El Dorado Springs

“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 policy, medical record review, and employee interviews, it was determined that the Hospital failed to comply with protecting and promoting each patient’s rights as evidenced by: Cross reference: 0119 : Hospital failed to ensure policies were implemented for a patient grievance regarding their safety 0130: Hospital failed to ensure patient’s had the right to participate int he development and implementation of their care plan. 0131: Hospital failed to ensure informed consents were obtained from a patient or patient representative. 0144: Hospital failed to ensure policies were implemented for detoxification protocols therefore failing to provide care in a safe setting to patients. The egregious nature and systemic issues of these deficient practices resulted in the Hospital’s failure to meet the requirement for the Condition of Participation for Patient Rights.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 45202 Based on review of policies and procedures, facility documentation, and staff interview, the Hospital failed to ensure policies were implemented for a patient grievance regarding their safety. This deficient practice resulted in a sexual assault allegation not being identified as a sentinnel event, which can result in patient harm if incidents are not classified and investigated appropriately. Findings include: Review of policy titled “Root Cause Analysis (RCA) and Sentinel Event”, Policy #19720320, last reviewed January 2025, revealed “...Sentinel Event includes:...4. Sexual abuse/assault ...In response to a Sentinel Event, an incident memorialized in an Incident Report classifying the underlying matter as a Level III Incident ...or a level IV Incident ...a RCA shall be conducted after conferring of the Co-Chairpersons ....” Review of facility documentation revealed a sexual assault allegation that Patient #1 made against Patient #2 on April 10, 2026. Review of Tucson Police Department Incident Report P2604100137-1, dated April 10, 2026, revealed “...{he} was cited for Assault and Disorderly Conduct ....”. Employee #2 confirmed in an interview that the individual cited in the aforementioned Police Report is Patient #2. Review of facility documentation revealed an Incident Report for Patient #1, dated April 10, 2026, that revealed details of the sexual assault allegation. It was observed that there was no evidence of an Incident Level included in the facility documentation.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 45202 Based on review of facility documents, patient medical records and interview, the Hospital failed to ensure patient’s had the right to participate int he development and implementation of their care plan. This deficient practice violates a patient’s rights and reduces the changes they will actively engage in treatment. Findings include; Treatment Planning-Philosophy and Purpose, Policy 20071464, last reviewed March 2026, states “...Treatment plan reviews and updates will evaluate patient progress toward goals and response to interventions and will be revised based on changes in condition, needs, risks, or level of care ....” Review of facility documentation revealed care plans have a signature page to verify patient’s were involved in and reviewed their care plan. Review of Patient #6 and Patient #7’s medical record revealed no signature page verifying their review of their care plan. A request was made on May 15, 2026, for the signature pages for Patient #6 & #7. None was provided. Employee #2 confirmed in an interview on May 15, 2026, that there was not evidence Patient #6 or #7 particpated in their care plan.”

“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 policies and procedures, medical records, and staff interview, the Department determined that the Hospital failed to ensure informed consents were obtained from a patient or patient representative. This deficient practice resulted in psychotropic medications being administered to patients without the patient, or patient’s representative, consent and therefore they may not be aware of the risks, benefits and alteranatives to psychotropic medications. Findings include: Review of policy titled “ Review of medical records on May 14, 2026 - May 18, 2026, revealed the following voluntary patients with no informed consent for the following non emergent medications: Patient #3: Patient #3 was ordered and administered Olanzapine 5mg for psychosis. A request was made for evidence of an informed consent from Patient #3, or their representative. None was provided. Patient #4: Patient #4 was ordered and administered Lorazepam. A request was made for evidence of an informed consent from Patient #4, or their representative. None was provided. Patient #5: Patient #5 was ordered and administered Lorazepam. A request was made for evidence of an informed consent from Patient #5, or their representative. None was provided. Patient #6: Patient #6 was ordered and administered Lorazepam. A request was made for evidence of an informed consent from Patient #6, or their representative. None was provided. Employee #2 confirmed in an interview conducted on May 15, 2026, that there were no informed consents for the aforementioned patient’s psychotropic medications.”

