patient #38) 2. 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-0145: Failure to ensure staff notified law enforcement of a sexual assault of a minor patient. Cross reference A-0213: Failure to notify CMS of a death of a patient who died within a half hour after receiving a chemical restraint (Patient #9). 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.”

“COMPLIANCE WITH LAWS CFR(s): 482.11(a) The hospital must be in compliance with applicable Federal laws related to the health and safety of patients. This Standard is not met as evidenced by: 43788 Based on document review and interview, it was determined that the administrator failed to ensure staff notified law enforcement of a sexual assault of a minor patient which has the high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility. Findings include: The policy titled “Abuse, Exploitation or Neglect Reporting - Child or Vulnerable Adult” requires: “...In cases of recent sexual abuse/assault, within 72 hours the patient will be referred to the emergency room for SARs evaluation....Reports will be called in to Child Protective Services and Pima County Sheriff’s Department as mandated by law....” The incident report dated [09/28/2023] revealed: “...[Patient (#5) reported roommate (Patient #8) walked toward (Patient #5) while (Patient #5) was laying (sic) in bed. (Patient #5) reports (Patient #8) then said a few words before putting his penis in (Patient #5’s) mouth]....” Patient #5’s medical record dated [09/29/2023] revealed: “...On call provider notified and order received to separate them (Patient #5 and Patient #8) and for follow up today...DCS [#10415478]...The family notified they have the option to contact police if they would like....” Employee #3 confirmed on 04/22/2024, that the facility did not report this case to law enforcement as outlined in the facility policy.”

“LICENSURE OF HOSPITAL CFR(s): 482.11(b) The hospital must be - o Licensed; or o Approved as meeting standards for licensing established by the agency of the State or locality responsible for licensing hospitals. This Standard is not met as evidenced by: 43788 Based on document review, observation, and interview, it was determined that the administrator failed to ensure the facility did not admit patients to units in excess of their licensed capacity for the service offered in that unit which poses a potential risk of impacting the quality of patient care provided. Findings include: The Arizona Department of Health Services licensing file revealed: “...Rincon - 10 beds (MOSU)...Santa Rita - 20 beds (MOSU)...Tortalita - 22 beds (adolescent)...Catalina - 12 beds (adolescent)...Pima - 18 beds (adults)...Sabino - 20 beds (adults)...Havasu - 18 beds (adults)...Madera - 20 beds (adults)....” The facility policy titled “Overflow Patients” requires: “...It is the policy of Sonora Behavioral Health (SBH) that all individuals that meet Admission criteria when unit needed is at capacity or approaching maximum capacity may be placed as an ‘overflow’ patient with guardian or patient consent...Spaced (sic) utilized as overflow should be limited to less than 24 hours and may be determined by patient preference and clinical consideration....” Observation on 04/22/2024 at 0400 revealed Patient #21 sleeping on a cot in the day room on Pima unit. Review of the facility “Census Report” dated 04/22/2024 at 0339 revealed that Pima unit has a total of (9) double occupancy bedrooms (rooms 501 - 509) for a total of (18) beds on the unit. One bed was blocked decreasing the unit capacity to (17). Patient #21 was listed on the census report as located/assigned to bed/room number 599. Employee #4 confirmed on that the room number 599 designation meant the patient was “sleeping out” on a cot in a common area on the unit. S/he confirmed that patients on “sleep out” are not assigned to a room with a designated bed, bathroom, and shower and are awaiting a bed assignment pending the discharge of another patient. Review of the “Census Report” dated 10/04/2023 revealed that Patient #28 was located/assigned to bed/room number 299 on Rincon unit. The unit had two blocked beds decreasing capacity to 8 with a total of 9 patients on the unit. Review of the “Census Report” dated 10/04/2023 revealed that Patient #29 and #30 were located/assigned to bed/room number 499 A and B respectively on Tortalita unit. The unit had two blocked beds decreasing capacity to 20 with a total of 22 patients on the unit. Review of the “Census Report” dated 10/17/2023 revealed that Rincon unit has a total of (5) double occupancy bedrooms (rooms 201 - 205) for a total of (10) beds on the unit. Patient #23 was listed on the census report as located/assigned to bed/room number 299 with a total of 11 patients housed in the 10-patient unit. Review of the “Census Report” dated 10/30/2023 revealed that Santa Rita unit has a total of (10) double occupancy bedrooms (rooms 101 - 110) for a total of (20) beds on the unit. Patient #22 was listed on the census report as located/assigned to bed/room number 199 with a total number of 21 patients housed in the 20-patient unit. Review of the “Census Report” dated 10/31/2023 revealed that Patient #6 was located/assigned to bed/room number 199 on Santa Rita unit. The unit had two blocked beds decreasing capacity to 18 with a total of 19 patients on the unit. Employee #1 and 2 confirmed that patients assigned to room numbers designated ending in “99” are assigned to sleep in a cot in a common area. Additionally, they confirmed that the facility admitted the above listed patients to each unit over the licensed capacity for each of those units/organized services.”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 43788 Based on review documents and staff interview,it was determined the administrator failed to ensure that medical staff recognized and responded to a patient’s suicide attempt (Patient #38). The deficient practice poses a risk to the health and safety of patients when medical staff do not identify and treat a potential life-threatening changes in a patient’s condition. Findings include: Document titled, “Rules and Regulations of the Medical Staff of Sonora Behavioral Health”, revealed: “...The Attending Physician has the ultimate responsibility for providing a diagnostic impression of each patient as required hereunder and for supervising the care of the patient in the Hospital...The decision to transfer a patient in the event of a medical emergency is the responsibility of a practitioner and a written order will be obtained. In the event the 911 Emergency response Team is contacted, the patient will be transferred according to EMS protocol....” Review of Patient #38 Seclusion/Restraint Progress Note dated 10/19/2023 revealed: “ ...on 18 October 2023 at approximately 2030 patient was in patient ’ s bathroom, the patient was observed face down on the floor near the door and under sink with seizure like movements. Staff initiated nursing care upon arrival patient was unresponsive to verbal command (baseline is