adhs statement of deficiencies at sierra tucson

8/12/2019 ADHS Statement of Deficiencies at Sierra Tucson

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ADHS LICENSING SERVICESX1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

BH 3923


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ADHS LICENSING SERVICESX1 PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

BH 3923

X2 MULTIPLE CONSTRUCTIONA. BUILDING:.

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PRINTED: 03/18/2014FORM APPROVED

X3) DATESURVEYCOMPLETEO

02 11 2014

NAMEOF PROVIDER OR SUPPLIERSIERRATUCSON INC

STREET ADDRESS. CITY.STATE. ZIPCODE39580 SOUTH LAGODEORO PARKWAYTUCSON AZ 85739

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SUMMARY STATEMENT OFDEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BYFULLREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 1documented and implemented that:R9-10-703.C.2.d. Cover the provisionofbehavioral health services and physical healthservices;

This RULE is not met as evidenced by:Basedondocument reviews and staff interviews,the administrator failed toensure that policies andprocedures were implemented for behavioralhealth services including SuicideRiskAssessment and Management SRA), PatientCareAssistant PCA) andAdmission Criteria.Findings include:1. PolicyReviews:A. Theagency policy and procedure MS0002titled Suicide Risk: Assessment andManagement SRA) and dated 08/28/2013stated: Policy:... Management ofsuicide risk will be based onthe clinical factors determined inthe assessmentand reassessment process ofthe patients/clientsthroughout the treatment stay. These will includebutnotbe limited to the Initial Suicide Risk ScaleSRS), theBDI-II and theBeck HopelessnessScale BNS) ;Procedure: ...3. L2 Behavioral HealthResidentialAgency :A. Upon discharge from the Special Hospitaland admission to the BehavioralHealthResidential Agency, a clinician will complete theSuicide Risk Scale for Residential Agencyadmission.B. AtBehavioral Health Residential Agency a

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ADHS LICENSING SERVICESX1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESANDPLANOF CORRECTIONBH 3923

X2) MULTIPLE CONSTRUCTIONA. BUILDING:

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PRINTED: 03 18 2014FORM APPROVED

X3 DATESURVEYCOMPLETED

02 11 2014

NAME OF PROVIDER OR SUPPLIERSIERRATUCSON, INC

STREET ADDRESS. CITY. STATE. ZIP CODE39580SOUTH LAGO DE ORO PARKWAYTUCSON,A2 85739

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SUMMARY STATEMENT OFDEFICIENCIESE CH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY ORLSC IDENTIFYING INFORMATION)

Continued From page 2clinician or nursewill address the suicidal risk onthe initial Treatment Plan ...E Ongoing Suicide RiskAssessment : iClients requiring PCA observations for self-harmwill be reviewed bya Medical Provider asclinically indicated, ii Nursing will follow Providerorders. i Nursing will reassess client, based onphysician order, for safety checks usingObservation Records as a tool for reassessment,iv Nursing will document narratively about clientsafety risk every shift, v High-risk clients will bediscussed by Treatment Team at least dailyduring morning staffing...F. Suicide Precautions: Assuicide potential isassessed/reassessed the treatment teamwillrecommend procedures and proactive responsestoensure thesafety oftheclient. The physicianwill write an order stating which response andprecautions apply.i Thefollowing will alsooccur: a. IndicateSuicide Precautions* onthe client s Kardex. b.Information about the client sstatus will beincluded onthe Kardex andtheNursing DailyNursing Report, c Documentation of the client sstatus inthemedical record will include theclient s status, the suicide precautioninterventions, andtheclient s response totheprecaution interventions.li Other options as decided by the Provider andclinical teammay include the following: a.Transfer the client to a higher level ofcare... b.Increase frequency ofre-assessment andfollow-up with Medical Provider... h High-riskclients will be placed ona schedule ofsafetycheck-ins at the appropriate Nurse s Station.The schedule of check-ins will be determined bythe client sclinical team. The RN will do anursing assessment at thetime ofsafetycheck-inson the observationform. i Ifappropriate, high-risk clients will be provided 24