“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 policies and procedures, medical records, and staff interview, the Department determined that the Hospital failed to ensure policies were implemented for detoxification protocols therefore failing to provide care in a safe setting to patients. This deficient practice resulted in a lack of Clinical Opiate Withdrawal Scale (COWS) protocols, as well as Clinical Institute Withdrawal Assessments (CIWA) not being completed according to policy and/or provider order. This has the opportunity to cause patient harm and/or death, if patients are not assessed at the times specified in policy and/or provider order. Findings include: A request was made on May 11, 2026, for the facility’s policies and procedures on detoxification protocols, including when staff would contact a provider based on the patient’s score on a Clinical Opiate Withdrawal Scale (COWS). Review of policy titled “CIWA-AR and COWS”, Policy #18583423, last reviewed July 2025, revealed “...A sum of all the scores for each category should provide a value that correlates with the severity index and intervention type and dose ...” Review of procedure titled “CIWA-AR and COWS Protocols”, no Policy #, no date, revealed “...CIWA-AR ...This protocol involves assessment of withdrawal symptoms every four hours using the Clinical Institute Withdrawal Assessment of Alcohol Scale Revised, abbreviated as “CIWA-AR” or just “CIWA”...Patients must be reassessed and re-scored two hours after any administration of PRN Ativan for a CIWA score of 20 or less ....” Further review of policy titled “CIWA-AR and COWS” and procedure titled “CIWA-AR and COWS Protocols” revealed no evidence of when staff would contact a provider based on a patient’s COWS score. On May 13, 2026, separate interviews were held with Employee #6 and Employee #7, both Registered Nurses (RN) on the unit. A request was made for Employee #6 and Employee #7 to provide the surveyor with their understanding of the facility’s protocol on when a provider should be contacted based on a patient’s COWS score. Employee #6 and Employee #7 both confirmed that they are unaware of an established protocol on when to contact a provider and that they would use “...nurse’s judgement ....” Patient #1/Immediate Jeopardy: Review of Patient #1’s medical record on May 7, 2026 - May 13, 2026, revealed the following: Patient #1 was admitted to the licensed facility from April 8, 2026 through April 15, 2026 A document titled “ Orders - Medications”, dated April 8, 2026 - April 15, 2026, revealed “...Lorazepam ...Alcohol withdrawal 1 mg = 1 tab, Oral ...every 2 hr for 7 days, PRN withdrawal symptoms ...Order Comment: CIWA score 9 to 15: Vital Signs EVERY 2 HOURS until CIWA LESS THAN 9. Give LORAZEPAM (ATIVAN) 1mg po EVERY 2 HOURS until patient has a CIWA LESS THAN 9 ......Lorazepam ...Alcohol withdrawal 2 mg = 1 tab, Oral ...every 2 hr for 7 days, PRN withdrawal symptoms ...Order Comment: CIWA score 16 to 20: Vital Signs EVERY 2 HOURS until CIWA LESS THAN 9. Give LORAZEPAM (ATIVAN) 2mg po EVERY 2 HOURS until patient has a CIWA LESS THAN 9 ......Lorazepam ...Alcohol withdrawal 4 mg = 2 tab, Oral ...every 1 hr for 7 days, PRN withdrawal symptoms ...Order Comment: CIWA score greater than 20: Vital Signs EVERY 1 HOUR until CIWA LESS THAN 9. Give LORAZEPAM 4mg po EVERY 1 HOUR. Psych on call must be notified ....” Review of Patient #1’s medical record on May 7, 2026 - May 13, 2026, revealed the following days where detox protocols were not followed per policies and/or per order: 4/9/2026 4:59am: CIWA-AR Score 10, 5:03am: 1 mg Lorazepam administered “ Vital signs required at 7:03am. It was observed that Patient #1 did not have vital signs taken again until 7:50am (Approximately 47 minutes after the required time) “ CIWA-AR required at 7:03am. It was observed that Patient #1 did not have a CIWA-AR completed again until 9:54am (Approximately 2 hours and 51 minutes after the required time) 9:45pm: CIWA-AR Score 16, 9:49pm: 2mg Lorazepam administered “ Vital signs required at 11:49pm. It was observed that Patient #1 did not have vital signs taken again until 1:05am the following morning (Approximately 1 hour and 16 minutes after the required time) 4/10/2026 1:00am: CIWA-AR Score 16, 1:05am: 2mg Lorazepam administered “ Vital signs required at 3:05am. It was observed that Patient #1 did not have vital signs taken again until 5:30am (Approximately 2 hours after the required time) “ CIWA required at 3:05am. It was observed that Patient #1 did not have a CIWA-AR completed again