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ADHS Statement of Deficiencies at Sierra Tucson

ADHS Statement of Deficiencies at Sierra Tucson

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Published by TucsonSentinel
Sierra Tucson, one of the nation's most prominent residential behavioral health clinics, is under investigation following the January suicide of a patient at the facility north of Tucson. The incident was the third death of a Sierra Tucson patient in the past six years. According to an investigative report by the Arizona Department of Health Services, the patient hung himself from a shower head Jan. 2, six days after being admitted to the facility. Staff tried to resuscitate the patient with CPR and an on-site defibrillator. He was taken to a hospital and placed on life support; he was pronounced dead on Jan. 5. More at http://tucsonsentinel.com/local/report/033114_sierra_tucson
Sierra Tucson, one of the nation's most prominent residential behavioral health clinics, is under investigation following the January suicide of a patient at the facility north of Tucson. The incident was the third death of a Sierra Tucson patient in the past six years. According to an investigative report by the Arizona Department of Health Services, the patient hung himself from a shower head Jan. 2, six days after being admitted to the facility. Staff tried to resuscitate the patient with CPR and an on-site defibrillator. He was taken to a hospital and placed on life support; he was pronounced dead on Jan. 5. More at http://tucsonsentinel.com/local/report/033114_sierra_tucson

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Published by: TucsonSentinel on Mar 31, 2014
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PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

<X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923

B. WING

02/11/2014

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY. STATE. ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX
TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BE PRECEDED BYFULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

D000 Initial Comments

D000

This Statement of Deficiencies supercedes the Statement of Deficiencies issued on March 3,
2014.

The following deficiencies werefound at the time
of the on-site investigation of complaint

AZ00121405 (Event ID #UK5H11) conducted on February 4, 2014 and February 6, 2014 and completed by off sitetelephonic interviews
conducted February 10 and 11, 2014.

Atelephonic exit was conducted February 19,
2014 with the Executive Director, the Medical Director and the Director of Nursing.

Upon completion ofthecomplaint investigation, it
was determined that the allegation was
substantiated.

Dianne Roberts, RN, BSN State Licensing Surveyor

Date

Ann Pearson, RN, BSN, MS Date
State Licensing Surveyor
D332 D332

R9-10-703.C.2.d. Administration

R9-10-703.C.
that

An administrator shall ensure

R9-10-703.C.2. Policies and procedures for behavioral health residential facility services and

physical health services are established,
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
STATE FORM
UK5H11
TITLE

(X6) OATE

If continuation sheet 1 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:.
B.WING.

(X3) DATESURVEY
COMPLETEO

BH-3923 NAME OF PROVIDER OR SUPPLIER

02/11/2014

STREET ADDRESS. CITY. STATE. ZIPCODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGODE ORO PARKWAY TUCSON,AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BEPRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCEDTO THE APPROPRIATE
DEFICIENCY)

D332

Continued From page 1 documented, and implemented that:

D332

R9-10-703.C.2.d.
services;

Cover the provision of

behavioral health services and physical health

This RULE is not met as evidenced by:

Based on document reviews and staffinterviews, the administrator failed to ensure that policies and

procedures were implemented for behavioral

health services including Suicide Risk Assessment and Management (SRA), Patient

CareAssistant (PCA) and Admission Criteria.
Findings include:

1. Policy Reviews:

A. Theagency policy and procedure MS0002
titled"Suicide Risk: Assessment and
stated:

Management (SRA)" and dated 08/28/2013
..."Management of suicide risk will be based on

" Policy:"

the clinical factors determined in the assessment and reassessment process of the patients/clients

throughout the treatment stay. These will include
but not be limited to the Initial Suicide Risk Scale

(SRS), the BDI-II, and the Beck Hopelessness
Scale (BNS)";
"Procedure:"...

"3. L2 Behavioral Health ResidentialAgency":
and admission to the Behavioral Health

"A. Upon discharge from the Special Hospital
Residential Agency, a clinician will complete the
Suicide Risk Scale for Residential Agency
admission."