selective muteness) visualized seizure like movements. ROM flaccid. Upon turning patient face up patient was on top of a towel and a towel string around patient ’ s neck and lips with dark discoloration. Towel string was double knotted with a tight grip first knot was removed and second know was difficult due to the tightness and no space between towel and skin. After removal of towel string patient gasped for air and coughed. Patient ’ s baseline is selective muteness and was not responding to verbal commands, eye movement and muscle spasms of legs noted. Patient ’ s vital signs obtained 145/84, pulse 134, oxygen 99% and temperature 98.2. Patient agreed to ambulate to bed, skin assessed redness to neck with scant skin lesions noted to right neck, cleaned with hydrogen peroxide open to air no other injuries noted or verbalized by patient. Psychiatrist notified placed on 1:1 monitoring, limit linens and unit restrictions orders entered. Zydis 10 mg OTD X1 order for mood stability ordered and administered no adverse effects assessed patient started talking with staff member on 1:1 and asked for snacks. No distress noted. Vital signs monitored. Contacted the following: (name) Guardian/Legal Representative: (phone number) “ mailbox is full and cannot except any messages ...Called DCS (phone number) spoke with (name) report #...Medical practitioner contacted and notified-no further orders received .... “ Review of Psychiatry Progress Note dated 10/19/2023 revealed: “...Patient seen, chart reviewed. Patient was seen in consult room with MSA and RN present. Case discussed with treatment team. S/he remains on a 1:1. Regarding this, s/he states: “I don’t think I need it “ ...When informed that s/he was found face down in bed last night d/t possible seizure, s/h responds,” I don’t know”...still tolerating medications well, although s/he refused Depakote yesterday .... “ Further review of Patient #38 medical record revealed no evidence of documentation that patient was seen and evaluated by a medical provider after the incident on 10/18/2023. Further review of the medical record revealed no suicide precautions or constant observations were implemented as per policy. Employee #1 confirmed on 4/23/2023 that staff did not implement all procedures required by hospital policies in regard to the incident with Patient #38. Employee #1 acknowledged that the medical staff did not evaluate the patient for seizure or injury from the attempted suicide.”

“CHIEF EXECUTIVE OFFICER CFR(s): 482.12(b) The governing body must appoint a chief executive officer who is responsible for managing the hospital. This Standard is not met as evidenced by: 43788 Based on review of hospital records, and interview, it was determined the Chief Executive Officer (CEO) 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: Cross reference: A0021: Failure to ensure staff notified law enforcement of a sexual assault of a minor patient A0022: Failure to ensure the facility did not admit patients to units in excess of their licensed capacity for the service offered in that unit A0049: Failure to ensure that medical staff recognized and responded to a patient’s suicide attempt (Patient #38). A0057: Failure to ensure failed the Chief Executive Officer managed the daily operation of the hospital. A0144: Failure to ensure: 1. a patient was provided a medical examination and treatment after a suicide attempt. (Patient #38) 2. 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. A0145: Failure to ensure staff notified law enforcement of a sexual assault of a minor patient. A0213: Failure to notify CMS of a death of a patient who died within a half hour after receiving a chemical restraint (Patient #9). A0395: Failure to ensure: 1. staff conducted complete observational rounding of patients on the Santa Rita unit which poses a risk to the health and safety of patients if staff are not thoroughly monitoring sleeping patients. 2. a patient was assessed and monitored after being placed in a physical restraint and receiving a chemical restraint (Patient #9). This failure poses the risk of a patient suffering injury or death without the proper assessments performed, or being restrained unnecessarily. The cumulative effect of these Condition level and Standard level deficiencies demonstrate the Chief Executive Officers inability to manage the day to day operation of the hospital.”

“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: 43788 Based on review of documents and staff interviews, it was determined the Hospital failed to ensure: 1. a patient was assessed and monitored after being placed in a physical restraint and receiving a chemical restraint (Patient #9). This failure poses the risk of a patient suffering injury or death without the proper assessments performed, or being restrained unnecessarily 2. a patient was provided a medical examination and treatment after a suicide attempt. (Patient #38)The deficient practice poses a potential risk to the patient’s health and safety if proper medical treatment and monitoring are not provided to a patient after an attempt at self-harm. 3. a patient bathroom ws 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: 1. Policy titled, “Seclusion and Restraint (Chemical and Physical)”, revealed: “... Chemical Restraint is defined as a drug or medication 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. These medications are used in addition to or in replacement of the patient’s regular drug regimen to control extreme behavior during an emergency...Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner. When medication categorized as chemical restraint is ordered the following actions will be taken: The RN will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion Assessment packet...The patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained registered nurse the chemical restraint has ended, based on assessment of the behavioral and medical condition of the patient. The nurse in charge will assign trained staff to continuously monitor the patient during the duration of the chemical restraint. Continuous means ongoing without interruption...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour after administration of the medication defined as chemical restraint to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or trained registered nurse will make a determination when the chemical restraint has ended based on the behavioral and medical assessment of the patient’s condition...The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring...The legal representative or an immediate family member as requested by the patient shall be promptly notified of the chemical restraint...All legal guardians will be notified of the chemical restraint...Physical Restraint: Physical restraint includes manual measures approved by Handle With Care (HWC) to limit or restrict body movement. Orders for use of physical restraint shall not exceed one hour for patients under 9 years of age, two hours for patients 9 to 17 years of age, 4 hours for adults 18 years of age and older...PROCEDURE: A trained Registered Nurse may initiate restraint without an order in the absence of a Practitioner when a patient poses an imminent danger to self or others. The attending/covering Practitioner will be contacted during the restraint or immediately (within a few minutes) of the initiation of the restraint to confirm and obtain orders to be written by a registered nurse...The order shall indicate the reason andmaximum duration of restraint...