until 5:30am (Approximately 2 hours after the required time) 5:30am: CIWA-AR Score 16, 5:54am: 2mg Lorazepam administered “ Vital signs required at 7:54am. It was observed that Patient #1 did not have vital signs taken again until 9:52am (Approximately 1 hour 58 minutes after the required time) “ CIWA required at 7:54am. It was observed that Patient #1 did not have a CIWA-AR completed again until 9:50am (Approximately 1 hour and 56 minutes after the required time) 5:21pm: CIWA-AR Score 9, 5:29pm: 1 mg Lorazepam administered “ Vital signs required at 7:29pm. It was observed that Patient #1 did not have vital signs taken again until 8:24pm (Approximately 55 minutes after the required time) “ CIWA required at 7:29pm. It was observed that Patient #1 did not have a CIWA-AR completed again until 10:03pm (Approximately 2 hours and 34 minutes after the required time) 10:03pm: CIWA-AR Score 16, 10:18pm: 2 mg Lorazepam administered “ Vital signs required at 12:18am. It was observed that Patient #1 did not have vital signs taken again until 2:20am the following morning (Approximately 2 hours and 2 minutes after the required time) “ CIWA required at 12:18am. It was observed that Patient #1 did not have a CIWA-AR completed again until 2:20am the following morning (Approximately 2 hours and 2 minutes after the required time) 4/11/2026 9:38am: CIWA-AR Score 9, 9:47am: 1 mg Lorazepam administered “ Vital signs required at 11:47am. It was observed that Patient #1 did not have vital signs taken again until 2:16pm (Approximately 2 hours and 29 minutes after the required time) “ CIWA required at 11:47am. It was observed that Patient #1 did not have a CIWA-AR completed again until 2:16pm (Approximately 2 hours and 29 minutes after the required time) 4/12/2026 5:05pm: CIWA-AR Score 16, 5:11pm: 2mg Lorazepam administered “ Vital signs required at 7:11pm. It was observed that Patient #1 did not have vital signs taken again until 8:42pm (Approximately 1 hour and 31 minutes after the required time) “ CIWA required at 7:11pm. It was observed that Patient #1 did not have a CIWA-AR completed again until 8:42pm (Approximately 1 hour and 31 minutes after the required time) 4/13/2026 8:23pm: CIWA-AR Score 12 “ 1mg Lorazepam required. None provided. “ Vital signs required at 10:23pm. It was observed that Patient #1 did not have vital signs taken again until 12:22am (Approximately 1 hour and 59 minutes after the required time) “ CIWA required at 10:23pm. It was observed that Patient #1 did not have a CIWA-AR completed again until 12:22am (Approximately 1 hour and 59 minutes after the required time) 4/14/2026 9:23am: CIWA-AR Score 17 “ 2mg Lorazepam required. None provided. Employee #2 confirmed that the facility did not follow policies and procedures on detoxification protocols in the aforementioned scenarios. Patient #3: Patient #3 medical record on May 15, 2025, revealed: COWS missing on 3/15/26 at 6am and 10am and the COWS due at 2000 was on hour late. Patient #4: Patient #4 medical record on May 15, 2025, revealed: COWS was ordered on 3/16/26 every four hours at 12:09pm and the patient arrived on the floor at that time. The first COWS was not completed until 9pm and there should have been 2 completed in that timeframe. On 3/17/26 a COWS was completed at 8:57 am and another one was not completed until 4:59pm. Employee #2 confirmed gaps in care for Patient #3 and Patient #4 and that the facility did not follow policies and procedures on detoxification protocols in the aforementioned scenarios.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 45202 Based on review of medical records, interview with nurses, and interview with administration, the Hospital failed to ensure a patient on a detox protocol had an order by a practitioner delineating the terms of the protocol and when it could be discontinued. This deficient practice resulting in RN’s making decisions outside their scope of practice. Findings include: Patient #3 had a CIWA started by an RN. The CIWA was completed 2 times and then discontinued by the RN. A request was made for a provider order that the CIWA could be discontiued and when. None was provided. Patient #14 had a CIWA started by an RN. The CIWA was completed for two days but with gaps in coverage and then discontinued by the RN. A request was made for a provider order that the CIWA could be discontiued and when. None was provided. Interview with Employee #2 on May 15, 2026, confirmed that the medical record did not contain evidence of provider order for CIWA protocols for Patient #3 and Patient #14.”

