Destiny Springs Healthcare

“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 accordance with policies and procedures, licensing regulations and nursing standards of care. Findings include: The Condition level deficiency is the result of the standard deficiencies found in the following tag: Cross reference A-0394 The facility failed to ensure appropriate licensure of nursing staff. Cross reference A-0395 The facility failed to ensure appropriate supervision of non licensed staff providing nursing services. These deficient practices resulted in the facility’s failure to meet the requirement for Condition of Participation for Nursing Services.”

“UTILIZATION REVIEW CFR(s): 482.30 The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. This Condition is not met as evidenced by: 45202 Based on a review of documentation and interviews, it was determined the Governing Body failed to have implement an effective utilization review plan that provided for review of services provided by the institution and the members of the medical staff to patients. Findings include: Cross reference A-0652 The Governing Body failed to convene a utilization review committee consisting of two or more practitioners. Cross reference A-0654 The governing body failed to implement the utilization review policy for review for Medicare and Medicaid patients. The cumulative effect of the systematic deficient practice resulted in the facility’s failure to meet the requirement for the Condition of Participation for Utilization Review, which poses a potential risk to the health and safety of patients when the facility fails to ensure appropriate utilization evaluation is ongoing for patients and reported to the Governing Body.”

“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: 45202 Based on review of facility policy, medical records and staff interview, the Administrator failed to ensure that the hospital did not engage in self-referral by the ownership entity. This deficient practice can result in patients not receiving appropriate referrals and appropriate care based on a vested financial interest. Findings include: Section 1877 of the Social Security Act (the Act) (42 U.S.C. 1395nn), also known as the physician self-referral law: “...Prohibits a physician from making referrals for certain designated health services payable by Medicare to an entity with which he or she (or an immediate family member) has a financial relationship, unless the requirements of an applicable exception are satisfied; and Prohibits the entity from filing claims with Medicare (or billing another individual, entity, or third-party payor) for any improperly referred designated health services. A financial relationship may be an ownership or investment interest in the entity or a compensation arrangement with the entity....” A Change of Ownership application signed September 28, 2020, with the Department reported Vidushi Soni, MD as the owner of Destiny Springs Healthcare. No updated ownership information has been received by the Department since the change of owernship on September 28, 2020. Review of Patient #20: Pre Admission Assessment dated July 18, 2024, states “...arrived to DSH on 07/18/2024 as a walk in. Patient informed the writer he went to his schedule appointment to meet with his primary care, and was informed to come to DSH for Detox and depression behaviors...During the end of the assessment the Patient’s Primary Care Dr. Ashish called the Intake Department to provide further collateral of the Patient’s background for admission. Dr. Ashish informed the Intake nurse the Patient had suicidal ideation and was detoxing from alcohol. Dr. Ashish requested to speak with the Patient to know his status of the admission process. After an unknown conversation between Dr. Ashish and the Patient, Dr. Ashish was transferred to speak with the writer to provide further collateral of the Patient for the assessment. During the conversation the writer asked Dr. Ashish “Did the Patient stated to you that he was suicidal?”. Dr. Ashish replied to the writer “no he did not really said he was suicidal, he said that he was having depression and anxiety because of the stress he was receiving from work ,and also drinking alcohol everyday for the past 6 months.” The writer informed Dr. Ashish the admission process will move forward due to his referral of informing the Intake Department the Patient was suicidal. Dr. Ashish replied to the writer “that is just misunderstanding. Let the Patient leave and I will put the Patient in my Out Patient Program.” The writer informed Dr. Ashish on what the discharge process will be for the Patient and that he does not have that approval to decide for the Patient to leave. Dr. Ashish informed the writer he will speak with Dr. Soni on this matter. After the conversation with Dr. Ashish, the writer recieved a call from Dr. Soni on this matter. The writer informed Dr. Soni all the information that occured in the Patient’s assessment and the conversation that occured with Dr. Ashish. Dr. Soni recommended to continue with the admission process and to inform Gregory Carr, MD on this matter. The writer informed the Intake Nurse of the information that was shared by Dr. Ashish and Dr. Soni. The writer also informed the Intake Nurse an update needs to be made to Gregory Carr, MD of the status on the Patient....” Nursing note dated July 19, 2024, states “...Pt stated;...I went to see a brand new PCP for an annual health check up...when when we sat down he asked me why my BMI is so high...PCP said it would be better to reduce body size...should think about Detox Center...we then asked how much it cost, he said that he had no details about it just stop by and inquire about the details and programs don’t worry about the price I will include it as Stress and SI that way insurance will pay for it all...while driving home decided to stop by to inquire further about the programs and how much it would cost...we inquired further about the programs...approximately 5:30pm and I started signing all the documentation,once completed and I selected to not sign the consent form said that we are free to go and once we signed, and that is when was not allowed to leave I then called my wife and she was shocked and so she called the PCP and he said it is ok it is just to cover the insurance part and he said don’t worry I am giving them a call....” Nursing note from July 19, 2024, further states “...PT CAME TO FLOOR, PT VSS, PT DENIES ANXIETY, DEPRESSION, SI, HI AND AVH AT THIS TIME. PT STATED,” I ONLY HAVE STRESS FROM MY BUSINESS....” Nurse Practitioner note dated July 19, 2024, states “...Pt is future and goal oriented. Patient’s mood is reported to be much improved. Symptoms of depression are convincingly denied. Feelings of anxiety are denied. Pt denies SI, HI, AVH. Pt is future oriented. Sleep quality has improved. Energy level is at baseline. Discussed discharge with Dr. Soni and medical director Dr. Carr. Ok to discharge....” Interview with Employee #2 on November 14, 2024, confirmed that Dr. Soni is the owner of Destiny Springs and is the owner of the private practice which refered Patient #20 to Destiny Springs on July 19, 2024.”

“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 facility job descriptions, personnel files, and staff interviews, the Department determined the administrator failed to ensure personnel records contained evidence that Employee #45 had a current Arizona Registered Nursing License. This deficient practice poses a potential risk to the overall health and safety of patients at the facility if personnel members do not have a current license necessary to provide patient care services. Finding include: Documentation from Arizona State Board of Nursing, Nurse Licensure Compact (NLC) revealed, “...When relocating to another compact state, it is the nurse’s responsibility to apply for licensure by endorsement. This should be completed within 60 days of relocation ....” Facility document titled “Job Description Registered Nurse” revealed, “...Required Education/Experience: Must possess a current Arizona RN license ...” Request for Employee #45’s current Arizona RN license was made on November 15, 2024. A Multistate license for Mississippi with an expiration date of 12/31/2024, for Employee #45 on November 15, 2024. Employee #2 confirmed on November 15, 2024, that Employee #45 had a start date of 02/01/2021, with the facility, and had no Arizona License for review.”

“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 12 Behavioral Health Technicians (BHT) at least once each two-week period if the 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: Policy titled, Clinical Oversight, #PC049 last revised: July 12, 2022, revealed “...Clinical oversight is provided at a minimum once every two weeks if the behavioral health technician or paraprofessional provides services related to client care....” Documentation for clinical oversight review was reviewed on November 13, 2024, for Employees #12, #15, #16, #21, #22, #23, #24, #26, #30, #32, #33, and #35 for the months of August, September, and October 2024. The following clinical oversights were missing: Employee #12 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversights in October 2024. Seven total missing. Employee #15 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversight in October 2024. Five total missing. Employee #16 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing. Employee #21 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & two clinical oversight in October 2024. Six total missing. Employee #22 was missing two clinical oversights in August 2024, missing one clinical oversight in September 2024 & three clinical oversight in October 2024. Six total missing. Employee #23 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing. Employee #24 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversights in October 2024. Seven total missing. Employee #26 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing. Employee #30 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing. Employee #32 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & three clinical oversight in October 2024. Six total missing. Employee #33 was missing one clinical oversight in August 2024, missing two clinical oversights in September 2024 & two clinical oversights in October 2024. Five total missing. Employee #35 was missing two clinical oversights in August 2024, missing two clinical oversights in September 2024 & three clinical oversight in October 2024. Seven total missing. A total of 69 sessions were missing for the 12 employees. Employee #9 confirmed in an interview on November 13, 2024, that available documentation of Clinical Oversight is located in individual employee files. The Department requested additional Clinical Oversight documentation on November 15, 2024 at 09:16, documentation for clinical oversight from October 30, 2024 was provided and reviewed.”