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ADHS LICENSING SERVICESSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

X1 PROVIDER/SUPPUER/CLIAIDENTIFICATION NUMBER:

BH-3923

X2 MULTIPLE CONSTRUCTIONA. BUILDING:

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X3)DATESURVEYCOMPLETED

02/11/2014

NAMEOF PROVIDER OR SUPPLIERSIERRATUCSON INC

STREETADDRESS. CITY. STATE. ZIPCODE39580SOUTH LAGO DEORO PARKWAYTUCSON AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BE PRECEDED BYUREGULATORY ORLSC IDENTIFYING INFORMATION

Continued From page 3hour PCA surveillance. This will be determinedby the Medical Provider in conjunction with theclient s clinical team. j.High-risk clients will bereviewed daily during the Multidisciplinary Staff forre-assessment. Additional staffings will bescheduled if needed, k. Shift-change reports withNursesand E/W Counselors will highlight thestatus of high-risk clients...B. Theagency policy and procedure NR0020titled PatientCareAssistant Staffing (PCA) anddated 08/22/2012 stated:Policy:It isthepolicy ofSierra Tucson toprovide a safeenvironment for patients. Ensuring patient safetymay require additional staffing for assistance inactivities ofdaily living, management ofbehavioror observation. AMedical Provider order isrequired for Patient Care Assistant Staffing.ProcedurePatient will be reassessed bya nurseevery shift

while on PCA status. Thisreassessment will bedocumented in Nursing Assessmentand will bewritten every shift.C The agency policy and procedure MS0003titled, Admission Criteria and dated 10/01/2013s ta ted1. F. All patients areadmitted tothe MedicalAssessmentand Stabilization (MAS) Unit untiltheir initial assessments are completed... If theymeetthe following clinical criteria they will be keptin MAS until they are sufficiently stable to transfertotheResidential/Level program...SRS scoreof7 or greater...2. Per the medical record residents wasadmitted tothe residential facility 12/28/2013 at1:30 PM from the Level 1 Sub-acute hospitalMAS) after he was hospitalized 12/27/2013 at

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ADHS LICENSING SERVICESSTATEMENTOF DEFICIENCIESAND PLAN OF CORRECTION

X1 PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

BH 3923


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PRINTED: 03 18 2014FORM APPROVED

X3) DATESURVEYCOMPLETED

02/11/2014

NAMEOF PROVIDEROR SUPPLIERSIERRA TUCSON INC

STREETADDRESS. CITY, STATE, ZIPCODE39580 SOUTH LAGO DEORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCYMUST BE PRECEDED BYULLREGULATORY ORLSC IDENTIFYING INFORMATION

Continued From page 43:43 PM. Based ontheSuicide Risk Scale (SRS)completed by the provider at the time sheorderedhistransfer to the Residential facility 12/28/2013at AM resident 1 scoredthirteen (13) whichis considered inthe very high risk range (13-20).PertheAdmission Criteria policy stated in1.C.above, patients with a SRS score of7orgreaterare to remain intheMAS. There is noevidenceof a progress note orfurther evaluation of theresident s SRS score indicating the rationale tosupport the resident was sufficiently stable totransfer to the residential program on 12/28/2013.Review of resident 1 s medical record found thedocument titled, ResidentialTreatment Plandated 12/28/2013 did notaddress the high risksuicidal assessmentofthe resident as required inthe SRA policy in 1.A.3.B above. The admissionordersdated12/28/2013 wrote todoevery fourhour checksfor support . Therewereno ordersregarding a Patient CareAssistant Staffing(PCA) for observation for safety as stated as asuicide precaution option in theSRA policy 1.Aunder 2.ii.h.Themedical record for resident 1 contained onlyevery four hour check-ins for support, while thesideof theobservation recordused forsafetychecks remained blank. The record did notcontain any documented checks for safety usingthe Observation Record as a toolforreassessment as stated in the SRApolicy in1.A.3E.iii. above. Daily review and discussionofthe resident s high risk status and needforreassessment (as required inthe policy in1A3.E.V. above) cannotbe verified as theExecutive Director and the Director of Nursingreported that no documentation ofthe dailymultidisciplinary staff meetings ismaintained.The status ofthe resident regarding suicide