“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 record reviews and staff interviews, it was determined the hospital failed to provide organized nursing services assessed the individual needs of each patient, and deliver and supervise the care required in accordance with physician orders, policies and procedures, and nursing standards of care. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tags: Cross reference A-0392: The facility failed to ensure medical screening examinations (MSE) were completed according to facility protocol to determine if an emergency medical condition existed. Cross reference A-0394: The facility failed to ensure personnel members have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description. Cross reference A-0395: The facility failed to document that clinical oversight was provided for nine behavioral health technicians (Patient Care Assistant) (Employees #16, #17, #18, #19, #20, #21, #22, #23, and #24), at least once each two-week period The cumulative effect of these systemic deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“FOOD AND DIETETIC SERVICES CFR(s): 482.28 The hospital must have organized dietary services that are directed and staffed by adequate qualified personnel. However, a hospital that has a contract with an outside food management company may be found to meet this Condition of Participation if the company has a dietitian who serves the hospital on a full-time, part-time, or consultant basis, and if the company maintains at least the minimum standards specified in this section and provides for constant liaison with the hospital medical staff for recommendations on dietetic policies affecting patient treatment. This Condition is not met as evidenced by: 45202 Based on policy and procedure, Arizona Administrative Code, United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, observation, and interview, the Department determined that the hospital failed to ensure: Cross reference A-0622: 1. Technical personnel are competent in their respective duties. 2. Food was stored, refrigerated and reheated according to policies and procedures. 3. Refridgerators are checked to ensure they are kept at proper temperatures for food storage. 4. The kitchen and equipment are cleaned and disinfected according to policies and procedures designed to prevent, minimize, and control illness or infection. The cumulative effect of these deficient practices poses a high potential risk of harm to patients and other individuals who may consume food that was stored and prepared in the facility kitchen in unsanitary equipment and environment if the facility does not follow guidelines set forth in dietary guidelines and policy as well as untrained staff to ensure guidelienes and policies are implemented. Findings include: The Arizona Administrative Code (9 A.A.C. 8, Article 1) requires: “...ARTICLE 1. FOOD ESTABLISHMENTS...R9-8-101. Purpose and Definitions...A. The Department incorporates by reference the United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration and shall comply with the 2017 Food Code (FC) as specified in this Article. This incorporation by reference contains no future editions or amendments. The incorporated material is on file with the Department and is available for order at: https://www.fda.gov/Food/ResourcesForYou/Consumers/ucm239035.htm, refer to publication number IFS17....” The United States Food and Drug Administration publication, Food Code: 2017 Recommendations of the United States Public Health Service, Food and Drug Administration incorporated by reference in subsection (A) from R9-8-101 Food Establishments Purpose and Definition and R9-10-231 Dietary Services requires: “...6-5 MAINTENANCE AND OPERATION Subpart 6-501 Premises...PHYSICAL FACILITIES shall be maintained in good repair. 6-501.12 Cleaning, Frequency and Restrictions. (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. 4-6 CLEANING OF EQUIPMENT AND UTENSILS...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch....(B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non FOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris....” Findings include: Facility policy document titled, “Kitchen Sanitation and Food Handling”, Policy ID15182964, Last revised March, 2024, revealed, “...cold foods are held and served at 41°F/5°C or less....” Review of facility document titled, “Patient and Food Temperature Log”, dated October 15, 2024 revealed “...If hot holding temperatures are not above 135°F, reheat food to 165°F for 15 sec prior to serving ...” Further review of the document revealed, “Holding Prior to Service” temperatures of “FT” and “Sausage” were recorded as 134°F and 131°F, respectively. The document failed to provide evidence that the food was reheated to 165°F for 15 sec prior to serving according to policy and procedure. Facility tour on October 21, 2024, revealed a tray of gelatin dessert unlabeled, undated