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion packet...Patients will be physically restrained in the supine position, unless contraindicated and in accordance with Handle with Care. Approved Handle with Care holds are considered a physical restraint...The patient shall be monitored and reassessed through continuous in-person observation and documented, at minimum, every 15 minutes. Continuous means ongoing without interruption. Monitoring to include the following: *signs of physical distress* Observed patient behavior* Offering fluids at minimum every hour* Vital signs-frequency will depend on patient condition and determined by RN assessment* offering opportunity for elimination every 2 hours* Evaluations of readiness for release from seculsion* Any other interventions...The Registered Nurse in charge will assign trained staff to continuously monitor the patient during the restraint event...Continuous means ongoing without interruption...A Practitioner or trained evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...The inperson evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condidtion and the need to continue or terminate the intervention...If the in person evaluation is conducted by a trained Registered Nurse, the Registered Nurse must consult with the attending/covering practitioner as soon as possible, but not to exceed one hour after completion of the inperson evaluation. Recommendations from the Pratitioner are to be documented on the Restraint/Seclusion Order...The Practitioner or the trained Registered Nurse will make a determination the restraint has ended based on assessment of the behavioral and medical condition of the patient....” Further review of the policy revealed no evidence of a designated timeframe/duration for monitoring of a patient receiving a chemical restraint, based on the chemical restraints side effects or half-life. Review of Patient #9 Seclusion/Restraint Packet dated 09/20/2023 revealed: “...Practitioner Order: Type:Physical Restraint; Chemical Restraint: Medication Haldol 10 mg IM Now X1, Ativan 2 mg IM Now X1, Benadryl 50 mg IM Now X1...Purpose: Threat to immediate physical safety of self; Threat to immediate physical safety of others...Maximum duration: Restraint 4 hours adults 18 and over...Criteria for release: No longer an immediate physical threat to self...No longer an immediate physical threat to others...Phone order at 9/20/2023 at 2015...Practitioner signed 09/21/2023 at 0900...Release from seclusion/restraint: Patient’s behavior and/or condition at time of release: Quiet, Calm, Cooperative...Date of release: 09/20/2023...Time of release: 2018...Initiation of Intervention: Date 09/20/2023, Time 2015, Face to Face assessment date 09/20/2023 time 2018...Patient’s immediate situation/reaction to restraint: pt initially aggressive and attempting to bang head, shove fingers up nose and calmed down when IMs were to be administered...Vitals: T 97.3, P 93, R 16, BP 110/72, pulse ox 95 RA ...9/20/20232015 called on call MD for further direction, advised on call MD of situation with new orders to administer Haldol 10mg IM, Ativan 2 mg Im and Benadryl 50 mg IM now...9/20/2023 2018 pt has been released from physical restraint and emergency IMs given at this time. Pt laying calm and quiet with even unlabored respirations. Restraint discontinued...Physical restraint time in 2016 time out 2018...chemical restraint time in 2017 time out 2018...Patient monitoring 2016 restraint seclusion initiated...2018 bp 110/74, resp16, pulse 93, t 97.3....” Further review of Patient #9 Seclusion/Restraint Packet dated 09/20/2023 revealed there was no continual monitoring of Patient #1 as required by hospital policy and procedure. Further review revealed nursing staff released the patient from restraint precautions within 3 minutes of receiving a chemical restraint. Employee #1 confirmed that there was no continual monitoring of Patient #1 after the chemical restraint had been administered and the patient was released from restraint precautions within 3 minutes of receiving a chemical restraint. 2. Policy titled, “ Incident Reporting-Risk Management Program”, revealed: “...Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day...If the incident involves a patient, staff must chart relevant information in the patient’s medical record. When documenting incidents in the medical records, staff will chart precisely what happened without making reference to an “error” or that an Incident Report was completed...Staff should immediately provide or coordinate appropriate care...Patient Injured - No Classification: Patient sustains an injury that may be accidental in nature and is not related to a fall while on the facility property (or during a facility outing off-site not related to a motor vehicle accident)...Self-Inflicted Injury: Any intentional or accidental injury inflicted on the patient by him/herself, or self- mutilation...Suicide Attempt: Any potentially life threatening or intentional self-destructive attempt by a patient that could result in his/her death or serious injury...Seizure: Patient presents with, or is observed experiencing, seizure like activity (observing a person in a convulsive state)...INCIDENT INTERVENTION It is the expectation that part of reporting the incident includes describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported requires that the interventions be identified. For example, any time that law enforcement is contacted, the facility must document who contacted the police and the subsequent police involvement...In States where the facility is required to report Tragic/Serious incidents to the State, it must be done within the State requirements and notification of completion to Corporate Risk Management and Corporate Clinical Services Departments...All Incident Reports received by the Risk Manager will be assigned a severity classification level in accordance with established Corporate Risk Management and Corporate Clinical Services criteria approved by the facility leadership and Board of Managers. The severity classification system will be utilized by the Risk Manager and facility leadership to identify significant incidents in an effort to facilitate referral of issues needing further evaluation and/or action to monitor failures in systems to improve the quality of care. The following severity classifications shall be used: Level I-Tragic: Incident which are considered sentinel or considered tragic in nature. Level II - Serious: Major injury or impairment in which the patient or visitor’s function is altered requiring outside medical intervention. Level III- Non-Serious: Minor injury or impairment in which a patient or visitor’s function may be altered with treatment limited to first aid. Level IV - Inconsequential: No injury or outcome that alters a patient or visitor’s function. EXAMPLES FOR SEVERITY CLASSIFICATION The following examples represent the typical initial severity level, however a final severity level may be determined after further review. Level I Tragic: ...Death at facility... Level II Serious: ...Suicide attempt... Level III Non-Serious: ... Self-inflicted injury resulting in minor injury...Suicide gesture....” Policy titled,”Precautions”, revealed: “...1. Precautions will be reviewed by a practitioner every 24 hours to determine if a change to the order is warranted. Discontinuation of precaution(s) may only be done by a practitioner...2. A patient may be placed on precautions at any point during his/her stay if high-risk behaviors and/or information a patient may be at risk is present. 