"B. At Behavioral Health Residential Agency, a
STATE FORM
UK5H11

if continuation sheet 2 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES
AND PLANOF CORRECTION
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATESURVEY
COMPLETED

BH-3923

B.WING.

02/11/2014

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY. STATE. ZIP CODE

39580SOUTH LAGO DE ORO PARKWAY
TUCSON, A2 85739
ID

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

REGULATORY ORLSC IDENTIFYING INFORMATION)

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

SUMMARY STATEMENT OFDEFICIENCIES

PREFIX
TAG

CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

(EACH CORRECTIVE ACTION SHOULD BE

PROVIDER'S PLANOF CORRECTION

(X6>
COMPLETE
DATE

D332

Continued From page 2

D332

clinician or nurse will address the suicidal risk on
the initial Treatment Plan"...

"E. Ongoing Suicide Risk Assessment': "i. Clients requiring PCA observations for self-harm
will be reviewed bya Medical Provider as

orders. Hi. Nursing will reassess client, based on physician order, for safety checks using

clinically indicated, ii. Nursing will follow Provider
Observation Records as a tool for reassessment,

safety risk every shift, v. High-risk clients will be
discussed by Treatment Team at least daily
during morning staffing..." "F. Suicide Precautions: As suicide potential is assessed/reassessed the treatment team will recommend procedures and proactive responses

iv. Nursing will document narratively about client

toensure the safety ofthe client. The physician will write an order stating which response and
precautions apply." "i. Thefollowing will alsooccur: a. Indicate 'Suicide Precautions* on the client's Kardex. b.
Information about the client's status will be

included on the Kardex and the Nursing Daily

Nursing Report, c. Documentation of the client's

status inthe medical record will include the client's status, the suicide precaution interventions, and the client's response to the precaution interventions."

"li. Other options as decided by the Provider and
clinical team may include the following: a. Transfer the client to a higher level ofcare... b. Increase frequency ofre-assessment and

follow-up with Medical Provider... h. High-risk

clients will be placed on a schedule ofsafety •check-ins' at the appropriate Nurse's Station. The schedule of 'check-ins' will be determined by the client'sclinical team. The RN will do a

nursing assessment at thetime ofsafety

check-ins on the observation form. i. If

appropriate, high-risk clients will be provided 24
UK5H11

Ifcontinuation sheet 3 of 16

STATE FORM

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPUER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATESURVEY
COMPLETED

BH-3923 NAMEOF PROVIDER OR SUPPLIER

B.WING.

02/11/2014

STREETADDRESS. CITY. STATE. ZIPCODE

39580 SOUTH LAGO DEORO PARKWAY
SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

TUCSON, AZ 85739
ID PREFIX
TAG

REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH DEFICIENCY MUST BE PRECEDED BYFULL

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X6)
COMPLETE
DATE

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY)

D332

Continued From page 3

D332

hour PCA surveillance. This will be determined

by the Medical Provider in conjunction with the
re-assessment. Additional staffings will be

client's clinical team. j. High-risk clients will be

reviewed daily during the Multidisciplinary Staff for

scheduled if needed, k. Shift-change reports with Nursesand E/W Counselors will highlight the
status of high-risk clients..."

B. Theagency policy and procedure NR0020
titled "Patient Care Assistant Staffing (PCA)" and
dated 08/22/2012 stated: "Policy:"

"It isthe policy ofSierra Tucson to provide a safe environment for patients. Ensuring patient safety
activities ofdaily living, management ofbehavior
or observation. AMedical Provider order is
"Procedure'"

may require additional staffing for assistance in
required for Patient Care Assistant Staffing."

"Patient will be reassessed bya nurse every shift while on PCA status. This reassessment will be documented in Nursing Assessmentand will be
written every shift."