and covered with plastic wrap. Facility tour on October 23, 2024 revealed that the tray of gelatin dessert was still present and had not been labeled. Interview on tour with Employee # 1, Employee #2, Employee #4, and Employee #14, on October 21, 2024, and again on tour with Employee #1 on October 23, 2024, confirmed that the gelatin dessert had not been labeled and dated. Facility tour on October 23, 2024 revealed “Refrigerator Temperature Log” and “Freezer Temperature Log” posted on patient care refrigerator and freezer, respectively. The last documented entry was October 21, 2024. Interview while on tour with Employee #1 and Employee #14 on October 23, 2024, confirmed temperature logs were not up to date. Facility policy document titled, “General Cleaning Policy”, Policy ID: 15182948, Last updated: March, 2024, revealed, “...Dining Areas...Daily... Spot clean walls, doors, door facings, columns, and other building surfaces to remove hand prints, smudges, and other obvious soil. Use a cloth and germicidal detergent solution from a spray bottle. Use lotion cleanser on hard-to-remove stains....” Facility policy document titled, “Kitchen Sanitation and Food Handling”, Policy ID15182964, Last revised March, 2024, revealed, “...cold foods are held and served at 41°F/5°C or less...Cafeteria table, walls, condiment area, service line, (sic) salad bar are cleaned and sanitized after each meal, as required....” Observations while on tour of the third floor dining hall on October 21, 2024, revealed stains on the walls, as well as crystalline residue on the water/ice and juice dispensing machines where patients place their cups. A request for daily cleaning documentation for the September was made on October 21, 2024. Employee #1 provided daily cleaning logs with entries from August 12, 2024 through August 27, 2024. During an interview on October 23, 2024, Employee #1 confirmed that the provided cleaning logs were the only logs available at the time of survey. A second facility tour of the third floor dining room and kitchen on October 23, 2024, revealed: -The water/ice and juice dispensing machines were observed with crystalline residue. -Staff lunch was stored in a patient care refrigerator. Interview with Employee #1 and Employee #14, on October 23, 2024, confirmed that crystalline residue remained on the water/ice and juice dispensing machines and the staff lunch was in a patient care refrigerator and should not have been.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 45202 Based on review of hospital records and staff interviews, it was determined the hospital failed to meet the emergency needs of patients within acceptable standards of practice as evidenced by: Cross reference A-1104: The hospital failed to ensure the policies and procedures governing medical care provided in an emergency were implemented to ensure that the continuity of patient care needs has been facilitated when transferring a patient to another facility for a medical emergency. Cross reference A-1112 The hospitla failed to ensure nursing personnel were qualified in emergency care by not maintaining up to date with current skills, Cardiopulmonary Resuscitation Certification (CPR), and other required competencies. The cumulative effects of this deficient practice resulted in the hospital failing to meet the condition of participation for emergency services.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(6) Orders for the use of restraint or seclusion must never be written as a standing order or on an as needed basis (PRN). This Standard is not met as evidenced by: 45202 Based on a review of policies and procedures, facility documentation, medical record, and staff interviews, the Department determined the administrator failed to ensure patients receiving a chemical restraint were recognized as restraints, were not given as PRN medication and documented as being under restraint. This deficient practice poses a risk to the health and safety of patients if they are not monitored, assessed, and evaluated when under chemical restraint and could result in patient harm including death. Findings include: A.A.C. Title 9 Chapter 10 Article 1 states “...’Restraint’ means any physical or chemical method of restricting a patient ’ s freedom of movement, physical activity, or access to the patient ’ s own body....” Policy titled “Seclusion and Restraint Policy” ID 15084525, with an effective date of January 2024 states, “...Definitions...Chemical Restraint: A drug or medication that is not being used as a standard treatment for the patient’s medical or psychiatric condition and that results in restriction of the patient’s freedom of movement. This Hospital/Outpatient Clinic does not practice the use of chemical restraints...Seclusion: Any involuntary confinement of a patient alone in a room or area where he/she is physically prevented from leaving. This includes situations where a