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BH 3923


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X3) DATE SURVEYCOMPLETED

02 11 2014

NAMEOF PROVIDEROR SUPPLIERSIERRATUCSON, INC

STREETADDRESS,CITY. STATE.ZIPCODE39580 SOUTH LAGO DEORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OFDEFICIENCIESEACH DEFICIENCY MUST BE PRECEDED BYUREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 5precautions on thenursing kardex and the DailyNursing Reports also could not beverified as theDirector ofNursing reportedthe kardexforresident 1 could not be located and and theDaily Nursing Reports are shredded; therefore,theywere not available to the surveyors.Review of narrativenursing notes for resident 1dated 12/28/2013 thru 01/02/2014 found noevidenceof narrative nursing notes on the6 PMto6 AM shifton 12/28/13and 12/29/13 followingresident 1 s admission to residential programeven though hewas assessed as a very highrisk (13) ontheSRSon 12/28/13 prior toadmissionIn interviewconducted 02/11/2014 at 3:40 PM,staff 20 reported that he received a report01/01/14between 7:15 and 7:30 PM from theresidential therapist (RT) on duty 01/01/2014 thatresident 1 reported suicidal intent to his wife in aphone conversation that theRT had justwitnessed. Per staff 20, the RT also reportedthat the residentasked hiswife ifshe had foundthe suicide note he had leftfor her priorto hisadmission. Staff 20 reported he contacted theprovider for orders for a PCAora and toseeifthe resident should be moved to the hospital.He received an order to continue the PCAthatwas due to end at 10 PM that nightforthe nexttwenty four hours. No evidence ofdocumentationwas found in the medical record of resident1 ofthe reportthat was receivedbythe nurse orareassessment by nursing of resident 1 for levelof risk. There was also no evidence ofdocumentation inthe medical record bythe RT ofhiscontactwith resident 1 or hisobservationsand riskreassessment of the resident and theresident s phonecall tohiswife. BasedontheSRA policy in 1.Aabove, the resident's behavior

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BH 3923


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X3)DATESURVEYCOMPLETED

02/11/2014

NAMEOF PROVIDER OR SUPPLIERSIERRA TUCSON INC

STREETADDRESS.CITY.STATE.ZIP CODE39580 SOUTH LAGO DEORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OFDEFICIENCIESEACH DEFICIENCY MUST BE PRECEDED BYUREGULATORY ORLSC IDENTIFYING INFORMATION

Continued From page 6and communication the evening of 01/01/14indicated the need for reassessment of hissuicide risk and documentation ofsame inthemedical record3. In interview conducted02/06/14, the ExecutiveDirector acknowledged the above failure to fullyimplement theabove identified policies aswritten.4. Thefindings werereviewed with theExecutiveDirector, Medical Director andNursing Directorduring the exitconference.R9-10-707.D.1. Admission; AssessmentR9 10 707 Dthat:

An administrator shall ensure

R9-10-707.D.1. A resident s assessmentinformation is reviewed and updated whenadditional information that affectsthe resident sassessment is identified, and

This RULE is not met as evidenced by:Based on document reviewsand staff interviews,the administrator failed to ensure that resident1 s assessment information was reviewed andupdated when additional information affecting theresident s assessment was identified.Findings included:1. Based on review of the medical record,resident 1was initially admitted totheMedicalAssessment and Stabilization MAS Unit (asubacute level1 licensed facility 12/27/2013 at332 PM. Apsychiatric evaluation was completedand dictated at 11:11AM 12/28/2013 bya

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ADHS LICENSING SERVICESX1 PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBERSTATEMENT OF DEFICIENCIESAND PLAN O F CORRECTION