C The agency policy and procedure MS0003 titled, "Admission Criteria" and dated 10/01/2013 "1. F. All patients areadmitted tothe Medical
stated'

Assessmentand Stabilization (MAS) Unit until theirinitial assessments are completed..." "If they meetthe following clinical criteria they will be kept
7 or greater..."

in MAS until they are sufficiently stable to transfer to the Residential/Level II program...SRS scoreof
2. Per the medical record, residents was admitted to the residential facility 12/28/2013 at 1:30 PM from the Level 1 Sub-acute hospital

(MAS) after he was hospitalized 12/27/2013 at

STATE FORM

UK5H11

Ifcontinuation sheet 4 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENTOF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATESURVEY
COMPLETED

BH-3923

B. WING.

02/11/2014

NAMEOF PROVIDER OR SUPPLIER

STREETADDRESS. CITY, STATE, ZIPCODE

SIERRA TUCSON, INC
(X4) ID
PREFIX
TAG

39580 SOUTH LAGO DEORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

<X5)
COMPLETE
OATE

(EACH DEFICIENCY MUST BE PRECEDED BYFULL REGULATORY ORLSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCEDTO THEAPPROPRIATE
DEFICIENCY)

D332

Continued From page 4

D332

completed by the provider at the time sheordered
his transfer to the Residential facility 12/28/2013

3:43 PM. Based on the Suicide Risk Scale (SRS)

at 11 AM, resident #1 scoredthirteen (13) which is considered inthe "very high" risk range (13-20). Per the Admission Criteria policy stated in 1. C. above, patients with a SRS score of7 orgreater
are to remain inthe MAS. There is no evidence

of a progress note orfurther evaluation of the

support the resident was sufficiently stable to

resident's SRS score indicating the rationale to

transfer to the residential program on 12/28/2013.

Review of resident #1's medical record found the document titled, "Residential Treatment Plan" dated 12/28/2013 did not address the high risk suicidal assessmentofthe resident as required in

the SRA policy in 1.A.3.B above. The admission
ordersdated 12/28/2013 wrote to do "every four hour checksfor support". Therewere no orders

regarding a Patient Care Assistant Staffing (PCA) for observation for safety as stated as a suicide precaution option in the SRA policy 1.A
under 2.ii.h.

The medical record for resident#1 contained only

every four hour check-ins for support, while the
side of the observation record used for safety checks remained blank. The record did not
the Observation Record as a tool for

contain any documented checks for safety using
reassessment as stated in the SRApolicy in #1.A.3E.iii. above. Daily review and discussion ofthe resident's high risk status and need for reassessment (as required inthe policy in 1A3.E.V. above) cannotbe verified as the Executive Director and the Director of Nursing

reported that no documentation ofthe daily

multidisciplinary staff meetings is maintained.
UK5H11

The status of the resident regarding suicide
tf continuation sheet 5 of 16

STATE FORM

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923

B.WING.

02/11/2014

NAMEOF PROVIDEROR SUPPLIER

STREETADDRESS,CITY. STATE.ZIPCODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX
TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE DATE

(EACH DEFICIENCY MUST BE PRECEDED BYFULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCEDTO THEAPPROPRIATE
DEFICIENCY)

D332

Continued From page 5

D332

precautions on the nursing kardex and the Daily Nursing Reports also could not beverified as the
Director of Nursing reported the kardexfor
resident #1 could not be located and and the

Daily Nursing Reports are shredded; therefore,
they were not available to the surveyors. Review of narrative nursing notes for resident #1 dated 12/28/2013 thru 01/02/2014 found no

evidenceof narrative nursing notes on the 6 PM to6 AM shifton 12/28/13and 12/29/13 following
resident #1's admission to residential program

even though he was assessed as a "very high risk (13)" on the SRS on 12/28/13 prior to
admission.

In interviewconducted 02/11/2014 at 3:40 PM,

staff#20 reported that he received a report 01/01/14 between 7:15 and 7:30 PM from the residential therapist (RT) on duty 01/01/2014 that resident #1 reported suicidal intent to his wife in a

phone conversation that theRT had just
witnessed. Per staff#20, the RT also reported that the resident asked his wife ifshe had found the suicide note he had leftfor her priorto his admission. Staff #20 reported he contacted the

provider for orders for a PCA ora 1:1 and tosee
ifthe resident should be moved to the hospital. He received an order to continue the PCAthat was due to end at 10 PM that nightfor the next

twenty four hours. No evidence ofdocumentation
was found in the medical record of resident#1 of the reportthat was received bythe nurse or a

reassessment by nursing of resident #1 for level

of risk. There was also no evidence of

documentation in the medical record bythe RT of his contactwith resident #1 or his observations
and risk reassessment of the resident and the

resident's phonecall to hiswife. Basedon the
STATE FORM

SRA policy in 1.Aabove, the resident's behavior
UK5H11

If continuation sheet 6 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATESURVEY
COMPLETED