staff physically prevents the patient from leaving or gives the perception that threatens the patient with physical intervention if he/she attempts to leave the room...Policy:...seclusions/restraints are implemented only as a last resort to support patient safety when behaviors pose a risk of imminent harm to the patient or others....All patients have the right to be free from seclusion/restraint of any form that is imposed as a means of coercion, discipline, convenience or retaliation by staff...Seclusion/restraint procedures are considered to be unusual, high-risk events that warrant timely assessment and continuous monitoring....” The policy further states, “...Procedures...QRN - Qualified Trained RN...Initiates, in an emergency, a seclusion/restraint as a protective measure, provided that a Physician’s order is obtained as soon as possible, but no longer than 30 minutes after the initiation of the seclusion/restraint. The QRN will contact the attending Physician, on-call Physician, or appropriate Practitioners/Providers/Physicians responsible for the care of the patient, to obtain an order for the restraint or seclusion (in accordance with the Hospital policy and state law)...Ensures that the seclusion/restraint orders are NOT written as standing or PRN orders...” Patient #5: A review of the incident report for Patient #5 dated October 2, 2024 revealed, “...Haldol 10mg, Ativan 2mg, Benadryl 50mg given...for imminent danger to self....” A review of the orders dated October 2, 2024 revealed, “....Description ...Physical & Chemical...”, “...Description ...Haloperidol 5mg....”, “...Description...Lorazepam 2mg (Ativan 2mg)....”, and “...Description...diphenhydrAMINE HCL 50mg (Benadryl 50mg)....” A review of Patient #5’s seclusion/restraint documentation packet revealed the following interventions utilized: “...Physical Restraint ...PRN Medications....” Interview with October 21, 2024 through October 23, 2024, Employee #1, Employee #40 & Employee #41, confirmed that there was inconsistent documentation on the chemical restraint given to Patient #5 and there was documentation that it was given as a PRN medication. Patient #6: Incident report for Patient #6 dated October 8, 2024, revealed “...Physical restraint initiated at 1644....” A review of the orders dated October 8, 2024 revealed, “....Description...Physical Hold ...”, “...Description ...Diphenhydramine HCL 50mg...”, “...Description...Lorazepam 2mg/ml (Ativan 2mg/ml)...”, and “...Description ...Haloperidol Lactate 5mg/ml....” A review of Patient #6’s seclusion/restraint packet revealed the following interventions utilized: “...Physical Restraint ....” A request for documentation for the chemical restraint to ensure restraint protocols were followed for the chemical restraint was requested. None was provided. Patient #9: A review of the incident report for Patient #9 dated October 20, 2024 revealed, “...physical hold, pt was also medicated....” A review of the orders dated October 20, 2024 revealed, “....Description...Physical Hold....”, “...Description ...Haloperidol Lactate 5mg/ml....”, “...Description...Lorazepam 2mg/ml (Ativan 2mg/ml)....”, and “...Description ...Diphenhydramine HCL 50mg/ml....” A review of Patient #9’s seclusion/restraint packet revealed the following interventions utilized: “...Physical Hold....” A request for documentation for the chemical restraint to ensure restraint protocols were followed for the chemical restraint was requested. None was provided. Patient #10: A review of the incident report on August 23, 2024 for Patient #10 revealed, “...Code Help...was called in intake ...Patient #10 was placed in a physical restraint for DTS/DTO at 1940 (sic)....” The report further states, Employee #20 “...gave verbal orders at 1952 (sic)...for Haldol 10mg (sic) IM...Benadryl 50 mg IM...Ativan 2mg IM...Physical restraint D/C ’ d at 1956 (sic)....” A review of the orders dated August 23, 2024 for Patient #10 revealed chemical restraints, “....Haloperidol Lactate 5 mg/ml...Lorazepam 2mg/ml...Diphenhydramine HCL 50mg/ml....” An additional order for restraint was entered, “Behavioral Restraint...Physical Hold...Imminent threat of harm to self or others...SECLUSION/RESTRAINT MUST NEVER BE WRITTEN AS A PRN ORDER....” A review of Patient #10’s seclusion/restraint packet revealed the following interventions utilized: “...Physical Restraint ...PRN Medications....” Interview with October 21, 2024 through October 23, 2024, Employee #1, Employee #40 & Employee #41, confirmed that there was inconsistent documentation on the chemical restraint given to Patient #5 and there was documentation that it was given as a PRN medication. In an interview conducted on October 21, 2024 through October 23, 2024, Employee #1, Employee #40 & Employee #41, confirmed the facility failed to ensure patients receiving a chemical restraint were recognized as such and restraint procedures were not followed as a result.”