3. When a patient is placed on precautions, the Observations Rounds Forms (Q sheet) will be revised to reflect the precaution(s) ordered. The patient’s precaution may be indicated on the unit’s whiteboard and/or bedboard...SELF HARM Behaviors/Information:...Attempts to self-harm during hospitalization...SEIZURES * Tonic: Muscles in rigid contracture (respirations may be suspended with the development of cyanosis, often eyes are open and pupils are dilated) * Clonic: Jerky movements (saliva may blow from the mouth creating froth. Urinary and fecal incontinence may occur). other areas. * Focal: (Localized Jacksonian) convulsive twitching, jerking in one part of the body, may then spread to*Petit Mal: Brief lapse or loss of consciousness (patient may suddenly stop what they are doing, seldom fall, but may lose bladder control). Seizure Precautions may include: *Monitor current signs and symptoms related to withdrawal: sweats, nausea/vomiting, cramps, fever, anxiety, hallucinations, etc...Suicide Precautions may include: * Ensure all linens/shower curtains are accounted for or no excess linen is present *Monitor for changes in environment such as damaged furniture, bent items, holes in wall, missing pieces, and look for anything out of place or out of the ordinary *Encourage patient to interact with peers, attend groups, and not to isolate. *Communicate clearly with the patient and ask questions regarding his/her safety...Utilize the patient’s safety plan and encourage use of coping skills...Ask patient to open mouth and lift tongue after administration of each medication* RN/LPN to monitor for “cheeking” - Ensure patient stays in common area under staff surveillance for 30 minutes after medication administration....” Document titled, “ Incident Report Form “ dated 10/18//2023 revealed: “ ...incident date: 10/18/2023, incident time: 2030 ...type of incident: self-inflicted injury ( written next to this is “ Omit EML 10/18) ...Restraint: Chemical time administered: 2055 ...Suicide attempt ...Summary of event: self-harm via attempted strangulation with towel string ...Interventions/Treatment: First Aid; PRN Med; Placed on 1:1; unit restriction; limited linen ...was an injury observed: yes type and body part: neck with scant blood ...Notification: Physician/practitioner date 10/18/2023 time 2040, CNO/DON: date 10/18/2023 time 2045, External agency notification: name /agency: DCS CM (name) NOVM, DCS rep( name) report #...Reviewed and completed by facility risk manager: severity level classification III .... “ Further review of the Incident Report Form revealed no evidence of documentation for the area designated Precautions Placed. Document titled, “ Incident Investigation Report “ dated 10/18/2023 revealed: “ ...Description of Incident: On 10/18/2023 at approximately 2030 patient was found by BHT (name) in [her] bathroom, on [her] floor with a towel wrapped around [her] neck. BHT immediately called out for assistance. BHT (name) responded, turned patient over (face up), and removed towel from around the patient ’ s neck. At that time, patient was not responding to verbal commands. Vitals were taken at 2030 and 2045 and were noted within normal limits. Following the incident, the patient ’ s vital were taken four additional times, and were noted to be within normal limits ...Patient remained on a Q5 minute level of observation, however, the provider gave an order for the patient to be placed on a 1:1 observation for increased safety ...Outcome of Investigation: On 10/19/203 the Director of Clinical Services spoke with the patient regarding the incident ...patient reported s/he was upset and decided to tie the piece of towel around [her] neck ...patient reported there was nothing that triggered this event ...reported that when staff were in [her] room, attempting to get [her] to speak, [she] heard them but did not want to say anything ...patient also reported [she] was able to breathe the whole time and did not lose consciousness at any point ...BHT reported when[she] was completing a round on the patient, [she] observed the patient in the bathroom face down on the floor with a piece of a towel wrapped around [her] neck ...also reported the patient appeared to be having a seizure ...immediately called out for assistance and BHT (name) responded, turned patient over so [she] was facing up and removed the towel from around the patient ’ s neck ...reported did not observe any discoloration in the patient ’ s face or lips ...reported when the RN responded to the room, s/he left and continues to round on the rest of the patients that were in the room while BHT and RN tended to the patient ...reported the towel that was around the patient ’ s neck was not tied to anything and the was the patient was not hanging from anything ...Corrective Action as a Result of Investigation: There was no corrective action as a result of the investigation .... “ Review of Patient #38 Seclusion/Restraint Progress Note dated 10/19/2023 revealed: “ ...on 18 October 2023 at approximately 2030 patient was in patient ’ s bathroom, the patient was observed face down on the floor near the door and under sink with seizure like movements. Staff initiated nursing care upon arrival patient was unresponsive to verbal command (baseline is selective muteness) visualized seizure like movements. ROM flaccid. Upon turning patient face up patient was on top of a towel and a towel string around patient ’ s neck and lips with dark discoloration. Towel string was double knotted with a tight grip first knot was removed and second know was difficult due to the tightness and no space between towel and skin. After removal of towel string patient gasped for air and coughed. Patient ’ s baseline is selective muteness and was not responding to verbal commands, eye movement and muscle spasms of legs noted. Patient ’ s vital signs obtained 145/84, pulse 134, oxygen 99% and temperature 98.2. Patient agreed to ambulate to bed, skin assessed redness to neck with scant skin lesions