BH 3923


B. WING

PRINTED: 03/18/2014FORMAPPROVED


02/11/2014NAME OF PROVIDER OR SUPPLIER

SIERRATUCSON, INC

STREETADDRESS. CITY. STATE.ZIP CODE39580 SOUTH LAGO DEORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BYFULLREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 7psychiatric provider (staff 5). In interviewconducted 02/06/2014, staff 5 reported she hadcompleted the psychiatric evaluation sometimethatmorning prior tothe dictation. Themedicalrecord for resident 1 also contained ordersdated 12/28/2013at 10:30AM to discharge fromLevel Itreatment and admit to Level care anda SuicideRiskScale (SRS)with a timeof 11 AMand no date and signed bystaff 5. Staff 5reported she completed thescaleon 12/28/2013at the same time she wrote the orders forresident 1 s transfer. The SRS scored theresident as a 13which according to the legend ofthis scale is inthe very high risk range (13-20).At admission to the MAS on 12/27/13, theregistered nurse (RN) scored resident 1 ata 16on the SRS. There was no reference to the SRSassessments contained in the psychiatricevaluationor inany subsequent progress notesupdating theassessmentofresident 1 uponadmission to the residential treatment program.2. In interview 02/06/2014, staff 5acknowledged she made no progress notesreferencing or updating the assessment toinclude the very high risk assessment findingfrom the SRS either before or after the residentwas admitted to the residential treatment programon 12/28/13. She also reported she was notaware ofall ofthe procedures requiredin thepolicy/ procedure titled, Suicide Risk:Assessment and Management (MS0002) .3. The Medical Director acknowledged 02/06/14,while present in the interview with staff 5, thatprogress notes referencing or updating theassessment to include the veryhigh riskassessment finding from the SRS either beforeorafter the residentwas admitted to the residentialtreatment program on 12/28/13were clinically

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02/11/2014

NAMEOF PROVIDEROR SUPPLIERSIERRA TUCSON INC

STREET ADDRESS. CITY, STATE, ZIPCODE39580 SOUTH LAGO DEORO PARKWAYTUCSON AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BE PRECEDED BYUREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 8indicated.4. Thefindings were reviewed with the ExecutiveDirector Medical Director and Nursing Directorduring the exitconference.R9-10-708.A.6.d. Treatment PlanR9-10-708.A. Anadministrator shall ensurethat a treatment plan is developed andimplemented for each resident that is:R9-10-708.A.6. Is reviewed and updated on anon-going basis:R9-10-708.A.6.d. When a resident ha s asignificant change condition orexperiences anevent that affects treatment.This RULE is not met as evidenced by:Based on record reviewand interview resident 1failed to have a treatment plan reviewedandupdated based ona significant change theresident s condition.

Findings Include:1. Review of the medical recordforresident 1found th e following:Per the SuicideRiskScales completed 12/27/13and 12/28/13 Resident 1,was at very high riskfor self harm. Reviewof the ResidentialTreatment Plan dated 12/28/13 found noreference toa problem ofvery high risk for selfharm or interventions planned for safety at anytime during hisstay in the residential program.Review of provider orders found resident 1 spsychiatrist ordered a patient care assistant

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ADHS LICENSING SERVICES X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLANOF CORRECTION

BH-3923

X2)MULTIPLE CONSTRUCTIONA. BUILDING:

B. WING


X3) DATE SURVEYCOMPLETED

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NAME OF PROVIDEROR SUPPLIER

SIERRATUCSON INC

STREETADDRESS. CITY.STATE. ZIPCODE39580 SOUTH LAGODE ORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BYFULLREGULATORYOR LSC IDENTIFYING INFORMATION