“UTILIZATION REVIEW COMMITTEE CFR(s): 482.30(b) A UR committee consisting of two or more practitioners must carry out the UR function. At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in §482.12(c)(1). (1) Except as specified in paragraphs (b)(2) and (3) of this section, the UR committee must be one of the following: (i) A staff committee of the institution; (ii) A group outside the institution-- (A) Established by the local medical society and some or all of the hospitals in the locality; or (B) Established in a manner approved by CMS. (2) If, because of the small size of the institution, it is impracticable to have a properly functioning staff committee, the UR committee must be established as specified in paragraph (b)(1)(ii) of this section. (3) The committee or group’s reviews may not be conducted by any individual who-- (i) Has a direct financial interest (for example, an ownership interest) in that hospital; or (ii) Was professionally involved in the care of the patient whose case is being reviewed. This Standard is not met as evidenced by: 45202 Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to have a Utilization Review committee with two or more practioner’s. This deficient practice poses a risk to the health and safety of the patients, when there is not at least two doctors on the Utilization Review Committee to evaluate a patient’s continued hospital stay and/or discharge. Findings include: Review of policy titled “Utilization Review Plan,” Policy #LD035, Last Reviewed July 24, 2024, states “...Destiny Springs Hospital meets this CMS provision through a contract with a Quality Improvement Organization (QIO). This organization is LIvanta. Livanta is reposible for reviewing services furnished to Medcicare benificiaries.....” A contract with Livanta was requested on November 13, 2024. Interview with Employee #1 and Employee #3 on November 13, 2024 confirmed that the facility does not have a contract with a QIO and does their own Utilization Committee. “Utilization Review Plan” states “...Destiny Springs montors service utilization through an interdepartmental Utilization Review Committee (URC) which consists of clinical, nursing, admissions, finance, and administration....” A request for Utilization Committee meeting minutes were requested on November 13, 2024, for the past year. Employee #3 provided “UM Committee” notes dated October 18, 2024, which states “...UM Committee will be meeting quarterly....” A request was once again made for the previous three quarters. None was provided. UM Committee attendees for October 18, 2024, included a list of “Staff Attending” which included one doctors of medicine or osteopathy. Interview with Employee #3 on November 13, 2024, confirmed that the UM Committee on October 18, 2024, had one doctors of medicine or osteopathy present.”

“SCOPE AND FREQUENCY OF REVIEW CFR(s): 482.30(c) (1) The UR plan must provide for review for Medicare and Medicaid patients with respect to the medical necessity of-- (i) Admissions to the institution; (ii) The duration of stays; and (iii) Professional services furnished including drugs and biologicals. (2) Review of admissions may be performed before, at, or after hospital admission. (3) Except as specified in paragraph (e) of this section, reviews may be conducted on a sample basis. (4) Hospitals that are paid for inpatient hospital services under the prospective payment system set forth in Part 412 of this chapter must conduct review of duration of stays and review of professional services as follows: (i) For duration of stays, these hospitals need review only cases that they reasonably assume to be outlier cases based on extended length of stay, as described in §412.80(a)(1)(i) of this chapter; and (ii) For professional services, these hospitals need review only cases that they reasonably assume to be outlier cases based on extraordinarily high costs, as described in §412.80(a)(1)(ii) of this chapter. This Standard is not met as evidenced by: 45202 Based on review of hospital policy, hospital documents, and staff interviews, it was determined the hospital failed to implement a Utilization Review process. This deficient practice poses a risk to the health and safety of the patients, when there is not a Utilization Review Committee to evaluate a patient’s continued hospital stay and/or discharge. Findings include: Review of policy titled “Utilization Review Plan,” Policy #LD035, Last Reviewed July 24, 2024, states “...Destiny Springs Hospital meets this CMS provision through a contract with a Quality Improvement Organization (QIO). This organization is Livanta. Livanta is responsible for reviewing services furnished to Medicare beneficiaries.....” A contract with Livanta was requested on November 13, 2024. Interview with Employee #1 and Employee #3 on November 13, 2024 confirmed that the facility does not have a contract with a QIO and does their own Utilization Committee. “Utilization Review Plan” also states “...Destiny Springs monitors service utilization through an interdepartmental Utilization Review Committee (URC) which consists of clinical, nursing, admissions, finance, and administration....” A request for Utilization Committee meeting minutes were requested on November 13, 2024, for the past year. Employee #3 provided “UM Committee” notes dated October 18, 2024, which states “...UM Committee will be meeting quarterly....” A request was once again made for the previous three quarters. None was provided. Interview with Employee #3 on November 13, 2024, confirmed that there is no additional documentation that the UM Committee has met once over the course of the year and not quarterly and they do not have a QIO contract in place as per policy.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 45202 Based on a review of facility documentation, medical records and staff interview, the Department determined that the administrator failed to ensure that a medical record for two patients was established & maintained. This deficient practice poses the risk of patient treatment not being accurate, timely and continuity of care being compromised. Findings include: Policy #PI005 titled “EMTALA”, last revised: July 12, 2022 revealed, “...Destiny Springs Healthcare shall provide a medical screening examination to any individual who comes to the Emergency Department....” Facility documentation titled “EMTALA & Patient Flow” revealed, “...We must provide an MSE to EVERYONE who presents at our ‘dedicated emergency department’...” Facility document titled “EMTALA Log” identified the following patients and corresponding information: Patient #11: November 1, 2024, Arrival: 2251, Car/Vehicle, Psych Emergency: No, Departure: 2320 Disposition: “911 called pt transferred to ER. SI and detox and No more information” Patient #14: November 3, 2024, Consents Sent: 0940, Walk-in, Comments: “PENDING N2N Pt was released back to her GH Pending Consents” Patient #11, and Patient #14 medical record were requested on November 13, 2024 and on November 15, 2024. None were provided. Interview with Employee #2 and Employee #12 on November 15, 2024, confirmed that a medical records were not available to review for Patient #11 and #14.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. 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 policy 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 #PI005 titled “EMTALA”, last revised: July 12, 2022 revealed, “...Destiny Springs Healthcare shall provide a medical screening examination to any individual who comes to the Emergency Department....” Facility documentation titled “EMTALA & Patient Flow” revealed, “...We must provide an MSE to EVERYONE who presents at our ‘dedicated emergency department’...” Facility document titled “EMTALA Log” identified the following patients and corresponding information: Patient #1 ’ s medical record revealed, “...Pt ’ s MSE completed by day shift RN ...” A request was made for documentation of the MSE completed by the RN. None was provided. No other documentation of a completed MSE was revealed in the medical record. Patient #11: November 1, 2024, Arrival: 2251, Car/Vehicle, Psych Emergency: No, Departure: 2320 Disposition: “911 called pt transferred to ER. SI and detox and No more information” Patient #14: November 3, 2024, Consents Sent: 0940, Walk-in, Comments: “PENDING N2N Pt was released back to her GH Pending Consents” Patient #1, Patient #11, and Patient #14 Medical Screening Exams were requested on November 13, 2024 and on November 15, 2024. None were provided. Interview with Employee #2 and Employee #12 on November 15, 2024, confirmed that a MSE were not available to review for Patient #1, #11 and #14.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 45618 Based on review of hospital policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by the hospital’s failure to: Cross reference A-0145: A failure to appropriately investigate and report potential abuse of a minor patient; Cross reference A-0159: The inability to recognize a physical hold for any length of time was a physical restraint; Cross reference A-0167: There was a failure to ensure physical restraints were conducted safely, after a patient suffered a serious injury, to prevent further injuries to patients; Cross reference A-0168: Failing to uphold patient rights by physically restraining patients only on the order of a licensed practitioner; Cross reference A-0169: Failing to ensure patients were not subjected to restraints on an as needed basis; Cross reference A- 0178: Ensuring patients received a face to face evaluation after receiving a physical restraint. 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.”

“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: 45618 Based on review of documents and staff interview, it was determined the Administrator 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: Document titled “Position Title: Chief Executive Officer,” revealed: “...Establishes credibility throughout the organization and with the executive staff as an effective developer of solutions to business challenges. 2. Provides leadership and management to ensure that the mission and core values of the company are put into practice...Fosters a success-oriented, accountable environment within the organization...This position manages subordinate supervisors who supervise employees and is responsible for the overall direction, coordination and evaluation of these units. The CEO also directly supervises non-supervisory employees. This position’s responsibilities include: interviewing, hiring and training employees...disciplining employees; addressing complaints and resolving problems....” During the survey it was determined the CEO failed to perform the core functions of the CEO as demonstrated by the following: Cross reference A-0145: A failure to protect patients from staff abuse; Cross reference A-0159: The inability to recognize a physical hold for any length of time was a physical restraint; Cross reference A-0167: There was a failure to ensure physical restraints were conducted safely, after a patient suffered a serious injury, to prevent further injuries to patients; Cross reference A-0168: Failing to uphold patient rights by physically restraining patients only on the order of a licensed practitioner; Cross reference A-0169: Failing to ensure patients were not subjected to restraints on an as needed basis; Cross reference A- 0178: Ensuring patients received a face to face evaluation after receiving a physical restraint.”

