Palo Verde Behavioral Health

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 45202 Based on hospital policy and procedure review, hospital documentation review, employee file review, and employee interview, it was determined that the hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following reference to standard-level deficiencies and Immediate Jeopardy: Findings include: Cross reference A-0395: The Nurse Executive failed to ensure employees followed hospital policy and procedure concerning: timely supervision of non-licensed employees providing services related to patient care; Cross reference A-0405: The Nurse Executive failed to ensure patients were administered medication in accordance with policy and procedures as well as provider orders, resulting in two medication errors and an Immediate Jeopardy as a result of a patient overdose; Cross reference A-0406: The Nurse Executive failed to ensure employees followed provider orders for as needed medication (PRN), failing to document that a patient was given PRN medication as a result of indications in the provider order. The cumulative and egregious nature of these deficient practices resulted in and Immediate Jeopardy and the facility’s failure to meet the requirement for the Condition of Participation for Nursing Services.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 45202 Based on review of hospital policy and procedure, medical records and staff interview, it was determined the hospital failed to ensure a patient or a patient’s representative provided informed consent regarding treatment, including being able to accept or refuse treatment, as evidenced by: (2) Failure to obtain written informed consent for psychotropic medication per hospital policy This deficient practice poses a potential risk to patients that may compromise the quality and safety of patient care for patients receiving psychotropic medications without understanding the risks, benefits, and effects the medications may have. Findings include: Policy titled “Informed Consent for Medication Administration” states “...The Treating Practitioner has the legal responsibility for obtaining the Patient’s (or the Legal Representative’s) informed consent and approval to proceed with the proposed medication involving significant risk prior to administration, except in emergencies. The Treating Practitioner should document that the informed consent process occurred...should either sign the informed consent...incident on the form ‘refused (or Unable) to sign: Verbal consent given’....” Medical record for Patient #1’s revealed the following: Patient #1 was prescribed Abilify and Lithium. Both medications were administered to Patient #1. A request was made for informed consent for Abilify and Lithium. None was provided. Medical record for Patient #12’s revealed the following: Patient #12 was prescribed Seroquel and it was administered to Patient #12. A request was made for informed consent for Seroquel. None was provided. Medical record for Patient #13’s revealed the following: Patient #13 was prescribed Lorazepam. Lorazepam was administered to Patient #13. A request was made for informed consent for Lorazepam. None was provided. Medical record for Patient #17’s revealed the following: Patient #17 was prescribed Benzotropine and Mirtazapine. Both medications were administered to Patient #17. A request was made for informed consent for Benzotropine and Mirtazapine. None was provided. Employee #4 confirmed during an interview conducted on July 16, 2025, that Patients #1, 12, 13, and 17, had been administered psychotropic medications with no documentation of informed consent in their medical record.”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 45202 Based on review of hospital policy/procedure, medical records and interviews, it was determined that the hospital failed to ensure a patient’s right to formulate advanced directives was given. This deficient practice can result in a patient’s wishes not being followed in the event of an emergency. Findings include: Document titled “Palo Verde Behavioral Health Advance Directive/Healthcare Plan Acknowledgement” has “Yes/NO” boxes to fill out regarding advanced directives followed by patient signature and staff signature lines. Furthermore, there is a”Staff Completion Only” section that requires boxes to be checked including “Patient has provided a copy of Advanced Directives.” Review of medical records revealed the following: Patient #1 did not have the “Yes/No” section or the “Staff Completion Only’ Section filled out. Patient #2 did not have the “Yes/No” section or the “Staff Completion Only’ Section filled out. Patient #8 did not have the form for Advanced Directives in their medical records. Patient #12 did not have the “Yes/No” section or the “Staff Completion Only’ Section filled out. Patient #16 did not have the “Yes/No” section or the “Staff Completion Only’ Section filled out. Interview with Employee #4 on July 16, 2025, confirmed that Patient #8 had no advanced directives filled out, and Patient #1, 2, 12, and 16 had incomplete forms.”