BH-3923

B. WING.

02/11/2014

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY. STATE.ZIPCODE

SIERRA TUCSON, INC
(X4)ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(EACH DEFICIENCY MUST BE PRECEDED BYFULL REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX TAG

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCEDTO THEAPPROPRIATE
DEFICIENCY)

(X5> COMPLETE
DATE

D332

Continued From page 6

D332

and communication the evening of 01/01/14 indicated the need for reassessment of his

suicide risk and documentation of same in the
medical record.

3. In interview conducted 02/06/14, the Executive Director acknowledged the above failure to fully

implement theabove identified policies as written.
4. Thefindings werereviewed with the Executive Director, Medical Director and Nursing Director
during the exit conference.
D729

R9-10-707. D.1. Admission; Assessment
R9-10-707.D.
that:

D729

An administrator shall ensure

R9-10-707.D.1. A resident's assessment information is reviewed and updated when

additional information that affects the resident's
assessment is identified, and

This RULE is not met as evidenced by: Based on document reviews and staff interviews,

the administrator failed to ensure that resident #1's assessment information was reviewed and
resident's assessment was identified.

updated when additional information affecting the
Findings included:

1. Based on review of the medical record,

resident #1 was initially admitted to the Medical
Assessment and Stabilization (MAS) Unit (a subacute level1 licensed facility) 12/27/2013 at
and dictated at 11:11 AM 12/28/2013 by a
STATE FORM
UK5H11

332 PM. Apsychiatric evaluation was completed
tf continuation sheet 7 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER.

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B. WING.

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

SIERRA TUCSON, INC
(X4)ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

<X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BEPRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

PREFIX
TAG

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

D729

Continued From page 7

D729

psychiatric provider (staff #5). In interview
conducted 02/06/2014, staff #5 reported she had

completed the psychiatric evaluation sometime that morning prior to the dictation. The medical
record for resident #1 also contained orders

dated 12/28/2013 at 10:30 AM to "discharge from Level I treatment and admit to Level II care" and a Suicide Risk Scale (SRS) with a time of 11 AM and no date and signed by staff #5. Staff#5

reported she completed the scale on 12/28/2013
at the same time she wrote the orders for resident #1's transfer. The SRS scored the resident as a 13 which according to the legend of this scale is in the "very high" risk range (13-20).
At admission to the MAS on 12/27/13, the

registered nurse (RN) scored resident #1 at a 16
on the SRS. There was no reference to the SRS
assessments contained in the psychiatric

evaluation or in any subsequent progress notes

updating the assessment ofresident #1 upon
admission to the residential treatment program. 2. In interview 02/06/2014, staff # 5

acknowledged she made no progress notes referencing or updating the assessment to

include the "very high" risk assessment finding
from the SRS either before or after the resident
was admitted to the residential treatment program

on 12/28/13. She also reported she was not

aware of all of the procedures required in the

policy/ procedure titled, "Suicide Risk:
Assessment and Management (MS0002)". 3. The Medical Director acknowledged 02/06/14,

while present in the interview with staff#5, that progress notes referencing or updating the
assessment to include the "very high" risk

assessment finding from the SRS either before or
after the resident was admitted to the residential

treatment program on 12/28/13 were clinically
STATE FORM
UK5H11 If continuation sheet 8 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923

B.WING.

02/11/2014

NAMEOF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY, STATE, ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BE PRECEDED BYFULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY)

D729

Continued From page 8
indicated.

D729

4. Thefindings were reviewed with the Executive Director, Medical Director and Nursing Director
during the exit conference.
D814

R9-10-708.A.6.d. Treatment Plan

D814

R9-10-708.A. An administrator shall ensure that a treatment plan is developed and

implemented for each resident that is:
R9-10-708.A.6. Is reviewed and updated on an on-going basis: R9-10-708.A.6.d. When a resident has a

significant change in condition orexperiences an
event that affects treatment.