“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: 45618 Based on a review of hospital record and interview, it was determined the hospital failed: 1. to protect Patient #1 from potential abuse, when Patient #1 suffered a fractured humerus while under staff care. 2. to protect Patient #2 from potential abuse, when Patient #2 was physically assaulted by an employee. This deficient practice poses the risk of further injury or death to patients while under the care of the facility. Findings Include: Policy titled, “Abuse, Assault or Neglect of a Patient,” revealed: “...All staff members are expected to treat patients with the utmost respect and dignity. Any evidence to the contrary will not be tolerated and will be subject to disciplinary action ...An employee suspected to have physically, verbally, or sexually abused a patient shall be subject to disciplinary action up to, and including, the possibility of termination. The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report. The above listed administrators will be responsible for conducting the investigation ...At the conclusion of the investigation if the facility has reasonable suspicion that the employee, did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire. Any employee that is a professional licensed or eligible for licensure will be reported to their respective state professional Board. The hospital also reserves the right to contact local law enforcement ...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later than twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation. ...” Policy titled, “Seclusion and Restraint,” revealed: “...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient ’ s body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...The nurse will assign trained staff to continuously monitor the patient during the restraint event. The staff member will visually monitor the patient ’ s physical and psychological condition...The person monitoring the patient must be trained to respond to an emergency should one occur...An RN will conduct a patient debriefing following each use of seclusion or restraint. Documentation of the debriefing shall include the following information...Any injuries to patients or staff...All seclusion and restraints may be reviewed via video to help ensure that the patient ’ s rights are respected as well as protecting the health and safety of the staff and patients...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints....” Policy titled “Incident Reporting Policy,” revealed: “...Incidents may include but are not limited to...a. injury to patient - accidental or intentional...i. Any unusual event that deviates from policy...Upon receipt, Quality Director or designee completes the investigation and notes any areas requiring follow-up...Events are analyzed for patterns and systems failures. However, if upon investigation, an adverse event appears to have been a result of intentional or neglectful action by staff, staff is subject to discipline....” Patient #1: Patient #1’s medical record contained a note titled “Seclusion and Restraint Individual,” dated 06/22/2024, which revealed: “...Pt did not take meds willingly required personal restraint. Meds given in room...Personal Restraint...Start time: 1924 End time: 1924...Name/Credentials/Title of Primary Individual involved in the Restraint: (Employee #5, Employee #7, Employee #12, Employee #14)...Description of Member Condition...Patient stated that [her] “f**king arm hurts.”, {sic} sat on [her] bed, tearful and allowed RN to assess [her] arm...Information discussed during the debriefing: Prevention of escalating behaviors, unit activities, safety planning....” Employee #7’s written statement dated 06/22/2024, revealed: “...Staff had to put [her] in a personal hold to safely administer the medication. Patient started to kick at staff...and then kicked off the wall and twisted [her] body. Staff reported that they heard a “pop” sound. Patient yelled that, “you hurt my f**king arm!”...The medication was administered, patient was released and [she] sat on [her] bed. TW assessed [her] left arm. No redness, swelling, or protrusion noted at this time. TW called the IM provider on call and requested to send patient to the ED for an x-ray...Maricopa Transport arrived at 2009 and escorted patient to [Del Webb] at 2011....” Employee #8’s written statement dated 06/22/2024, revealed: “...At approx 19:30 staffs were asked to assist Patient to receiving [her] shots due to patient refusing to taking them. While assisting the patient to the east wall of [her] room. Patient jumped up and kicked the causing [her] to hyperextend [her] left shoulder. Medical attention where {sic} given to patient no further incident....” Employee #5’s written statement dated 06/22/2024, revealed: “...Pt refused to go to exam room for medication administration but was willing to go into [her] room. This nurse, second RN and to{sic}BHT staff members went into pt room to administer medications. Pt sat on [her] bed and then refused to take ordered meds. Pt was informed that [she] would be placed in a hold while medications were given and pt became extremely agitated...Pt used [her] feet to push against the wall and continued kicking. Once pt was facing the wall and continued kicking. Once pt was facing the wall [she] yelled “you f**king hurt my arm” and BHT stated [he] heard a “pop.” Medication administration was completed and pt was released. Pt sat on [her] bed and was tearful stating [her] arm hurt. Pts arm was assessed by [her] RN and provider notified. Pt was sent to ED for xray and exam....” Employee #12’s written statement dated 06/22/2024, revealed: “...Once pt was put in a hold to receive shots. Once pt was put in a hold [she] began to jerk [her] body around and kicking. As we moved out way towards the wall pt kicked [her] legs up and tried to push off wall. Once the pt did that you could hear a pop, immediately after the popping noise pt screamed “you hurt my arm”. Pt then received shots and sat back down on bed as the nurses examined [her] arm....” Patient #1’s medical record contained a note titled “Nursing Note,” dated 06/23/2024, which revealed: “...This writer called [Banner Del E. Webb] ER to get an update on this patient...an employee of [Banner] informed this writer that patient sustained left Humerus Fracture, and that the Social Workers will be investigating how [she] sustained this injury, that for the mean time, they were not comfortable send this patient back to Destiny Springs....” Patient #1’s medical record from [Banner Del E. Webb], contained a note titled “ED Pertinent Report,” which revealed: “...Patient was then restrained by staff which caused sudden onset of pain of [her] left arm...I feel that the patient’s presentation is most consistent with left midshaft spiral humerus fracture with angulation and shortening...I spoke with [Dr. Vu], [Banner Pediatric] Orthopedic Surgery, regarding the patient’s case...States the patient will require plating but recommends following up in the clinic in 2 weeks....” Patient #1’s medical record from [Banner Del E. Webb], contained a note titled “Diagnostic Radiology,” which revealed: “...Elbow 3 or More Views Lt...Impression: Acute, spiral-type fracture of the left distal humeral diaphysis with medial angulation and posterior displacement....” Employee #2 confirmed in an interview on 06/25/2024, Patient #1 was placed in a physical hold to receive an IM medication, and was injured during the hold and sent to the ED. Employee #2 further confirmed, the hold took place in the patient bedroom where there is no video footage. Employee #2 further confirmed there were no actions taken by the hospital as a result of the event, and Employees #5, 7, 8, and 12, were not placed on administrative leave while an investigation took place. Employee #2 also confirmed the facility determined the patient suffered a broken arm due to their own actions. Patient #2: Video footage from the Intake Department, dated 06/15/2024, revealed: 13:25:44 - Employee #11 and Patient #2 seen walking down hallway 13:26:24 - Patient #2 picks up mop from unattended EVS cart and throws mop at Employee #11 13:26:25 - Employee #11 tackles Patient #2 to the floor, holding Patient #2 between the wall and EVS cart, on his back. Patient #2 is observed hitting left side of head on EVS cart. Employee #11 is on top of Patient #2. Employee #11 is seen extending their legs while shifting their upper body onto Patient #2 ’ s upper body. 13:26:33 - Patient #2 observed with legs twitching, still under Employee #11. No change in restraint 13:27:06 - Patient #2 observed with legs/body not moving. Employee #11 shifted weight back, and Patient #2 positioned on left side. Employee #11 is holding Patient #2 ’ s arms with their right hand, and Employee #11 ’ s left hand was on Patient #2 ’ s right shoulder. 13:28:15 - Employee #11 releases Patient #2 from hold and stands up. Patient #2 is observed struggling to stand up from floor. Blood observed on floor from where Patient #2 ’ s head was. 13:33:12 Code team arrives. Document titled, “Daily Assignment,” revealed Employee #11 was on duty 06/19/2024, 06/20/2024, 06/21/2024, and 06/22/2024. Document titled, “Incident Report 6/15/24”, written by Employee #16 revealed: “...(Patient #2) turned to swing stick at (Employee #11). Staff proceeded to block stick and leaped at patient, knocking patient onto floor ....” Document titled, “Incident Report 6/15/24”, written by Employee #17 revealed: “...I saw (Patient #2) arguing grabing {sic} [his] belongings and (Employee #11) walking arguing with the patient to have a seat. (Patient #2) got upset [he] could not go out for a smoke pointed at (Employee #11) ’ s face told [him] to ’ leave [him] alone liar ’ . (Employee #11) continued to tell (Patient #2) to sit down don ’ t be pointing in [his] face. (Patient #2) then grabed {sic} a mop stick from housekeeping cart and swung it at (Employee #11) saying ’ I said to back tf up man leave me alone ’ (Employee #11) tackled (Patient #2) onto house keeping cart. (Patient #2) head hit the cart and rib on [his] left side ...” Document titled, “Written Warning Form,” revealed: “...Final Written Warning ...(Employee #11) attempted a 1-person restraint, and the patient was injured in the process. Pt had laceration to left brow and shoulder. When reviewing camera footage, it is observed, (Employee #11) used excessive force when attempting to restrain the pt ... Plan for Improvement (be specific): (Employee #11) will be required to complete CPI to help re-train and re-educate [him] on proper holds and de-escalation techniques ....” Restraint documentation and orders were requested and none provided. Employee #1 confirmed during an interview conducted on 7/2/2024, Employee #11 was not placed on administrative leave or terminated following this incident. Employee #1 also confirmed they did not follow policy due to Employee #11 not having any other incidents similar to this. Employee # 2 confirmed during an interview conducted on 07/03/2024, Employee #11 was given a final written warning, retraining, and weekly monitoring and oversight from the Intake Director.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(i)(A) Definitions. (i) A restraint is- (A) Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or This Standard is not met as evidenced by: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients who were restrained in a personal hold by staff were recognized as being under a physical restraint. This deficient practice poses the risk of a patient being physically restrained unnecessarily, and proper restraint procedures, such as de-escalation, and appropriate monitoring, not being performed. Findings include: Policy titled, “Seclusion and Restraint,” revealed: “...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints.....” Video footage from the Monarch Unit, dated 06/22/2024, revealed: 19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14. Video footage from the Lotus Unit, dated 06/25/2024, revealed: Patient #8 was placed in a physical restraint at 19:48, by an employee, who was then relieved by Employee #18 and #21. Patient #8 was placed in a physical restraint at 19:53, by Employee #18 for an undetermined amount of time as both exit the video field of view at 19:56 with physical hold still in place. Patient #10 was placed in a physical restraint at 19:53 until 19:54, by Employee #7 and Employee #21. Patient #11 was placed in a physical restraint at 19:53 until 19:54, by Employee #22 and Employee #23. Restraint documentation and orders were requested for Patient #3, #4, #6, #8, #10 and #11, and none were provided. Employee #2 confirmed in an interview conducted on 06/27/2024, Patient’s #4, #6, and #3, were in a physical restraint for less than five minutes, therefore they are not required to have orders or restraint documentation.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure restraints were conducted safely, resulting in Patient #1 suffering a fractured humerus. This deficient practice poses the risk of further injury or death to patients. Findings include: Policy titled, “Seclusion and Restraint,” revealed: “...It is the intent of Destiny Springs Healthcare to provide a safe environment for patients and staff, utilizing the least restrictive environment needed to achieve the best outcomes...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body...Following the initiation of restraint or seclusion the RN shall...Determine the person’s current physical, emotional and mental status...The nurse will assign trained staff to continuously monitor the patient during the restraint event. The staff member will visually monitor the patient’s physical and psychological condition. If the patient is observed to be in physical or psychological distress, the monitoring staff member will immediately alert an RN...The person monitoring the patient must be trained to respond to an emergency should one occur...An RN will conduct a patient debriefing following each use of seclusion or restraint. Documentation of the debriefing shall include the following information...Any injuries to patients or staff...All seclusion and restraints may be reviewed via video to help ensure that the patient’s rights are respected as well as protecting the health and safety of the staff and patients...The Chief Quality Officer, or designee, will report any incidents of Seclusion and Restraint that result in an injury or complication requiring medical attention to the Health Plan within 24 hours through the AHCCCS IAD portal....” Patient #1’s medical record contained a note titled “Seclusion and Restraint Individual,” dated 06/22/2024, which revealed: “...Pt did not take meds willingly required personal restraint. Meds given in room...Personal Restraint...Start time: 1924 End time: 1924...Name/Credentials/Title of Primary Individual involved in the Restraint: (Employee #5, Employee #7, Employee #8, Employee #12)...Description of Member Condition...Patient stated that [her] “fucking arm hurts.”, {sic} sat on [her] bed, tearful and allowed RN to assess [her] arm...Information discussed during the debriefing: Prevention of escalating behaviors, unit activities, safety planning....” Employee #7’s written statement dated 06/22/2024, revealed: “...Staff had to put [her] in a personal hold to safely administer the medication. Patient started to kick at staff...and then kicked off the wall and twisted [her] body. Staff reported that they heard a “pop” sound. Patient yelled that, “you hurt my f***ing arm!”...The medication was administered, patient was released and [she] sat on [her] bed. TW assessed [her] left arm. No redness, swelling, or protrusion noted at this time. TW called the IM provider on call and requested to send patient to the ED for an x-ray...Maricopa Transport arrived at 2009 and escorted patient to Del Webb at 2011....” Employee #8’s written statement dated 06/22/2024, revealed: “...At approx 19:30 staffs were asked to assist Patient to receiving [her] shots due to patient refusing to taking them. While assisting the patient to the east wall of [her] room. Patient jumped up and kicked the causing [her] to hyperextend [her] left shoulder. Medical attention where {sic} given to patient no further incident....” Employee #5’s written statement dated 06/22/2024, revealed: “...Pt refused to go to exam room for medication administration but was willing to go into [her] room. This nurse, second RN and to{sic}BHT staff members went into pt room to administer medications. Pt sat on [her] bed and then refused to take ordered meds. Pt was informed that [she] would be placed in a hold while medications were given and pt became extremely agitated...Pt used [her] feet to push against the wall and continued kicking. Once pt was facing the wall and continued kicking. Once pt was facing the wall [she] yelled “you f***ing hurt my arm” and BHT stated [he] heard a “pop.” Medication administration was completed and pt was released. Pt sat on [her] bed and was tearful stating [her] arm hurt. Pts arm was assessed by [her] RN and provider notified. Pt was sent to ED for xray and exam....” Employee #12’s written statement dated 06/22/2024, revealed: “...Once pt was put in a hold to receive shots. Once pt was put in a hold [she] began to jerk [her] body around and kicking. As we moved out way towards the wall pt kicked [her] legs up and tried to push off wall. Once the pt did that you could hear a pop, immediately after the popping noise pt screamed “you hurt my arm”. Pt then received shots and sat back down on bed as the nurses examined [her] arm....” Patient #1’s medical record contained a note titled “Nursing Note,” dated 06/23/2024, which revealed: “...This writer called [Banner Del E. Webb] ER to get an update on this patient...an employee of [Banner] informed this writer that patient sustained left Humerus Fracture, and that the Social Workers will be investigating how [she] sustained this injury, that for the mean time, they were not comfortable send this patient back to Destiny Springs....” Patient #1’s medical record from [Banner Del E. Webb], contained a note titled “ED Pertinent Report,” which revealed: “...Patient was then restrained by staff which caused sudden onset of pain of [her] left arm...I feel that the patient’s presentation is most consistent with left midshaft spiral humerus fracture with angulation and shortening...I spoke with [Dr. Vu], [Banner Pediatric] Orthopedic Surgery, regarding the patient’s case...States the patient will require plating but recommends following up in the clinic in 2 weeks....” Patient #1’s medical record from Banner Del E. Webb, contained a note titled “Diagnostic Radiology,” which revealed: “...Elbow 3 or More Views Lt...Impression: Acute, spiral-type fracture of the left distal humeral diaphysis with medial angulation and posterior displacement....” Employee #2 confirmed in an interview on 06/25/2024, Patient #1 was placed in a physical hold to receive an IM medication, and was injured during the hold and sent to the ED. Employee #2 also confirmed the injury was not included in the debriefing. Employee #2 further confirmed there were no actions taken by the hospital as a result of the event, and Employees #5, 7, 8, and 12, were not placed on administrative leave while an investigation took place. Employee #2 confirmed it was determined by the hospital the patient caused the injury by their actions during the restraint.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 45618 Based on a review of hospital records and interview, it was determined the hospital failed to ensure patients were only placed in a physical restraint with an order from a licensed provider. This deficient practice poses the risk of a patient being physically restrained unnecessarily and a violation of patient rights. Findings include: Policy titled, “Seclusion and Restraint,” revealed: “...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints.....” Video footage from the Monarch Unit, dated 06/22/2024, revealed: 19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14. Video footage from the Lotus Unit, dated 06/25/2024, revealed: Patient #8 was placed in a physical restraint at 19:48, by an employee, who was then relieved by Employee #18 and #21. Patient #8 was placed in a physical restraint at 19:53, by Employee #18 for an undetermined amount of time as both exit the video field of view at 19:56 with physical hold still in place. Patient #10 was placed in a physical restraint at 19:53 until 19:54, by Employee #7 and Employee #21. Patient #11 was placed in a physical restraint at 19:53 until 19:54, by Employee #22 and Employee #23. Restraint documentation and orders were requested for Patient #3, #4, #6, #8, #10, and #11 for these episodes, and none were provided. Employee #2 confirmed in an interview conducted on 06/27/2024, Patient’s #4, #6, and #3 were in a physical restraint for less than five minutes, therefore they are not required to have orders or restraint documentation.”