“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 review of policies and procedures, medical records, facility documents, and staff interview, the Department determined that the administrator failed to ensure medical screening examinations (MSE) were completed according to facility protocol to determine if an emergency medical condition existed. This deficient practice poses a risk to the health and safety of patients if life-threatening or potentially life-threatening conditions are not recognized and treated upon admission. Findings include: Policy titled “Admission Process Inpatient” ID 16398565, last updated: August, 2024 revealed, “...A nurse will begin the Admission Nursing Assessment by completing a full set of vital signs....” A review of the EMTALA Log for Patient #9 revealed that the Medical Screening Exam (MSE) was initiated 50 minutes after the patient’s arrival to the facility. A review of the EMTALA Log for Patient #10 revealed that the MSE was initiated 2 hours & 12 minutes after the patient’s arrival to the facility. A review of the medical record for Patient #18 revealed that the patient entered the facility, but left before any MSE was conducted. A review of the EMTALA Log for Patient #13 revealed that the MSE was initiated 40 minutes after the patient’s arrival to the facility. A review of the EMTALA Log for Patient #62 revealed that the MSE was initiated 1 hour & 25 minutes after the patient’s arrival to the facility. A review of the EMTALA Log revealed the MSE for 39 additional patients, Patient #23 through Patient #61, were not conducted in a timeframe of 40 minutes or less after the patients’ arrival to the facility. During an interview on October 23, 2024, Employee #13 confirmed that the facility’s policies and procedures do not state a specific timeframe for MSE to be conducted from the time of arrival. However, Employee #13 reported, “...Our goal is 15 minutes, but never over 30....” Employee #13 confirmed that a patient walking into the facility needs to be seen in 30 minutes or less to determine if they have a medical or psychiatric emergency that needs immediate treatment.”

“LICENSURE OF NURSING STAFF CFR(s): 482.23(b)(2) The nursing service must have a procedure in place to ensure that hospital nursing personnel for whom current licensure is required have a valid and current licensure. This Standard is not met as evidenced by: 45202 Based on review of facility policy, personnel records, and interview, the Administrator failed to ensure personnel members have acquired the specific skills and knowledge for the personnel member to provide the expected physical health services or behavioral health services listed in the established job description. This deficient practice can result in patient harm if unqualified staff are providing patient care outside their scope of practice. Findings include: Job description titled “Intake Coordinator” Job Code 3012, last revised August 2017, states “...Certifications, Licenses, Registrations: Current, in good standing, by the state of employment as LPC, LMSW, LCSW, PH.D, Psy.D or RN...CPR certification and SAMA training required prior to any patient contact...job function...Conduct intake assessments, triage...Provides recommendations in levels of care for the treatment of mental disorders....” Licenses as a LPC, LMSW, LCSW, PH.D, Psy.D or RN and SAMA training was requested for Employee #28 and #33. None was provided. Interview with Employee #13 on October 23, 2024, confirmed that Employee #28 and #33 were not licensed individuals and did not meet the job requirements for the position of intake coordinator by licensure and training.”

“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 review of policy, facility documents, personnel records, and interview, the Department determined the Nurse Executive failed to document that clinical oversight was provided for nine behavioral health technicians (Patient Care Assistant) (Employees #16, #17, #18, #19, #20, #21, #22, #23, and #24), at least once each two-week period if the Behavioral Health Technician (BHT) provides services related to patient care at the health care institution during the two-week period. This deficient practice poses a potential risk that staff is not adequately supervised by Behavioral Health Professionals (BHP) to provide services to patients that they do not have the education background to do independently. Findings include: Documentation for clinical oversight was requested for Employees #16, #17, #18, #19, #20, #21, #22, #23, and #24, for the months of July, August and September 2024. No documented clinical oversight was provided. Job description titled “Patient Care Assistant” describes the job duties as follows: “...Responsible for observation and maintenance of safe milieu through patient checks, safety monitoring, etc.: completes 15 minute checks...Adheres to tasks delegated by the RN related to the care of the patients including, but not limited to vital signs, specimen collection, documentation, group education, and patient monitoring...Facilitates or co-facilitates psychoeducational and therapeutic activity groups effectively...Employs appropriate crisis intervention and de-escalation techniques as required and according to policy and procedure...Provides pertinent feedback to the interdisciplinary treatment team regarding patient response to treatment interventions that assists in the development and revision of the treatment plan....” Policy titled “Clinical Oversight,” policy #16233991, last reviewed July 2024, states “...To provide consultation and oversight to any staff as needed and required by state-specific standards or regulations....” Behavioral Health Technician is defined as “”...an individual who is not a behavioral health professional who provides, with clinical oversight by a behavioral health professional, the following services to a patient to address the patient ’ s behavioral health issue: a. Services with clinical oversight by a behavioral health professional, services that, if provided in a setting other than a health care institution, would be required to be provided by an individual licensed under A.R.S, A.R.S. Title 32, Chapter 33; or b. Health-related services....” Health-related services is defined as :...services, other than medical, that pertain to general supervision, protective, preventive and personal care services, supervisory care services or directed care services....” Interview with Employee #2 confirmed that Employees #16, #17, #18, #19, #20, #21, #22, #23, and #24, performed health related services in July, August and September 2024, and that there is not documentation of clinical oversight.”