This RULE is not met as evidenced by:

Based on record reviewand interview,resident #1 failed to have a treatment plan reviewed and

updated based ona significant change in the
resident's condition.

Findings Include:

1. Review of the medical record for resident #1
found the following:

Per the Suicide Risk Scales completed 12/27/13

and 12/28/13, Resident #1, was at "very high" risk
for self harm. Review of the Residential Treatment Plan dated 12/28/13 found no

reference to a problem of"very high" risk for self
harm or interventions planned for safety at any

time during his stay in the residential program. Review of provider orders found resident#1's psychiatrist ordered a patient care assistant
STATE FORM
UK5H11

If continuation sheet 9 of 16

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ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2)MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B. WING

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

39580 SOUTH LAGO DE ORO PARKWAY
SIERRA TUCSON, INC
(X4) ID
PREFIX
TAG

TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X6)
COMPLETE
DATE

(EACH DEFICIENCY MUST BEPRECEDED BY FULL
REGULATORYOR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D814

Continued From page 9

D814

beginning 12/31/2013 for support and continuing
the orders through 01/01/14 and 01/02/14. The treatment plan was again not updated to reflect
the additional concerns and ordered
interventions.

2. In phone interview conducted02/11/2014, staff# 15 reported contact with resident#1
sometime between 6:30 and 7 PM on 01/01/2014

when the resident requested assistance with a

phone call to his wife. Staff #15 reported he
listened in on the conversation and heard the

resident making plans to split finances so she
would not be responsible for his debts,

encouraging his wife to takecare of[named person] and"sounded like he was making plans
for suicide". He also heard the resident ask his wife ifshe found the suicide note he had left for her. Staff #15 reported he passed the information on to the unit nurse and the nursing

supervisor because of hisconcern that he was
suicidal. He also reported he did not document

any oftheinformation in the resident's medical
record nor did he reassess the resident's risk

level perpolicy MS0002 using the SRS and did
not revise or update the resident's treatment plan
to reflectthis significant change in condition.

3. In phone interview conducted 02/11/14, staff #14, the nursing supervisor on duty 01/01/14,
confirmed that staff #15 reported the above observations to her. She reported she was not
aware that the observations were not

documented in the record. She reported she did not conduct a SRS reassessment of the resident

any progress notes in the medical record and did
not revise the treatment plan. She reported

following receiving this report and did not make

giving a verbal report to the nurseon duty in
Resident #1's lodge and instructed him to call the
STATE FORM
UK5H11 IIcontinuation sheet 10 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2)MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B.WING.

02/11/2014

STREET ADDRESS. CITY, STATE, ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BEPRECEDED BY FULL
REGULATORYOR LSC IDENTIFYING INFORMATION)

PREFIX TAG

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D814

Continued From page 10

D814

psychiatrist for further orders. She reported she
also sent an email to the treatment team for the

meeting the nextmorning regarding the
information she received.

4. In phone Interview conducted 02/11/14,staff
#20, the nurse on duty in resident #1's lodge, 6
PM to 6 AM shift 01/01/14 to 01/02/14,

acknowledged he did receive a report between
7:15 PM and 7:30 PM from both staff #14 and

#15 regarding the change incondition of resident #1. He reported he was veryconcerned that resident #1 was a very high riskfor self harm and called the medical psychiatrist to see ifhe should be on a 1:1 or perhaps moved back to MAS. He stated the psychiatrist ordered a continuation of
the PCAfor the next 24 hours. Staff #20 reported

he did not update the treatment plan to reflect the change in condition. He reported he did give a verbal report to the technicians that provided the PCA coverage from 6 PM to 6 AM as well as the
technician that came on shift to relieve at 6 AM.

Staff#20 reported that he instructed the
technicians that although the resident is on a

PCA, they should maintain continuous sight ofthe
resident at all times as he was at very high risk

forself harm. He again acknowledged he did not make a narrative nursing note or update the
treatment plan regarding this.