“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: 45202 Based on hospital policy and procedure review, hospital documentation review, employee file review and request, and employee interview, it was determined that the hospital failed to ensure non-licensed employees providing patient care received timely supervision by appropriate nursing staff. These deficient practices pose risks of non-licensed employees providing services to patients that they have not been supervised by competent nursing staff to provide, which increases the risk of harm to the health and safety of patients. Findings include: A review of hospital policy titled “Clinical Oversight for Behavioral Health Technicians and Paraprofessionals” Policy HR.06, Issued March 2022 and revised May 2025, states “...BHTs, BHPPs, Licensed Practical Nurses, and Registered Nurses with less than one year of behavioral health experience shall receive clinical oversight at least ever two weeks....” A review of employee files related to clinical oversight on July 16, 2025 revealed the following: Employee #15, 16, 17, 18, 19, and 21 were identified as Behavioral Health Technicians (BHT’s). All were identified as full time employees working from January 1, 2025 to May 31, 2025. A request was made on July 16, 2025, for clinical oversight for BHT’s, Employee #15, 16, 17, 18, 19, and 21, from January 1, 2025 to May 31, 2025. None was provided. Employee #4 confirmed in an interview on July 16, 2025, that no clinical oversight was available to review for Employee #15, 16, 17, 18, 19, and 21 for the dates requested.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45202 Based on review of policies and procedures, facility documents, medical records, and staff interviews, the Department determined that the administrator failed to ensure drugs were prepared and administered according to the practitioners orders. This deficient practice resulted in a patient being administered methadone they were not prescribed by a provider and a patient being administered a medication they were documented as being allergic to. Findings include: Review of policy titled “Medication Administration”, No Policy #, last reviewed 04/2025, revealed “ ...Purpose: To identify guidelines for the safe and effective administration of prescribed medications ...1. Controlled medications shall be maintained in a secure area ...4. Any controlled medications signed out of the Omnicell and not given shall be wasted by two Nurses ...8. Before the nurse administers the medication, the patient ’ s wristband barcode will be scanned and/or use at least 2 patient identifiers to ensure the correct patient ...9 ...The 5 rights of medication administration will be observed during administration to the patient (right patient, right medication, right dose, right route, right time) ....” Patient #4: Review of Patient #4 ’ s orders revealed methadone was not listed in Patient #1 ’ s ordered medications. Review of Patient #4 ’ s Medication Administration Record revealed no evidence that methadone was administered during Patient #4 ’ s stay at the licensed facility. Review of Patient #4 ’ s Nursing Note, dated 6/26/2025, revealed “ ...At approximately 0830, lead BHT was completing standard Q15 minute safety rounds and noticed that {Patient #1} appeared to be unresponsive. Lead BHT called a hospital-wide code blue and informed RN ’ s at med window ...RN immediately ran to pt. ’ s room and found {her} blue-grey in color and unable to respond to verbal direction ...Staff immediately called 9-1-1 and RN attempted sternum rubs ...RN began compressions ...Second RN checked blood sugar ...Non-breather mask was placed on patient. Second RN placed AED pads on patient ...Chest compressions continued by staff while waiting for emergency responders to arrive ...EMS arrived on scene at 0847 ...at 0850 EMS ...transferred patient to {Hospital} for stabilization ....” Patient #4 ’ s Toxicology Document from Hospital revealed “ ...Urine Methadone Screen ...Detected ....” Review of Investigative Summary, dated 6/26/2025, revealed “ ...Investigation Notes: Interview with the night shift RN shared that the patient ’ s roommate was prescribed methadone, {he} called {her} name and did not verify second patient identifier for patient before providing the medication. {He} reported {he} spilled that morning dose and left the cup and spill for a moment to get paper from their bathroom to clean the spill leaving the methadone dose unattended ...The RN ’ s interview showed that {he} did not follow policy and procedure regarding medication administration. Data from the medication cabinet ...corroborates that two doses of methadone were pulled. The controlled medication requires two staff, the second staff reported the RN told {her} that {he} spilled the medication when retrieving the second dose ...There is no camera in the bedroom ...Toxicology and medical record from {Hospital} showed that the patient experienced an opiate overdose and was positive for methadone ....” Employee #4 confirmed in interviews conducted on July 15, 2025, that policies were not followed for medication administration and that Patient #4 was administered methadone despite not being prescribed by a provider. Patient #8 Review of Patient #8’s medical record revealed an admission note on May 2, 2025, that states “Allergies” “Zyprexa.” Review of medical record for Patient #8 revealed an intramuscularly Zyprexa verbal order dated May 6, 2025 stating “...IM Now....” A review of medication informed consents revealed and informed consent dates May 6, 2025, indicating that guardian refused to give consent for medication, “...Refused to sign due to not consenting to mediation-pt has allergy to Zyprexa (given medication)....” Furthermore, the provider noted “It was in his chart that he was allergic...I was not told until after it was given....” Employee #4 confirmed in interviews conducted on July 15, 2025, that policies were not followed for medication administration and that Patient #8 was administered a medication they had a documented allergy to. Employee #4 confirmed in interviews conducted on July 15, 2025, that policies were not followed for medication administration and that Patient #4 and Patient #8.”