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 45202 Based on review of facility policy, personnel records and interview, the Administrator failed to ensure technical personnel are competent in their respective duties. This deficient practice can result in patient harm or death if food is not properly handled and becomes contaminated. Findings include: Policy titled: Kitchen Sanitation and Food Handling” Policy ID15182964, Last updated: March, 2024, does not address training procedures for personnel handling food. A policy regarding training that culinary assistants are provided was requested. None was provided. Evidence that Employee #34 and #35 were trained in proper food handling techniques was requested. None was provided. Interview with Employee #1 on October 23, 2024, confirmed that Employee #34 and #35 should have food handling training evidence and it was not able to be produced.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 45202 Based on the review of policy and procedure, medical record, and staff interview the facility failed to ensure the policies and procedures governing medical care provided in an emergency were implemented to ensure that the continuity of patient care needs has been facilitated when transferring a patient to another facility for a medical emergency. This deficient practice resulting in no transfer report (nurse to a nurse prior to patient transfer) and can result in patient’s not getting proper care at the new facility, not being aware of medical activities already performed, and can result in patient harm or death. . Findings include: Policy #16479503 titled “Transfer to Another Facility” last revised 09/2024, revealed, “...Transfer to an Emergency Room A. The RN (Registered Nurse) assesses and determines the patient has an unstable medical condition. The RN contacts the Physician and they provide orders to transfer the patient ...Complete a Transfer Form send the original with the patient and place a copy in the chart ....” Patient #21’s medical record revealed “...Disposition Comment ...returned pt to hospital ...” Patient #21’s medical record revealed no Transfer Form or documentation of a nurse to nurse report from the transferring facility to the receiving facility. Employee # 5 confirmed during an interview conducted on October 23, 2024, that there was no Transfer Form or documentation of a nurse to nurse report or evidence of acceptance from the receiving facility for Patient #21.”

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 45202 Based on review of policy, personnel files and staff interview, it was determined that the Hospital failed to ensure nursing personnel were qualified in emergency care by not maintaining up to date with current skills, Cardiopulmonary Resuscitation Certification (CPR), and other required competencies. This deficient practice may result in patient harm or death if staff are not properly trained and assessed for competency and skill level to participate in emergency care. Findings include: Policy titled “Staff Orientation Education, Development and Competency Plan for Clinical Facilities” policy #15961947, last reviewed June 2024, states “...All employees must attend a Facility orientation upon commencement of employment and complete competency reviews aligning with applicable standards...All employees are required to participate in specified curriculum of training as determined by regulatory requirements and Facility leadership....” Competency reviews specific to RN’s were requested. Interview with Employee #2 on October 23, 2024, confirmed that nursing specific competencies included a skills verification at hire, an EMTALA training and an annual Infection Control training. Competency reviews specific to BHT’s were requested. Interview with Employee #2 on October 23, 2024, confirmed that BHT specific competencies included a skills verification at hire. Policy titled “Staff Orientation Education, Development and Competency Plan for Clinical Facilities” policy #15961947, last reviewed June 2024, states “...Direct Care Staff must either present verification of Crisis Prevention Intervention (CP) and Cardiopulmonary resuscitation (CPR) certification or complete certification during their orientation period. Under no circumstances will Direct Care staff be allowed to work independently on a patient unit without these certifications....” Skills verification, EMTALA training, Infection Control training, and CPR as required were requested for Employee #5, #7, #9, #15, #24, #25, #27, #32, and #36. The following training’s were not provided: Skills verification was not provided for Employee #24. Orientation was not provided for Employee #17 EMTALA training was not provided for Employee #5, #7, #15, #25, #32, and #36. Infection control training was not provided for #5, #7, #15, #25, #32, and #36. Employee #15 and #27 had expired CPR in their personnel file. Employee #9 had no CPR in in their personnel file. Interview with Employee #2 on October 23, 2024, confirmed that the training documentation for Employee #5, #7, #9, #15, #24, #25, #27, #32, and #36 was not able to be provided.”