5. In reviewof the treatment plan 02/04/14, the Director of Nursing and the Executive Director

acknowledged that the treatment planwas not reviewed and updated on an ongoing basis when the residentexperienced a significant change in
condition that affected treatment.

6. The findings were reviewed with the Executive
Director, Medical Directorand Nursing Director during the exit conference.
STATE FORM
UK5H11 If continuation sheet 11 of 16

PRINTED: 03/18/2014

FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

<X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923 NAME OF PROVIDER OR SUPPLIER

B.WING.

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

39580 SOUTH LAGO DE ORO PARKWAY
SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE DATE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D1228

R9-10-712.C.11. Medical Records

D1228

R9-10-712.C. An administrator shall ensure that a resident's medical record contains:

R9-10-712.C.11.

Progress notes;

This RULE is not met as evidenced by: Based on document reviews and staff interviews, the administrator failed to ensure that progress

notes reflecting resident#1's changing condition
were entered into his medical record.

Findings included: 1. Per R9-10-101.147, the definition of progress
note states:

" 'Progress note' means documentation by a
medical staff member, nurse, or personnel
member of:

a. An observed patient response to a physical
health service or behavioral health service

provided to a patient,

b. Apatient'ssignificant change in condition, or c. Observed behavior of a patient related to the

patient's medical condition or behavioral health
issue."

2. Review of narrative nursing notes in the medical record for resident #1 dated 12/28/2013 thru 01/02/2014 found no evidence of narrative

nursing notes on the 6 PM to 6 AM shift on
12/28/13 and 12/29/13 following resident #1's
admission to residential even though he was

assessed as a "very high risk (13)" on the SRS
on 12/28/13 priorto admission.
3. In interview conducted 02/11/2014 at 3:40 PM, staff #20 reported that he received a report
STATE FORM
UK5H11
If continuation sheet 12 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B.WING.

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE
DATE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTIONSHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D1228

Continued From page 12
01/01/14 between 7:15 and 7:30 PM from the

D1228

residential therapist (RT)on duty 01/01/2014 that resident #1 reported suicidal intent to his wife in a phoneconversation that the RT had just
witnessed. Per staff #20, the RT also reported that the resident asked his wife if she had found the suicide note he had left for her prior to his admission. Staff #20 reported he contacted

resident #1's psychiatrist for orders for a PCAor a
1:1 and to see if the resident should be moved to

the hospital. He received an order to continue
the PCA that was due to end at 10 PM that night

forthe next twenty four hours. Noevidence of
documentation was found in the medical record

of resident #1 of the report that was received by the nurse or a reassessment by nursing of
resident #1 for level of risk. No progress notes

regarding the resident's status between 6 PM and
6 AM 01/01/14 were evident. Staff #20

acknowledged he did not complete any progress
notes on 01/01/14 for resident #1.

4. There was also no evidence of documentation

of progress notes in the medical record of resident #1 bythe RT of his contact with the
resident or his observations and risk reassessment of the resident and the resident's

phone call to his wife. Basedon the SRA policy
MS0002, the resident's behavior and

communication the evening of 01/01/14 indicated
the need for reassessment of his suicide risk and documentation of same in the medical record.

5. In interview conducted 02/06/14, the Executive

Director and the Nursing Directoracknowledged
that the medical record did not contain all of the appropriate progress notes.

6. The findings were reviewed with the Executive Director, Medical Director and Nursing
STATE FORM UK5H11
If continuation sheet 13 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B.WING.

02/11/2014

STREET ADDRESS, CITY. STATE. ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE DATE

(EACH DEFICIENCY MUST BEPRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D1228

Continued From page 13

D1228

Director during the exit conference.
D1606

R9-10-716.A.5.a. Behavioral Health Services R9-10-716.A.
that:

D1606

An administrator shall ensure

R9-10-716. A.5. A resident does not:

R9-10-716.A.5.a.