noted to right neck, cleaned with hydrogen peroxide open to air no other injuries noted or verbalized by patient. Psychiatrist notified placed on 1:1 monitoring, limit linens and unit restrictions orders entered. Zydis 10 mg OTD X1 order for mood stability ordered and administered no adverse effects assessed patient started talking with staff member on 1:1 and asked for snacks. No distress noted. Vital signs monitored. Contacted the following: (name) Guardian/Legal Representative: (phone number) “ mailbox is full and cannot except any messages ...Called DCS (phone number) spoke with (name) report #...Medical practitioner contacted and notified-no further orders received .... “ Review of Psychiatry Progress Note dated 10/19/2023 revealed: “ ...Patient seen, chart reviewed. Patient was seen in consult room with MSA and RN present. Case discussed with treatment team. S/he remains on a 1:1. Regarding this, s/he states: “ I don ’ t think I need it “ ...When informed that s/he was found face down in bed last night d/t possible seizure, s/h responds, “ I don ’ t know “ ...still tolerating medications well, although s/he refused Depakote yesterday .... “ Further review of Patient #38 medical record revealed no evidence of documentation that patient was seen and evaluated by a medical provider after the incident on 10/18/2023. Further review of the medical record revealed no suicide precautions or constant observations were implemented as per policy. Employee #1 confirmed that staff did not implement all procedures required by hospital policies in regard to the incident with Patient #38. Employee #1 acknowledged that the medical staff did not evaluate the patient for seizure or injury from the attempted suicide. 3. Policy titled “Patient Rights and Responsibilities” requires: “...Safety and the Therapeutic Environment...Communicating and functioning in a manner that is free from violence, risk to others or self, or otherwise place other or the treatment setting at risk for harm/accident....” Observation on 04/22/2024 revealed that shower faucet face plate in room #301 was not mounted flush against the shower wall presenting an area of opportunity for a ligature tie off point. Employee #3 and 7 confirmed that the shower faucet face plate was not flush mounted with a gap behind the plate large enough for patients to use as a tie off point.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 43788 Based on document review and interview,it was determined the Hospital failed to ensure staff notified law enforcement of a sexual assault of a minor patient which has the high potential risk of harm to patients if the facility does not take the appropriate actions to report and protect individuals abused while receiving services within the facility. Findings include: The policy titled “Abuse, Exploitation or Neglect Reporting - Child or Vulnerable Adult” requires: “...In cases of recent sexual abuse/assault, within 72 hours the patient will be referred to the emergency room for SARs evaluation....Reports will be called in to Child Protective Services and Pima County Sheriff’s Department as mandated by law....” The incident report dated [09/28/2023] revealed: “...[Patient (#5) reported roommate (Patient #8) walked toward (Patient #5) while (Patient #5) was laying (sic) in bed. (Patient #5) reports (Patient #8) then said a few words before putting his penis in (Patient #5’s) mouth]....” Patient #5’s medical record dated [09/29/2023] revealed: “...On call provider notified and order received to separate them (Patient #5 and Patient #8) and for follow up today...DCS [#10415478]...The family notified they have the option to contact police if they would like....” Employee #3 confirmed on 04/22/2024, that the facility did not report this case to law enforcement as outlined in the facility policy.”

“PATIENT RIGHTS:RESTRAINT/SECLUSION DEATH RPT CFR(s): 482.13(g)(1) & (3)(i) [Death Reporting Requirements: Hospitals must report deaths associated with the use of seclusion or restraint.] (1) With the exception of deaths described under paragraph (g)(2) of this section, the hospital must report the following information to CMS by telephone, facsimile, or electronically, as determined by CMS, no later than the close of business on the next business day following knowledge of the patient’s death: (i) Each death that occurs while a patient is in restraint or seclusion. (ii) Each death that occurs within 24 hours after the patient has been removed from restraint or seclusion. (iii) Each death known to the hospital that occurs within 1 week after restraint or seclusion where it is reasonable to assume that use of restraint or placement in seclusion contributed directly or indirectly to a patient’s death, regardless of the type(s) of restraint used on the patient during this time.”Reasonable to assume” in this context includes, but is not limited to, deaths related to restrictions of movement for prolonged periods of time, or death related to chest compression, restriction of breathing or asphyxiation.... (3) The staff must document in the patient’s medical record the date and time the death was: (i) Reported to CMS for deaths described in paragraph (g)(1) of this section; or .... This Standard is not met as evidenced by: 43788 Based on review of documents and staff interviews, it was determined the Hospital failed to notify CMS of a death of a patient who died within a half hour after receiving a chemical restraint (Patient #9). This failure poses the risk of an incomplete evaluation as to contributory factors in the death due to passage of time, and an inability to identify potentially dangerous practices with the use of restraint and/or seclusion. Findings include: Policy titled, “ Incident Reporting-Risk Management Program”, revealed: “...Any facility staff member who witnesses, discovers, or has direct knowledge of an incident must complete an Incident Report before the end of the shift/work day...If the incident involves a patient, staff must chart relevant information in the patient’s medical record...Restraint - Physical control applied by appropriate hands-on hold techniques. Chemical - Use of a sedating psychotropic drug to manage or control behavior that is not a usual and customary part of the diagnostic treatment plan. Mechanical - Use of a device, material, or equipment attached or adjacent to the body. SBHH does not utilize mechanical restraints...Active Patient Death: Death within the facility or while actively participating in outpatient treatment programming. Accidental - This may include death resulting from an automobile accident or unintentional drug overdose for IOP/PHP/OP patients...INCIDENT INTERVENTION It is the expectation that part of reporting the incident includes describing the actions taken to mitigate damages and/or prevent further loss. Every incident reported requires that the interventions be identified. For example, any time that law enforcement is contacted, the facility must document who contacted the police and the subsequent police involvement...In States where the facility is required to report Tragic/Serious incidents to the State, it must be done within the State requirements and notification of completion to Corporate Risk Management and Corporate Clinical Services Departments....” Policy titled, “Seclusion and Restraint (Chemical and Physical)”, revealed: “... Chemical Restraint is defined as a drug or medication 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. These medications are used in addition to or in replacement of the patient’s regular drug regimen to control extreme behavior during an emergency...Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner. When medication categorized as chemical restraint is ordered the following actions will be taken: The RN will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion Assessment packet...The patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained registered nurse the chemical restraint has ended, based on assessment of the behavioral and medical condition of the patient. The nurse in charge will assign trained staff to continuously monitor the patient during the duration of the chemical restraint. Continuous means ongoing without interruption...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour after administration of the medication defined as chemical restraint to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the intervention. The practitioner or trained registered nurse will make a determination when the chemical restraint has ended based on the behavioral and medical assessment of the patient’s condition...The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring...The legal representative or an immediate family member as requested by the patient shall be promptly notified of the chemical restraint...All legal guardians will be notified promptly of the chemical restraint...The Chief Executive Officer/designee will report to CMS and AZ DHS any death that occurs while a patient is chemically restrained, within 24 hours after chemical restraint is utilized, or within one week after chemical restraint is utilized where it is reasonable to assume the use of the chemical restraint contributed directly or indirectly to a patient’s death...Physical Restraint: Physical restraint includes manual measures approved by Handle With Care (HWC) to limit or restrict body movement. Orders for use of physical restraint shall not exceed one hour for patients under 9 years of age, two hours for patients 9 to 17 years of age, 4 hours for adults 18 years of age and older...PROCEDURE: A trained Registered Nurse may initiate restraint without an order in the absence of a Practitioner when a patient poses an imminent danger to self or others. The attending/covering Practitioner will be contacted during the restraint or immediately (within a few minutes) of the initiation of the restraint to confirm and obtain orders to be written by a registered nurse...The order shall indicate the reason and maximum duration of restraint...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion packet...Patients will be physically restrained in the supine position, unless contraindicated and in accordance with Handle with Care. Approved Handle with Care holds are considered a physical restraint...The patient shall be monitored and reassessed through continuous in-person observation and documented, at minimum, every 15 minutes. Continuous means ongoing without interruption. Monitoring to include the following: *signs of physical distress* Observed patient behavior* Offering fluids at minimum every hour* Vital signs-frequency will depend on patient condition and determined by RN assessment* offering opportunity for elimination every 2 hours* Evaluations of readiness for release from seculsion* Any other interventions...The Registered Nurse in charge will assign trained staff to continuously monitor the patient during the restraint event...Continuous means ongoing without interruption...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...The inperson evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condidtion and the need to continue or terminate the intervention...If the in person evaluation is conducted by a trained Registered Nurse, the Registered Nurse must consult with the attending/covering practitioner as soon as possible, but not to exceed one hour after completion of the inperson evaluation. Recommendations from the Pratitioner are to be documented on the Restraint/Seclusion Order...The Practitioner or the trained Registered Nurse will make a determination the restraint has ended bases on assessment of the behavioral and medical condition of the patient....” Policy titled, “Sentinel Event”, revealed: “...Sentinel Event- “A sentinel event is a patient safety event (not primarily related to the natural course of a patient’s illness or underlying condition) that reaches a patient and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). Sentinel events are not only events that occur during the care and treatment of individuals. Physical and verbal violence, abductions, and power failures are all potential sentinel events that can affect the health care organization and its patients...Death caused by self-inflicted injurious behavior if any of the following apply: While in a health care setting...Within 7 days of discharge from inpatient services...Within 7 days of discharge from emergency department (ED)....” Document titled, “Code Blue Record dated 09/20/2023”, revealed: “...Time of Event: 2045...Witnessed: No, By whom: Unwitnessed...Actual Code...Description of Event: Patient unresponsive, code blue procedure followed...Time Code Blue called: 2045.. was 911 called: yes time 2051...Time CPR began: 2047...Time CPR ended: 2056 EMS resumed...Time AED arrived: 2048...were shocks given: no...Did patient regain pulse: no, regain consciousness: no, resume breathing: no...was oxygen applied: Yes ambu bag...EMS arrival: 2056...Condition of patient upon departure or end of event: Deceased...Attending/covering physician order to transfer obtained: yes...Transfer paperwork completed: yes...Legal representative/Family notified, name of person notified: NA....” Review of Patient #9 Seclusion/Restraint Packet dated 09/20/2023 revealed: “...Practitioner Order: Type:Physical Restraint; Chemical Restraint: Medication Haldol 10 mg IM Now X1, Ativan 2 mg IM Now X1, Benadryl 50 mg IM Now X1...Purpose: Threat to immediate physical safety of self; Threat to immediate physical safety of others...Maximum duration: Restraint 4 hours adults 18 and over...Criteria for release: No longer an immediate physical threat to self...No longer an immediate physical threat to others...Phone order at 9/20/2023 at 2015...Practitioner signed 09/21/2023 at 0900...Release from seclusion/restraint: Patient’s behavior and/or condition at time of release: Quiet, Calm, Cooperative...Date of release: 09/20/2023...Time of release: 2018...Initiation of Intervention: Date 09/20/2023, Time 2015, Face to Face assessment date 09/20/2023 time 2018...Patient’s