“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: 45618 Based on a review of hospital record and interview, it was determined the hospital failed to ensure restraint and seclusion orders were time limited and not used for a second episode of restraint and seclusion. This deficient practice poses the risk of a restraint and seclusion order being used as a PRN order or on an as needed basis. Findings include: Policy titled “Seclusion and Restraint,” revealed: “... Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...If restraint or seclusion use needs to be continued beyond the expiration of the time-limited order, a new order for restraint or seclusion is obtained.....” Patient #7’s medical record contained a note titled “Seclusion and Restraint Individual Reporting Form,” dated 06/25/2024, which revealed: “...Personal Restraint...Start time: 1947 1st hold End time: 1948/ 2nd hold 2036-2037 1 minute...Seclusion...1st Seclusion...Start time: 1950 End time: 2027...Minutes: 37 minutes/2nd seclusion 2037-2122 55 minutes...Pt refused to follow directions and started to throw books at staff. Patient was taken to seclusion 2nd time....” Patient #7’s medical record contained a form titled “Physician Orders Seclusion and Restraint Order,” dated 06/25/24, which revealed: “...Date and time order obtained: 6/25/24 1945...Order for: Seclusion; Personal Restraint; Chemical Restraint; Seclusion/Restraint start time 1947 for max 2 hours....” An order for the second seclusion and restraint episode that began at 20:36 was requested and could not be provided. Employee #4 confirmed in an interview conducted on 07/05/2024, there was not a provider order for the second seclusion and restraint episode. Employee #4 further confirmed that patient restraint and seclusion orders are good for two hours, so if the patient gets released from one restraint or seclusion incident, and need another one within the two hour time frame, a second order is not needed, they can still use the first order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 45618 Based on a review of hospital record and interview, it was determined the hospital failed to ensure patients undergoing restraint, had a face to face evaluation. This deficient practice poses the risk of physical or psychological injury to the patient going unreported after a restraint is used. Findings include: Policy titled, “Seclusion and Restraint,” revealed: “...Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body. A personal restraint does include holding a patient for no longer than five minutes, without undue force, in order to calm or comfort the patient...Following the initiation of restraint or seclusion, the RN shall...Obtain the order from the physician, cannot be a standing order...The order shall indicate the reason and maximum duration of restraint, date and time of assessment...The registered nurse will document they type of restraint i.e...: personal, seclusion, chemical...The patient shall be monitored and reassessed through continuous in- person observation and documented on the Seclusion and Restraint Observation Form...An AHCCCS seclusion and restraint packet and patient observation form must be completed after all seclusion and restraints.....” Video footage from the Monarch Unit, dated 06/22/2024, revealed: 19:46:29 - Patient #4 in a physical restraint, performed by Employee #9; Patient #6 in a physical restraint, performed by Employee # 13; Patient #3 in a physical restraint performed by Employee #14. Restraint documentation and orders were requested for Patient #3, #4, and #6, and none were provided. Employee #2 confirmed in an interview conducted on 06/27/2024, Patient’s #4, #6, and #3, were in a physical restraint for less than five minutes, therefore they are not required to have the documentation required for a restraint.”