“STANDING ORDERS FOR DRUGS CFR(s): 482.23(c)(1)(ii ),(c)(3) & (c)(3)(iii) (ii) Drugs and biologicals may be prepared and administered on the orders contained within pre-printed and electronic standing orders, order sets, and protocols for patient orders only if such orders meet the requirements of §482.24(c)(3). (3) With the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved hospital policy after an assessment of contraindications, orders for drugs and biologicals must be documented and signed by a practitioner who is authorized to write orders in accordance with State law and hospital policy, and who is responsible for the care of the patient as specified under §482.12(c) ... This Standard is not met as evidenced by: 45202 Based on review of hospital policies/procedures, medical records, and staff interviews, it was determined that nurse executive failed to require as needed (PRN) medications were administered according to complete physicians’ orders as evidenced by Vistaril given PRN for anxiety when patient was not documented to be exhibiting anxiety. This deficient practice can result in hypersedation of patients. Findings include: Policy titled “Medication Administration” Issued May 2015 and last reviewed April 2025, states “...The administration of mediations (sic) shall conform to the local and state Pharmacy regulations as well as meeting The Joint Commission guidelines for Pharmaceutical Services....” Review of Patient #8 medical record revealed a “PRN” order for Vistaril “For Anxiety....” Patient #8 nursing noted dated May 7, 2025 at the time of administration for PRN Vistaril states “...Anxiety 0....” Patient #8 nurse notes dated May 8, 9 and 10th do not have times indicated. They also do not document anxiety and the need for a PRN administration of Vistaril. At the time of administration for Vistaril PRN on May 8, 9 and 10, 2025, the “Patient Observation Record & Milieu Groups” forms document the patient as “Awake” and do not document the patient with other identifiers available such as “...Agitated, Restless, Confused, Crying, Pacing....” Evidence that Patient #8 was administered PRN Vistaril for May 7, 8, 9, and 10, 2025 for Anxiety was requested. None was provided. Interview with Employee #4 on June 16, 2025, confirmed that there is not documented evidence that these administrations were a direct result of Patient #8 exhibiting or experiencing Anxiety.”

“CONTENT OF RECORD: CONSULTATIVE RECORDS CFR(s): 482.24(c)(4)(iii) [All records must document the following, as appropriate:] Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. This Standard is not met as evidenced by: 45202 Based on review of facility policy, medical record review and interview, the Medical Director failed to ensure Patient #1’s medical record contained the results of consultative findings for Methadone maintenance therapy. This deficient practice can result in the patient being placed on the incorrect dosage leading to withdrawal or overdose. Findings include: Policy titled “Methadone & Buprenorphine For Opiate Dependence” states “...The use of methadone and buprenorphine products ad maintenance therapy for opioid used disorder is limited to patients admitted to the hospital...and are already under the care of a registered Narcotic/Opioid Treatment Program...Verify and document the medication and dose with the patient’s OUD treatment provider....” Review of Patient #1’s medical record revealed they were on maintenance therapy for Methadone. A requested was made on June 16, 2025, for the documented verification of Patient #1’s OUD treatment. None was provided. Employee #4 confirmed in an interview on June 16, 2025, that no documentation was available for the consult with the OUD treatment provider.”