immediate situation/reaction to restraint: pt initially aggressive and attempting to bang head, shove fingers up nose and calmed down when IMs were to be administered...Vitals: T 97.3, P 93, R 16, BP 110/72, pulse ox 95 RA...current medical diagnosis: PE, DM, Asthma, TBI, GERD, BPH...skin warm and dry...injuries noted: location: nose; description: bleeding, recommendation: due to shoving fingers into nostrils...physical restraint from 2016-2018. Narrative: 9/20/2023 1950 starting preparing to give out HS medication in the medication room. pt requesting meds and prns...9/20/2023 2005 called out of med room due to pt behavior. pt reported to have groped peer’s genitals. broke another peer’s glasses and thrown object at staff, Notified oncall MD with orders to attempt PO PRN/HS meds. Pt refused when asked, “Fuck you”, “I’m not taking any meds”. Pt was slapping/punching at staff. Code grey was called...9/20/20232015 called on call MD for further direction, advised on call MD of situation with new orders to administer Haldol 10mg IM, Ativan 2 mg Im and Benadryl 50 mg IM now...9/20/2023 2018 pt has been released from physical restraint and emergency IMs given at this time. Pt laying calm and quiet with even unlabored respirations. Restraint discontinued...Physical restraint time in 2016 time out 2018...chemical restraint time in 2017 time out 2018...Patient monitoring 2016 restraint seclusion initiated...2018 bp 110/74, resp16, pulse 93, t 97.3....” Document titled, “Incident Investigation Report”, revealed: “...Description of Incident: admitted on 08/02/2023...history of schizoaffective disorder, paranoid schizophrenia, PTSD and and intellectual disability...admitted on revoked court order treatment due to noncompliance...throughout hospitalization had numerous outburst on the unit, and required frequent redirection and emergency medication intervention due to inappropriate and aggressive behaviors...received ECT consult on 9/19/2023...ECT services were recommended three times a week with the first being scheduled for 9/20/2023. On 9/20/2023, patient received first ECT treatment...tolerated ECT treatment well, there were no remarkable findings and was discharged to unit...On 9/20/2023 at approx. 1954 routine vitals were taken and were WNL ...The on call provider was called at 2004 due to patient groping roommate and was having difficulty with redirection/boundaries on the unit ...also grabbed and broke roommate ’ s glasses ...On call provider ordered po medications (standing PRNs) ...refused prn po medications ...on call provider was contacted again at approx. 2010 due to behavior escalating, head banging, digging in nose causing it to bleed and increased agitation ...At that time an order was given for a physical and chemical restraint ...received IM medication (Benadryl 50 mg, Haldol 10 mg, Ativan 2 mg) ...This was an IM medication pt. had received and tolerated before ...remained on Q15 minute observations, which were verified as timely ...After IM medication was administered, pt. was de-escalated and in room ...At 2041 vitals were obtained and WNL ...At approx. 2045 a code blue was called due to pt. being discovered to be unresponsive by BHT. Staff responded and CPR was initiated and AED pad were applied (no shock was advised by the AED) ...911 was called immediately by the House Supervisor ...EMS arrived at the facility at approx. 2056 and took over resuscitation efforts ...pt. remained unresponsive, had no pulse and time of death was called by EMS at 2132 ...Leadership notifications were made timely .... “ Review of Patient #9 medical record revealed no evidence of nursing documentation regarding events leading up to the initiation of Patient #9 requiring a physical or chemical restraint on 9/20/2023. Further review revealed no evidence of nursing documentation regarding staff finding the patient unresponsive or calling a Code Blue. Review of Patient #9 medical record revealed no evidence of hospital staff notifying the Department or CMS of Patient #9 death following the initiation of a chemical restraint on 09/20/2023. Employee #1 confirmed that the hospital had not notified the Department or CMS about Patient #9 ’ s death. Employee #1 stated that the hospital as well as the corporate office were unaware of the requirement for reporting deaths associated with chemical restraints.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 43788 Based on document review, observation, and interview, the Department determined that the administrator failed to ensure: 1. staff conducted complete observational rounding of patients on the Santa Rita unit which poses a risk to the health and safety of patients if staff are not thoroughly monitoring sleeping patients. 2. a patient was assessed and monitored after being placed in a physical restraint and receiving a chemical restraint (Patient #9). This failure poses the risk of a patient suffering injury or death without the proper assessments performed, or being restrained unnecessarily. Findings include: 1. The facility policy titled “Levels of Observation” requires: “...All patients will be closely observed in compliance with physician orders and prescribed protocols...Routine (Q 15 minute) Observations...This is the minimum level of observation for all patients...Assigned staff are to make direct visual contact with patients, at minimum every 15 minutes, and confirm they are in no danger or distress...Observations are not to be completed while standing in the doorway, or at a distance, particularly for patients who are sleeping. While patients are sleeping, observations are to be made in close enough proximity to the patient that the observer can verify the patient’s identify (sic) and visualizing the face and respirations to ensure the patient is not in any distress...Q 5 minute observations...Observations are not to be completed while standing in the doorway, or at a distance, particularly for patients who are sleeping. While patients are sleeping, observations are to be made in close enough proximity to the patient that the observer can verify the patient’s identify (sic) and visualizing the face and respirations to ensure the patient is not in any distress....” Observation on 04/22/2024 at approximately 0430 revealed a staff member documenting observational rounds on an electronic tablet device on Santa Rita unit. The patients on the unit were still asleep in their assigned rooms and doorway, just outside of (4) of (5) patient rooms tapping on the device and moving on to the next room. The staff member was solely focused on documenting on the tablet and did not enter the room or stay in the doorway long enough to visualize the faces or verify that each of the room’s two occupants were breathing. Employee #1 confirmed that staff are required to enter the patients’ rooms to visualize faces and verify breathing by watching three breaths (chest rise/fall) to document the observational round/monitoring. 