“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: 45618 Based on record reviews and staff interviews, it was determined the hospital failed to ensure there were sufficient numbers of nursing staff to provide patient care according to hospital policies and procedures for 13 shifts in the past 2 months. This deficient practice poses a risk to the health and safety of patients when there is insufficient staff on the units to meet patient needs, and resulting in inadequate monitoring of patients. Findings include: Policy titled, “Staffing/Acuity Plan,” revealed: “...Determination of staffing needs based on scoring as follows: a. Review the Core Staffing Matrix which identifies the number of RN’s and BHT’s needed without acuity per unit per shift...RN assess each patient under the 5 categories...on a scale of 1 to 4 per the acuity plan...Each category is calculated and averaged to come up with the average score which equals acuity for the unit...The supervisor will reference the key below the average score on the acuity form in identify the next step in adding, deleting staffing....” Document titled, “Core Staffing Nursing,” revealed on night shifts, defined as 23:00 to 07:00, by the facility, each unit should have one RN and two BHTs, without factoring in acuity, if there are nine or more patients in the unit. The document also revealed four of the units, with the exception of the Monarch unit, should have two RNs and two BHTs for a census of six patients or more, for the afternoon shift, defined by the facility as 15:00 to 23:00, without factoring in the patient acuity. Documents titled “Daily Assignment,” were reviewed for 06/16/2024, through 06/25/2024, which revealed the following: 06/16/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift 06/17/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift 06/18/2024: 3 out of 5 units (excluding Lotus and Cicada), were staffed with one RN and one BHT, for night shift 06/19/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift 06/20/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift 06/21/2024: 4 out of 5 units (excluding Phoenix and Cicada), were staffed with one RN and one BHT, for night shift 06/22/2024: 4 out of 5 units (excluding Phoenix), were staffed with one RN and one BHT, for night shift 06/23/2024: 4 out of 5 units (excluding Cicada), were staffed with one RN and one BHT, for night shift 06/24/2024: 2 out of 5 units (excluding Cicada, Phoenix, and Koi), were staffed with one RN and one BHT, for night shift 06/25/2024: 2 out of 5 units (excluding Cicada, Phoenix, and Koi), were staffed with one RN and one BHT, for night shift Documents titled “Cicada Acuity,” “Lotus Acuity,” “ Koi Acuity,” Monarch Acuity,” and “Phoenix Acuity,” were reviewed for 06/16/2024, through 06/25/2024, which revealed “...Plan; Drop Staff: N....” Employee #4 confirmed during an interview conducted on 07/02/2024, night shift staffing was not done according to the Core Staffing Nursing chart, and was short on staff.”

“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 the review of documents and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations, functions, and responsibilities are able to provide a safe and healthy environment for the patient population. These deficient practices pose a potential risk for patients of receiving inadequate care and treatment timely, which could lead to avoidable lengthy patient admissions, unwarranted development of disease complications, and probable poor patient prognosis. Findings include: Hospital document titled, “Medical Staff Bylaws”, revealed: “...Governing Board means the group that has ultimate authority and responsibility for establishing policy; maintaining quality of care, treatment or services; and providing for organization management and planning....” Cross reference: A0057, A0115 A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law. Cross reference: A0057, A0115 A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night. Cross reference: A0057, A0115 A-0145: The Hospital failed: 1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a 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. 2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a Endotherapy and unsafe environment, intimidation of patients and is a violation of patient rights. Cross reference: A0057, A0115 A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8). Cross reference: A0057 A-0392: The Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital. Cross reference: A0057 A-0534: The Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe. 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 policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient’s rights as evidenced by the hospital’s failure to: Repeat deficiency from event SLZZ11 02/03/2023 Findings include: The Condition level deficiency is the result of the standard deficiencies found under the Conditions of Patient Right in the following citations: Cross reference: A0043, A0057, A0115 A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law. Cross reference: A0043, A0057, A0115 A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night. Cross reference: A0043, A0057, A0115 A-0145: The Hospital failed: 1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a 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. 2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights. Cross reference: A0043, A0057, A0115 A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8). 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 review of documents and staff interviews, it was determined the Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a 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. Cross reference: A0043, A0057, A0115 Findings include: Policy titled “Abuse, Assault or Neglect of a Patient,” revealed: “...Any incident of suspected abuse, neglect, or exploitation of a patient by a staff member is to be reported to the Administrator on Call (AOC)...The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report...At the conclusion of the investigation if the facility has reasonable suspicion that the employee did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire...The Director of Quality and Compliance will have the obligation to report all substantiated cases of abuse, neglect, or exploitation by staff to any applicable department of protective services as well as any applicable licensed services...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later that twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation....” Policy titled “Abuse and Neglect, Identification and Reporting of,” revealed: “...All staff members employed by the hospital are considered mandated reporters by the State of Arizona and therefore have a legal and ethical obligation to act upon any suspicion of abuse, neglect, or exploitation. Department of Protective Services must be notified within twenty-four (24) hours of discovery by the Social Worker...Documentation of the reporting must be made in the patient’s medical record by the mental health professional who contacted DPS and/or DCS...If desired by the patient or guardian, or requested by the community agency contacted, hospital staff may also contact local law enforcement...Documentation in the medical record shall include the following reportable information: a. Notification to patient and guardian of obligation to report the information. b. Time and place of alleged incidents (if known). c. Persons involved. d. Supporting evidence. e. Detailed description of the incident. f. Detailed description of who was notified and when (to include APS personnel with name, date, time as well as those listed above).... “ While on survey at facility on 04/24/2024 the SA reviewed hospital documentation of a camera review on 04/24/2024, of a seclusion episode involving Patient #5, on 04/20/2024, revealed: “ ...(Employee #9) puts [his] hands on pt first, grabs by arm. Pt exculated {sic}...Techs holding (Employee #9) back...(Employee #9) assaults patient.... “ Hospital documentation revealed Employee #9 was seen on video showing “aggression” towards Patient #5. The documentation also revealed the DON would be performing employee interviews, and HR, along with Employee #1, were “handling the suspension of (Employee #9).” Further hospital documentation revealed Employee #9 was placed on administrative leave pending an investigation, and then terminated, when the investigation was completed, due to the interaction with Patient #5 seen during the camera review. Patient #5’s medical record was reviewed and revealed no documentation of assault or abuse, nor documentation of notification to the Department of Child Services (DCS), or to Patient #5’s guardian. Documentation of notification of Patient #5’s guardian and DCS, of the abuse and assault incident was requested during state survey on 04/24/2024 from Employee #1, and was not provided. Employee #2 confirmed in an interview on 06/04/2024, while reviewing a video on 04/24/2024, of a seclusion episode on 04/20/2024, for Patient #5, Employee #9 was seen assaulting Patient #5. Employee #2 also confirmed the abuse was not reported to Patient #5’s guardian or to DCS.”

“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 documents and staff interview, it was determined the Administrator 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: Policy titled, “Written Plan of Service and Staff Composition: Leadership”, revealed: “...Chief Executive Officer, (CEO) role: The CEO is responsible for leading the development and execution of the hospital’s long term strategy with a view to creating shareholder value. The CEO acts as a direct liaison between the Board and management of the hospital and communicates to the Board on behalf of the hospital leadership. The CEO is responsible administratively for the development and implementation of each offered service. In collaboration with the Medical Director, and Director of Social Services, the CEO shares the responsibility for the overall function of each offered service. He/she serves as the liaison with outside agencies and provides/ensures community involvement. The CEO reports to the governing board....” Hospital document titled, “Medical Staff Bylaws”, revealed: “...Chief Executive Officer is the individual responsible for the overall administrative management of the Hospital....” During the survey it was determined the CEO failed to perform the core functions of the CEO as demonstrated by the following: Cross reference: A0043, A0115 A-0021: The Hospital failed to report patient abuse by a staff member to the appropriated agencies as required by law. Cross reference: A0043, A0057, A0115 A-0144: The Hospital failed to ensure four (4) adolescent patients were not able to elope from the hospital during the night. Cross reference: A0043, A0057, A0115 A-0145: The Hospital failed: 1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a 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. 2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights. Cross reference: A0043, A0057, A0115 A-0154: The Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8). Cross reference: A0043, A0057 A-0392: The Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital. Cross reference: A0043, A0057, A0115 A-0534: The Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe. Employee #3 confirmed the Chief Executive Officer (CEO) is responsible for the management of the hospital. Employee #3 confirmed that the CEO was on leave at the time of the survey and was not to be disturbed. The cumulative effect of these systematic problems resulted in the CEO’s inability to ensure the facility provided quality health care in a safe environment.”