Use or have access to any

materials, furnishings, or equipment or participate in any activity or treatment that may present a threat to the resident's health or safety based on
the resident's documented diagnosis, treatment

needs, developmental levels, social skills, verbal
skills, or personal history; or
This RULE is not met as evidenced by: Based on observation, document reviews and staff interviews, the administrator failed to ensure that resident #1 did not have access to equipment

that may present a threat to his health and safety
based on the resident's identified treatment

needs for safety resulting in death by hanging.
Findings included;

1. During environmental inspection of room #36
in Crescent Moon Lodge on 02/04/2014, the following ligature points were observed: -non break away shower heads with long extending rods from the wall in the shower;
-handles on doors to the room and the bathroom that extend out from the door and are not break

away handles; -a non break away shower rod for the shower
curtain;

STATE FORM

UK5H11

If continuation sheet 14 of 16

PRINTED: 03/18/2014

FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2)MULTIPLE CONSTRUCTION
A. BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923 NAME OF PROVIDER OR SUPPLIER

B.WING

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

39580 SOUTH LAGO DE ORO PARKWAY
SIERRA TUCSON, INC
(X4)ID
PREFIX TAG

TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE DATE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORYOR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTIONSHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D1606

Continued From page 14
2. Per the medical record, resident #1 was

D1606

admitted to the residential facility 012/28/2013 at
1:30 PM from the Level 1 Sub-acute hospital

(MAS) after he was hospitalized 012/27/2013 at
3:43 PM. The nursing assessment using the
Suicide Risk Scale on 12/27/2013 scored the

patient at 16 which is considered "very high" risk range (13-20). Based on the Suicide Risk Scale (SRS) completed bythe psychiatrist at the time
she ordered resident #Vs transfer to the

Residential facility 12/28/2013 at 11 AM, resident #1 scored thirteen (13)which is in the "very high" risk range (13-20). Per facility policy MS 0003
titled "Admission Criteria" patients with a SRS

score of 7 or greater are to remain in the MAS.
There is no evidence of a progress note or further
evaluation of the resident's SRS score indicating

the rationale to support the resident was

sufficiently stable to transferto the residential program on 12/28/2013 where the above identified ligature points are partof the design of
the milieu.

3. In interview conducted 02/11/2014 at 3:40 PM,

staff #20 reported that he received a report
01/01/14 between 7:15 and 7:30 PM from the

residential therapist (RT) on duty that resident #1 reported suicidal intent to hiswife in a phone
conversation that the RT had just witnessed. Per staff #20, the RT also reported that the resident
asked his wife if she had found the suicide note

he had left for her priorto his admission. Staff #20 reported he contacted the provider for orders
for a PCA or a 1:1 and to see if the resident

should be moved to the hospital. He received an order to continue the PCA that was due to end at

10 PM that night for the nexttwenty fourhours
and maintain the resident in the residential
program.

STATE FORM

UK5H11

If continuation sheet 15 of 16

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES
STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION
A BUILDING:

(X3) DATE SURVEY
COMPLETED

BH-3923
NAME OF PROVIDER OR SUPPLIER

B. WING

02/11/2014

STREET ADDRESS. CITY. STATE. ZIP CODE

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739
ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(X5)
COMPLETE DATE

(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(EACH CORRECTIVE ACTIONSHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)

D1606

Continued From page 15
4. In interview conducted 02/11/2014, the RT

D1606

confirmed the above report of his observations
and stated he believed the resident was suicidal. He documented his account of the encounter with

the resident and the phone call between the
resident and his wife in an email to the treatment

team. He reported he informed the lodge nurse
and the nursing supervisor as well.
5. Based on review of the medical record,

resident #1 was found at approximately 12:35 PM
01/02/2014 unconscious with head and left

shoulder against the shower wall in room #36 with a cord wrapped tightly around his neck. He had no pulse and was not breathing.
Cardiopulmonary resuscitation (CPR) was
initiated. An automated external defibrillator was

applied and order "no shock"times two. CPR
continued until the emergency services arrived and took over care. The patient was transported to the hospital where he died 01/05/2014.
6. Based on the forensic exam dated

01/07/2014, "the cause of death is ascribed to

hanging" for resident #1 and the "manner of
death is suicide".

7. The findings were reviewed with the
Executive Director, Medical Director and Nursing Director during the exit conference.

STATE FORM

UK5H11

If continuation sheet 16 of 16

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