2. The facility policy titled, “Seclusion and Restraint (Chemical and Physical)”, revealed: “... Chemical Restraint is defined as a drug or medication 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. These medications are used in addition to or in replacement of the patient’s regular drug regimen to control extreme behavior during an emergency...Patients will be administered medication categorized as chemical restraint on the direction of the attending/covering practitioner. When medication categorized as chemical restraint is ordered the following actions will be taken: The RN will document behaviors which led to the need for the use of chemical restraint in the Restraint/Seclusion Assessment packet...The patient shall be monitored and reassessed through continuous in-person observation until determination by the practitioner or the trained registered nurse the chemical restraint has ended, based on assessment of the behavioral and medical condition of the patient. The nurse in charge will assign trained staff to continuously monitor the patient during the duration of the chemical restraint. Continuous means ongoing without interruption...A practitioner or trained registered nurse shall conduct an in-person evaluation of the patient within one hour after administration of the medication defined as chemical restraint to assess physical and psychological status. The in-person evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or trained registered nurse will make a determination when the chemical restraint has ended based on the behavioral and medical assessment of the patient’s condition...The patient shall be debriefed by a staff person to determine the sequence of events or circumstances that precipitated the need for restraint. Debriefing occurs in order to develop a plan that actively involves the patient to prevent future episodes from occurring...The legal representative or an immediate family member as requested by the patient shall be promptly notified of the chemical restraint...All legal guardians will be notified of the chemical restraint...Physical Restraint: Physical restraint includes manual measures approved by Handle With Care (HWC) to limit or restrict body movement. Orders for use of physical restraint shall not exceed one hour for patients under 9 years of age, two hours for patients 9 to 17 years of age, 4 hours for adults 18 years of age and older...PROCEDURE: A trained Registered Nurse may initiate restraint without an order in the absence of a Practitioner when a patient poses an imminent danger to self or others. The attending/covering Practitioner will be contacted during the restraint or immediately (within a few minutes) of the initiation of the restraint to confirm and obtain orders to be written by a registered nurse...The order shall indicate the reason andmaximum duration of restraint...The Registered Nurse will document behaviors which led to the need for the use of restraint in the Restraint/Seclusion packet...Patients will be physically restrained in the supine position, unless contraindicated and in accordance with Handle with Care. Approved Handle with Care holds are considered a physical restraint...The patient shall be monitored and reassessed through continuous in-person observation and documented, at minimum, every 15 minutes. Continuous means ongoing without interruption. Monitoring to include the following: *signs of physical distress* Observed patient behavior* Offering fluids at minimum every hour* Vital signs-frequency will depend on patient condition and determined by RN assessment* offering opportunity for elimination every 2 hours* Evaluations of readiness for release from seculsion* Any other interventions...The Registered Nurse in charge will assign trained staff to continuously monitor the patient during the restraint event...Continuous means ongoing without interruption...A Practitioner or trained evaluation of the patient within one hour of initiation of restraint to assess physical and psychological status...The inperson evaluation includes the patient’s immediate situation, reaction to the intervention, medical and behavioral condidtion and the need to continue or terminate the intervention...If the in person evaluation is conducted by a trained Registered Nurse, the Registered Nurse must consult with the attending/covering practitioner as soon as possible, but not to exceed one hour after completion of the inperson evaluation. Recommendations from the Pratitioner are to be documented on the Restraint/Seclusion Order...The Practitioner or the trained Registered Nurse will make a determination the restraint has ended based on assessment of the behavioral and medical condition of the patient....” Further review of the policy revealed no evidence of a designated timeframe/duration for monitoring of a patient receiving a chemical restraint, based on the chemical restraints side effects or half-life. Review of Patient #9 Seclusion/Restraint Packet dated 09/20/2023 revealed: “...Practitioner Order: Type:Physical Restraint; Chemical Restraint: Medication Haldol 10 mg IM Now X1, Ativan 2 mg IM Now X1, Benadryl 50 mg IM Now X1...Purpose: Threat to immediate physical safety of self; Threat to immediate physical safety of others...Maximum duration: Restraint 4 hours adults 18 and over...Criteria for release: No longer an immediate physical threat to self...No longer an immediate physical threat to others...Phone order at 9/20/2023 at 2015...Practitioner signed 09/21/2023 at 0900...Release from seclusion/restraint: Patient’s behavior and/or condition at time of release: Quiet, Calm, Cooperative...Date of release: 09/20/2023...Time of release: 2018...Initiation of Intervention: Date 09/20/2023, Time 2015, Face to Face assessment date 09/20/2023 time 2018...Patient’s immediate situation/reaction to restraint: pt initially aggressive and attempting to bang head, shove fingers up nose and calmed down when IMs were to be administered...Vitals: T 97.3, P 93, R 16, BP 110/72, pulse ox 95 RA ...9/20/20232015 called on call MD for further direction, advised on call MD of situation with new orders to administer Haldol 10mg IM, Ativan 2 mg Im and Benadryl 50 mg IM now...9/20/2023 2018 pt has been released from physical restraint and emergency IMs given at this time. Pt laying calm and quiet with even unlabored respirations. Restraint discontinued...Physical restraint time in 2016 time out 2018...chemical restraint time in 2017 time out 2018...Patient monitoring 2016 restraint seclusion initiated...2018 bp 110/74, resp16, pulse 93, t 97.3....” Further review of Patient #9 Seclusion/Restraint Packet dated 09/20/2023 revealed there was no continual monitoring of Patient #1 as required by hospital policy and procedure. Further review revealed nursing staff released the patient from restraint precautions within 3 minutes of receiving a chemical restraint. Employee #1 confirmed that there was no continual monitoring of Patient #1 after the chemical restraint had been administered and the patient was released from restraint precautions within 3 minutes of receiving a chemical restraint.”