“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 four (4) adolescent patients were not able to elope from the hospital during the night. This deficient practice poses a risk to the health and safety of patients if hospital services are not provided in a safe, secure environment. Repeat deficiency from event# SLZZ11 02/03/2023 Cross reference: Cross reference: A0043, A0057, A0115 Findings include: A request was made for a policy on accompanying patients to the patio. None was provided. Policy titled, “Patient Rights”, revealed: “...Patients Rights according to federal and state guidelines include the following at a minimum: j. The right to receive care in a safe setting....” Policy titled, “Elopement/AMA”, revealed: “...Elopement: Patients who leave the hospital without a discharge order are considered to have “eloped”. Staff shall make every effort to locate the patient and make notifications to designated persons regarding the elopement...At the time of discovering a patient is missing, a staff member will call a code orange over the radio and repeat it three times...Staff will search the hospital and immediate hospital grounds...In the event that the patient leaves the hospital grounds the Surprise police are to contacted immediately...Staff will notify the following of the patient’s elopement* Attending/Covering Physician* CEO/AOC*CNO* Police*Guardian or Emergency Contact...Documentation of the elopement consists of: Documenting the sequence of events in the Incident Reporting System, including date, time, and circumstances under which the patient was noted missing, If patient is locate but not returned the disposition of the patient and If the patient is located and returned, staff shall: Document the time, condition of the patient and circumstances of the return of the patient...An RCA surrounding the event will be completed....” Policy titled, “Code Orange-Missing Patient/Elopement”, revealed: “...Code Orange-Elopement: In the event a patient is observed eloping, staff should announce: CODE ORANGE ELOPEMENT, the location of the elopement and whether it is adult or adolescent male or female, three times via the radio....” Document titled, “Incident report”, revealed: “...Location: Lotus Unit (RN) called for assistance with four patients being unruly and belligerent with staff. Upon arrival to the unit noted 4 patients in the hallway upset and refusing to enter their rooms. (Patient #3) was so upset s/he stated s/he could not even talk about it. S/he was upset because s/he felt the staff on duty were being disrespectful to hem/her and the other kids. Pt was harming by banging fists into the wall. Pt was asked if s/he would calm down if we called the provider and got something to help him/her relax. Pt stated s/he would because it;s just too much here and they (staff on duty) make it harder. (RN) stated s/he had already given Patient #3 the “max” there was nothing else s/he could do. Call placed to DR. with the above and informed [him] that the pt had already received a Benadryl 50 mg and Vistaril 50 mg but still extremely agitated. [Dr. Carr] ordered Zyprexa 10 mg PO to be given. Pt took the medication but was still irate. Explained to the pt that it would take a little while to take effect. Pt was about to start banging the wall again, when it was suggested s/he try walking around the courtyard to get some fresh air. Pt agreeable. The other three patients also wanted to go so they included. All four patients did start to calm down and were expressing their concerns as they walked around, at 1305 (RN) on Phoenix unit came out and sat on a chair outside. The kids started saying they did not want her/him out there with them. They all started to escalate and start cursing and asking for her/him to leave, I informed them that s/he was just making sure all was safe. All four patients began to retaliate the decision was made to go back in side, when Patient #3 began kicking at the doors to the back wall across the glass doors of the hallway. The other kids also began kicking the doors because the two nurses and the BHT the patients were upset with were coming up the hallway towards them. They continued to kick in the doors until the doors busted open and all 4 patients escaped. A CODE support was called however the kids busted the door open before staff could arrive. [Dave] CEO was called with the above. Surprise PD was called. Pts [father] was called and informed....” Hospital document titled, “Incident report”, revealed: “...Lotus unit...While conducting 0100 HRS Q 15 rounding supervisor on duty opened the patio door from the outside hand gesturing for me to come to the door. At which time s/he shouted inside the hallway requesting both RNs in the hall to leave the hall. however, (RN from Phoenix unit) was the only RN in the hall. I approached the door entrance speaking directly to (Patient #4) I asked (Patient #4) to not disrespect me verbally as I had not shown disrespect to [her] during redirectives. Patient #4 placed [her] head on the outside exit door sighing “UGH”. Patient #4 proceeded to take [her] foot kicking the bottom of the exit door. The door moves slightly outward, Supervisor hand gestured for me to leave closing the door....” Hospital document titled, “Video Review”, revealed: “...(Location Lotus unit) 00:24:55 pts down hall, in and out of rooms...00:28:29 Back to rooms...00:28:38 House supervisor shows up...00:29:30 patients in hall with RN and House supervisor escalating...00:33:57 2 patients at nurse station with house supervisor...00:39:09 House supervisor goes to take one patient our to courtyard, other patients in rooms, s/he allows for them to come first patient goes and gets 4th patient from room...00:40:03 RN from Phoenix unit goes outside...00:40:22 RN From Phoenix unit leaves courtyard with house supervisor and patients...00:44:41 RN enters hallway while supervisor and patients remain in corridor...00:46:07 patient starts to kick at exterior door...00:47:04 door starts to give way and all the patients begin kicking at door...00:48:31 Door gives way and all 4 elope...00:50 CODE called...” Hospital document titled, “Follow up for Nursing Leadership”, revealed: “...On 05/28/2024 at 00:40 am four adolescent patients were taken outside of lotus unit by acting House Supervisor (name). The patients walked around courtyard #2 for approximately five minutes. At 00:44:48 the adolescents were being escorted back to the unit from the courtyard and entered breezeway leading from courtyard #2 to Lotus unit exit door. Adolescent patients paused in breezeway. Adolescent patient #1 began hitting at fire exit door in breezeway which exits the west end and leads outside facility. Patient #2 walks over to the same door and begins pushing/kicking at door. Patient #3 starts hitting/pushing door approximately 30 seconds later. HS is seen standing next to the door and appears to be talking to patients. At 00:48 the exit door fails at the bottom corner end. A space is created in which the adolescents slide through one after the other and AWOL from facility...HS failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety. HS failed to call code during three minutes of patients attempting to elope...Monitoring and safety of patients inadequate....” Hospital document titled, “Written Warning Form”, revealed: “...Performance/Behaviors Observed: RN failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety....” Review of Patient #2 nurse note dated 05/28/2024 revealed: “..At approximately 2300 patient came to nursing counter stating they did not want to go to their room to sleep. Pt and other 3 patients were grilling the RNS about their badges and how they worked...The patients were seen by this RN at various times whispering to each other in the hallway, they would go back to their rooms and peek out of the doors and signal the other patient then would come back out into the hallways and walk toward the exit doors to rear of unit and were repeatedly redirected back to the front of the unit...pt and other 3 patients became agitated...0040 house sup came to floor to speak with one of the patients...the hours charge took over control of the patients telling this RN “I got this” as the charge nurse walked toward the back door of the building with the other patients involved exiting their rooms and following the house charge and patient outside to the courtyard...The writer determined this was a safety issue and sent another nurse out to the courtyard...0046 the house charge attempted to bring the patients back into the unit. they came through the doors exiting the courtyard into and outdoor hallway...the patients began kicking and pushing on the door that led to the outside they attempted to break the door free for approximately 2 minutes as the house charge asked them to come in but they refused...0048 all four patients broke the door open and ran out of the hospital. As the pts AWOL the house charge called for code support....” Employee #2 confirmed during an interview conducted on 06/05/2024 that the four patients eloped from the hospital while outside in the courtyard accompanied by only one employee. Employee #2 confirmed the hospital has no policy regarding staff accompanying patients to the courtyard. Employee #2 confirmed the house supervisor did not call for code support until after the patients had eloped from the hospital.”

“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 review of documents and staff interviews, it was determined the Hospital failed: 1. To report patient abuse by a staff member to the appropriated agencies as required by law. Failure to report patient abuse as mandated by law poses a 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. 2 To ensure staff did not abuse a patient (Patient #8) by administering a chemical restraint unnecessarily and swearing at the patient. This deficient practice poses the potential risk to the health and safety to patients, by restraining patients unnecessarily with no danger of imminent harm, a nontherapeutic and unsafe environment, intimidation of patients and is a violation of patient rights. Repeat deficiency from event# SLZZ11 02/03/2023 Cross reference: Cross reference: A0043, A0057, A0115 Findings include: Policy titled “Abuse, Assault or Neglect of a Patient,” revealed: “...Any incident of suspected abuse, neglect, or exploitation of a patient by a staff member is to be reported to the Administrator on Call (AOC)...The employee will be immediately sent home from the facility and placed on unpaid administrative leave. An investigation will commence immediately, but no later than 24 hours after the report...At the conclusion of the investigation if the facility has reasonable suspicion that the employee did, in fact, perpetrate abuse in any form, he or she will be terminated for cause and not eligible for re-hire...The Director of Quality and Compliance will have the obligation to report all substantiated cases of abuse, neglect, or exploitation by staff to any applicable department of protective services as well as any applicable licensed services...The hospital CEO or designee will have the obligation to speak with the patient, guardian, and/or family members/caregivers, with appropriate consent, regarding the circumstances of the abuse, neglect, or exploitation. The initial interaction must occur immediately, but no later that twenty-four (24) hours after the occurrence. The patient, guardian, family and/or caregivers will be updated with the results of investigation no later than twenty-four (24) hours after the conclusion of the investigation....” Policy titled “Abuse and Neglect, Identification and Reporting of,” revealed: “...All staff members employed by the hospital are considered mandated reporters by the State of Arizona and therefore have a legal and ethical obligation to act upon any suspicion of abuse, neglect, or exploitation. Department of Protective Services must be notified within twenty-four (24) hours of discovery by the Social Worker...Documentation of the reporting must be made in the patient’s medical record by the mental health professional who contacted DPS and/or DCS...If desired by the patient or guardian, or requested by the community agency contacted, hospital staff may also contact local law enforcement...Documentation in the medical record shall include the following reportable information: a. Notification to patient and guardian of obligation to report the information. b. Time and place of alleged incidents (if known). c. Persons involved. d. Supporting evidence. e. Detailed description of the incident. f. Detailed description of who was notified and when (to include APS personnel with name, date, time as well as those listed above).... “ Policy titled, “Rights and Responsibilities of the Individual”, revealed: “...Patient Rights according to federal and state guidelines include the following at a minimum: ...b. The right to receive considerate, respectful care in the least restrictive environment which preserves your dignity and contributes to a positive self-image regardless of race, ethnicity, sexual orientation, culture, religion. gender identity, age, marital status, national origin, disability (mental or physical), socioeconomic status or diagnosis, that is humane treatment environment that ensures protection from harm, provides privacy to as great degree as possible with regards to personal needs....” Policy titled,” Standards of Conduct”, revealed: “...A. Work Rules: Violation of the following standards shall be deemed good cause for which an employee may be subject to disciplinary corrective action...6. Fighting or threatening violence in the workplace...7. Boisterous or disruptive activity in the workplace...9. Insubordination or other disrespectful conduct...11. Unprofessional conduct...18. Comments construed as disloyal or damaging to client relations or contracts....” Policy titled, “Written Plan of Service and Staff Composition: Leadership”, revealed: “...The first priority in staffing the facility is to provide a safe environment while maintaining a therapeutically sound program...The nursing staff is responsible for the delivery of quality care to all patients; maintains confidentiality of patient information and respect for the patient’s dignity and maintains professional competency....” Policy titled, “Restraint and Seclusion,” revealed: “...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion...Restraint-(42CFR 482.13 (c)(1)) Any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a (patient to move his or her arms, legs, body, or head freely)- Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body....” 1. While on survey at facility on 04/24/2024 the SA reviewed hospital documentation of a camera review on 04/24/2024, of a seclusion episode involving Patient #5, on 04/20/2024, revealed: “ ...(Employee #9) puts [his] hands on pt first, grabs by arm. Pt exculated {sic}...Techs holding (Employee #9) back...(Employee #9) assaults patient.... “ Hospital documentation revealed Employee #9 was seen on video showing “aggression” towards Patient #5. The documentation also revealed the DON would be performing employee interviews, and HR, along with Employee #1, were “handling the suspension of (Employee #9).” Further hospital documentation revealed Employee #9 was placed on administrative leave pending an investigation, and then terminated, when the investigation was completed, due to the interaction with Patient #5 seen during the camera review. Patient #5’s medical record was reviewed and revealed no documentation of assault or abuse, nor documentation of notification to the Department of Child Services (DCS), or to Patient #5’s guardian. Documentation of notification of Patient #5’s guardian and DCS, of the abuse and assault incident was requested during state survey on 04/24/2024 from Employee #1, and was not provided. Employee #2 confirmed in an interview on 06/04/2024, while reviewing a video on 04/24/2024, of a seclusion episode on 04/20/2024, for Patient #5, Employee #9 was seen assaulting Patient #5. Employee #2 also confirmed the abuse was not reported to Patient #5’s guardian or to DCS. 2. A video review of the hallway camera from Lotus unit, an adolescent unit, on May 25, 2024, at 2020 to 2220 identified: At 2020-2030, Patient #8 is seen walking animated up and down the hallway and into the day room on multiple occasions. During this time Patient #8 is observed to be talking to other patients in the hallway and staff members in the day room and at the nurse’s station. At 2030, Patient #8 is seen going to the nurse’s station and throws papers and a clipboard that were on the counter of the nurse’s station desk onto the floor. Employee # 11 is observed redirecting Patient #8. At 2031- 2153 Patient #8 is seen walking up and down the hallway, talking to other patients and staff members in the hallway. At 2138 -2152 Employee #12 is observed at the nurse’s station on the telephone. Employee #4 is observed entering the nurse’s station from the Phoenix unit and entering the medication room. At 2153 Employee #4, #11, #12, #13 and #14 are observed leaving the nurse’s station and walking toward Patient #8 in the hallway. Patient #8 is observed walking toward the direction of the employees. Patient #8 sees the employees, stops and removes [her] socks and turns around walking hurriedly away from the employees. Patient #8 is met by [her] bedroom by another unidentified employee by the door to [her] bedroom and turns away toward the direction of the employees. Patient #8 attempts to walk past the employees but is blocked in the hallway by the employees and is directed toward the entrance to [her] room. At 2154 Patient #8 enters [her] room followed by the five (5) employees #4,11,12,13, and 14. At 2156 the five employees exit Patient #8 room and return to the nurse’s station. At 2156-2220 Patient #8 is observed walking up and down the hallway talking animatedly to other patients. Patient #8 “Grievance Report Form” revealed: “...On 25 May nurse (Employee #4) being unprofessional s/he said “Why don’t you do it your f***ing self....Because I wouldn’t shut the hell up. Then s/he gave me shots like s/he was playing dots....” Patient #8 Grievance Follow up Form revealed: “...Details of Grievance: A nurse (Employee #4) being unprofessional ‘why? Do it your f****** self’’, because I wouldn’t shut the hell up. Then s/he was given the shots like s/he was playing dots...Interview with patient and staff: (patient) confirmed what was written. S/he mentioned the nurse was nurse(Employee #4). S/he felt that this was not okay and felt something should be done about [her] being treated this way...BHT (Employee #13) stated this was said and wrote an IR stating that nurse (Employee #4) was administering a B52 shot to patient (Patient #8), (Employee #4) stated “If you can take f****** needles you should have just taken the f****** shot”...This incident was also noted in the shift report from 05/25/2024 by the house supervisor (Employee #14)...CNO will be writing up RN....” Document titled, “Incident Report” revealed: “...While nurse (Employee #4) was administering a B52 shot to patient (Patient #8), (Employee #4) stated “If you can take f***ing needles you should have just taken the f***ing shot... Additional Comments: Awaiting incident report from another witness to incident in order to verify and discipline nurse named in incident....” Employee #3 confirmed on 06/04/2024 that Patient #8 threw the papers and clipboard at the nurse’s station at 2038 and received a chemical restraint for aggressive behavior at 2155. Employee #3 could not confirm the reason for the delay in the administration of the chemical restraint. Employee #3 confirmed that Employee #4 did swear and spoke unprofessionally at Patient #8 during the administration of the chemical restraint.”

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 43788 Based on review of documents, videotape review and staff interviews, it was determined the Hospital failed to ensure staff did not utilize a chemical restraint as a means of coercion, discipline, convenience or retaliation for one (1) patient (Patient #8). This deficient practice poses the potential risk of injury to patients, being unnecessarily restrained with no danger of imminent harm, a nontherapeutic and unsafe environment, and is a violation of patient rights. Repeat deficiency from event#SLZZ11 02/03/2023 Cross reference: Cross reference: A0043, A0057, A0115 Findings include: Policy titled, “Restraint and Seclusion,” revealed: “...All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion...Restraint-(42CFR 482.13 (c)(1)) Any manual method, physical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a (patient to move his or her arms, legs, body, or head freely)- Personal Restraint: Defined as the application of a physical force without the use of any device, for the purpose of restricting the free movement of a patient’s body....” A video review of the hallway camera from Lotus unit, an adolescent unit, on May 25, 2024, at 2020 to 2220 identified: At 2020-2030, Patient #8 is seen walking animated up and down the hallway and into the day room on multiple occasions. During this time Patient #8 is observed to be talking to other patients in the hallway and staff members in the day room and at the nurse’s station. At 2030, Patient #8 is seen going to the nurse’s station and throws papers and a clipboard that were on the counter of the nurse’s station desk onto the floor. Employee # 10 is observed redirecting Patient #8. At 2031- 2153 Patient #8 is seen walking up and down the hallway, talking to other patients and staff members in the hallway. At 2138 -2152 Employee #12 is observed at the nurse’s station on the telephone. Employee #4 is observed entering the nurse’s station from the Phoenix unit and entering the medication room. At 2153 Employee #4, #11, #12, #13 and #14 are observed leaving the nurse’s station and walking toward Patient #8 in the hallway. Patient #8 is observed walking toward the direction of the employees. Patient #8 sees the employees, stops and removes [her] socks and turns around walking hurriedly away from the employees. Patient #8 is met by [her] bedroom by another unidentified employee by the door to [her] bedroom and turns away toward the direction of the employees. Patient #8 attempts to walk past the employees but is blocked in the hallway by the employees and is directed toward the entrance to [her] room. At 2154 Patient #8 enters [her] room followed by the five (5) employees #4,11,12,13, and 14. At 2156 the five employees exit Patient #8 room and return to the nurse’s station. At 2156-2220 Patient #8 is observed walking up and down the hallway talking animatedly to other patients. Employee #3 confirmed on 06/04/2024 that Patient #8 threw the papers and clipboard at the nurse’s station at 2038 and received a chemical restraint for aggressive behavior at 2155. Employee #3 could not confirm the reason for the delay in the administration of the chemical restraint.”

“MEDICAL STAFF BYLAWS CFR(s): 482.22(c) The medical staff must adopt and enforce bylaws to carry out its responsibilities. The bylaws must: This Standard is not met as evidenced by: 43788 Based on review of documents and staff interview, it was determined the Hospital failed to ensure medical staff authenticated a telephone order for a chemical restraint for one (1) patient (Patient #8) within the required 48 hour timeframe. This deficient practice poses a risk to the health and safety of patients if medical staff do not follow the hospital’s rules and regulations when providing patient care. Cross reference: Cross reference: A0043, A0057 Findings include: Hospital document titled, “Medical Staff Rules and Regulations”, revealed: “...All medical record documents shall be completed within the timeframes defined below: Telephone orders: Date, time, and authenticated within 48 hours....” Review of Patient #8 medical record identified a telephone physician order which revealed: “...Seclusion and Restraint Order date and time 05/25/2024 2138...Seclusion/restraint start time: 2155 for 2 hr max (not to exceed 2 hours for adolescents, 3 hours for adults)...Medication ordered Benadryl 50 mg IM, Zyprexa 10mg IM...Indication for S&R/medications: Danger to others...Providers signature, credentials, date and time: (Provider signed) 05/28/2024 at 1106....” Employee #3 confirmed on 06/04/2024 that the chemical restraint order for Patient #8 was not authenticated by the provider until 05/28/2024, 72 hours after the order was given to the RN.”

“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: 43788 Based on review of documents and staff interviews, it was determined the Hospital failed to ensure there were sufficient numbers of nursing personnel to assist patients to prevent four (4) patients from eloping from the hospital. This deficient practice is poses a risk to the health and safety of patients when there is not sufficient staff on units to prevent adverse events from occurring which can potentially cause patient harm. Cross reference: Cross reference: A0043, A0057 Findings include: A request was made for a policy on accompanying patients to the patio. None was provided. Policy titled, “Written Plan of Service and Staff Composition”, revealed: “...The first priority in staffing the facility is to provide a safe environment while maintaining a therapeutically sound program. Staffing patterns may be adjusted according to census and level of acuity and are adjusted to meet the needs of the patients at any particular time....” Policy titled, “Staffing/Acuity Plan”, revealed: “...Staffing Patterns: a. Number of Staff: Nursing units are staffed according to full-time equivalents (FTEs) derived from the average daily census of that unit. The hours of nursing care have been based on national averages of patient acuity levels adjusted to this institution and utilized through the patient acuity classification system...b. Staffing Mix: Consideration is given in the staffing plan to the utilization of registered nurses, behavioral health techs, and nursing assistants (if applicable) according to identified patient requirements for nursing care and the scope of nursing practice permitted by applicable law and regulation...Acuity Tool: The acuity tool is based on five categories: Utilization, Behaviors, Medical Complexity, Mobility, Toileting...A nursing average and a BHT average is determined to ensure the right skill mix for each unit....” Review of Core Staffing Nursing Matrix for each inpatient unit was reviewed and revealed the following staff patterns for each unit (Monarch, Phoenix, Lotus, Cicada, Koi): Monarch Days Afternoon Nights Census RN/BHT RN/BHT RN/BHT 7-10 1/2 1/2 1/2 5-6 1/2 1/2 1/1 1-4 1/1 1/1 1/1 Phoenix Days Afternoons Nights 9-20 2/2 2/2 1/2 6-8 2/2 2/2 1/1 4-5 1/2 1/2 1/1 1-3 1/1 1/1 1/1 Lotus Days Afternoons Nights 9-20 2/2 2/2 1/2 6-8 2/2 2/2 1/1 4-5 1/2 1/2 1/1 1-3 1/1 1/1 1/1 Cicada Days Afternoons Nights 9-10 2/2 2/2 1/2 6-8 2/2 2/2 1/1 4-5 1/2 1/2 1/1 1-3 1/1 1/1 1/1 Koi Days Afternoons Nights 9-20 2/2 2/2 1/2 6-8 2/2 2/2 1/1 4-5 1/2 1/2 1/1 1-3 1/1 1/1 1/1 Review of the staffing assignments for 05/27/2024 2300-05/28/2024 0700 for Lotus and Phoenix units were as follows: Phoenix Unit: Census 20 patients # of RNs: 1 # of BHTs: 1 Lotus Unit: Census 14 patients # of RNs: 1 # of BHTs: 1 Review of the staffing matrix revealed on Phoenix unit for 20 patients staffing should have been 1 RN and 2 BHT and Lotus unit for 14 patients staffing should have been 1RN and 2 BHT. Document titled, “Incident report”, revealed: “...Location: Lotus Unit (RN) called for assistance with four patients being unruly and belligerent with staff. Upon arrival to the unit noted 4 patients in the hallway upset and refusing to enter their rooms. (Patient #3) was so upset s/he stated s/he could not even talk about it. S/he was upset because s/he felt the staff on duty were being disrespectful to hem/her and the other kids. Pt was harming by banging fists into the wall. Pt was asked if s/he would calm down if we called the provider and got something to help him/her relax. Pt stated s/he would because it;s just too much here and they (staff on duty) make it harder. (RN) stated s/he had already given Patient #3 the “max” there was nothing else s/he could do. Call placed to DR. with the above and informed [him] that the pt had already received a Benadryl 50 mg and Vistaril 50 mg but still extremely agitated. [Dr. Carr] ordered Zyprexa 10 mg PO to be given. Pt took the medication but was still irate. Explained to the pt that it would take a little while to take effect. Pt was about to start banging the wall again, when it was suggested s/he try walking around the courtyard to get some fresh air. Pt agreeable. The other three patients also wanted to go so they included. All four patients did start to calm down and were expressing their concerns as they walked around, at 1305 (RN) on Phoenix unit came out and sat on a chair outside. The kids started saying they did not want her/him out there with them. They all started to escalate and start cursing and asking for her/him to leave, I informed them that s/he was just making sure all was safe. All four patients began to retaliate the decision was made to go back in side, when Patient #3 began kicking at the doors to the back wall across the glass doors of the hallway. The other kids also began kicking the doors because the two nurses and the BHT the patients were upset with were coming up the hallway towards them. They continued to kick in the doors until the doors busted open and all 4 patients escaped. A CODE support was called however the kids busted the door open before staff could arrive. [Dave] CEO was called with the above. Surprise PD was called. Pts [father] was called and informed....” Hospital document titled, “Video Review”, revealed: “...(Location Lotus unit) 00:24:55 pts down hall, in and out of rooms...00:28:29 Back to rooms...00:28:38 House supervisor shows up...00:29:30 patients in hall with RN and House supervisor escalating...00:33:57 2 patients at nurse station with house supervisor...00:39:09 House supervisor goes to take one patient our to courtyard, other patients in rooms, s/he allows for them to come first patient goes and gets 4th patient from room...00:40:03 RN from Phoenix unit goes outside...00:40:22 RN From Phoenix unit leaves courtyard with house supervisor and patients...00:44:41 RN enters hallway while supervisor and patients remain in corridor...00:46:07 patient starts to kick at exterior door...00:47:04 door starts to give way and all the patients begin kicking at door...00:48:31 Door gives way and all 4 elope...00:50 CODE called...” Hospital document titled, “Follow up for Nursing Leadership”, revealed: “...On 05/28/2024 at 00:40 am four adolescent patients were taken outside of lotus unit by acting House Supervisor (name). The patients walked around courtyard #2 for approximately five minutes. At 00:44:48 the adolescents were being escorted back to the unit from the courtyard and entered breezeway leading from courtyard #2 to Lotus unit exit door. Adolescent patients paused in breezeway. Adolescent patient #1 began hitting at fire exit door in breezeway which exits the west end and leads outside facility. Patient #2 walks over to the same door and begins pushing/kicking at door. Patient #3 starts hitting/pushing door approximately 30 seconds later. HS is seen standing next to the door and appears to be talking to patients. At 00:48 the exit door fails at the bottom corner end. A space is created in which the adolescents slide through one after the other and AWOL from facility...HS failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety. HS failed to call code during three minutes of patients attempting to elope...Monitoring and safety of patients inadequate....” Hospital document titled, “Written Warning Form”, revealed: “...Performance/Behaviors Observed: RN failed to ensure the safety of staff and patients. Error in judgement AEB by allowing patients outside without proper staffing to ensure safety....” Employee #3 confirmed on 06/04/2024 that the staffing in all of the inpatient units at night is 1 RN and 1 BHT regardless of the patient census or patient acuity. Employee #3 confirmed that on 05/25/2024 at the time the four (4) patients eloped the RN from Phoenix unit was not on the Phoenix unit but was on the Lotus unit. Employee #3 confirmed that when the RN from Phoenix unit left to go to the Lotus unit there was no RN on the Lotus unit, only 1 BHT was on the Phoenix unit. Employee #3 confirmed that if a nurse or BHT is required on another unit to assist with a CODE situation then there is only 1 staff member remaining on the unit. Employee #3 confirmed that the House Supervisor is part of a CODE response team and would not be able to cover the unit that is short a staff member.”