Continued From page 9beginning 12/31/2013 for support and continuingtheorders through 01/01/14 and 01/02/14. Thetreatment plan wasagainnotupdated to reflectthe additional concerns and orderedinterventions.2. In phone interview conducted02/11/2014,staff 15 reported contactwith resident 1sometime between 6:30 and 7 PMon 01/01/2014when the resident requested assistance with aphone call to his wife. Staff 15reported helistened inon the conversation and heard theresidentmaking plansto split finances so shewouldnot be responsible for his debts,encouraging his wife totakecareof [namedperson] and sounded like hewasmaking plansfor suicide . Healso heard the resident ask hiswife ifshe found the suicide note he had leftforher. Staff 15 reported he passed theinformation on to the unit nurse and the nursingsupervisor because ofhisconcern that hewassuicidal. Healso reported he did not documentany ofthe information the resident s medicalrecord nor did he reassess the resident's risklevel perpolicy MS0002 using theSRS and didnot revise or update the resident'streatment planto reflect thissignificant change incondition.3. In phone interview conducted 02/11/14, staff14, thenursing supervisor on duty 01/01/14,confirmed that staff 15 reported the aboveobservations to her. She reported she was notaware that the observationswere notdocumented in the record. She reported she didnot conduct a SRS reassessment of the residentfollowing receiving this report and did notmakeany progress notes themedical record and didnot revise the treatment plan. She reportedgiving a verbal report tothe nurseon duty Resident 1's lodge and instructed himto callthe

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02/11/2014

NAME OF PROVIDER OR SUPPLIER

SIERRA TUCSON INC

STREETADDRESS. CITY, STATE, ZIP CODE39580 SOUTH LAGODEORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BYFULLREGULATORYOR LSC IDENTIFYING INFORMATION

Continued From page 10psychiatrist for further orders She reported shealso sent an email to the treatment team for themeeting thenextmorning regarding theinformation sh e received.4. n phone Interview conducted 02/11/14 staff20, the nurse ondutyin resident 1 s lodge 6PM to 6 AM shift 01/01/14 to 01/02/14,acknowledged he did receive a reportbetween7:15 PMand 7:30 PMfrom both staff 14 and15 regarding the change incondition of resident1. Hereported he was veryconcerned thatresident 1 was a veryhigh riskforself harmandcalled the medical psychiatrist to see ifhe shouldbeona 1:1 or perhaps movedback toMAS Hestated the psychiatrist ordered a continuation ofthe PCAforthe next 24 hours. Staff 20 reportedhe did notupdatethe treatmentplan to reflect thechange in condition He reported he did give averbal report tothe technicians that provided thePCA coverage from 6 PM to6 M as well as thetechnician that came on shift to relieve at 6 AMStaff 20 reported that he instructed thetechnicians that although the resident is on aPCA they should maintain continuous sight oftheresident at all times as he was at very high riskforself harm Heagain acknowledged he did notmake a narrative nursing note or update thetreatment plan regarding this.5. Inreviewof the treatment plan 02/04/14, theDirector of Nursing and the Executive Directoracknowledged that the treatmentplanwas notreviewed and updated on an ongoing basis whenthe residentexperienceda significant change incondition that affected treatment.6. The findings were reviewed with theExecutiveDirector, Medical Directorand Nursing Directorduring the exit conference.

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SIERRATUCSON INC

STREETADDRESS. CITY. STATE. ZIP CODE39580 SOUTH LAGO DE ORO PARKWAYTUCSON AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESE CH DEFICIENCY MUST BEPRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 1201/01/14 between 7:15 and 7:30 PM from theresidentialtherapist (RT)on duty 01/01/2014 thatresident 1 reportedsuicidal intentto hiswife inaphoneconversation that the RThad justwitnessed. Per staff 20, the RT also reportedthat the resident asked his wife if she had foundthe suicide note he had leftfor her prior to hisadmission. Staff 20 reported he contactedresident 1 s psychiatrist for orders for a PCAor a1:1 and to see if the resident should be moved tothe hospital. He received an order to continuethe PCA thatwas due to end at 10 PM that nightforthe nexttwenty four hours. Noevidenceofdocumentation was found in the medical recordof resident 1 of the reportthat was received bythe nurse or a reassessment by nursing ofresident 1 for level of risk. No progress notesregarding the resident s statusbetween 6 PM and6 AM01/01/14 were evident. Staff 20acknowledged he did not complete any progressnotes on 01/01/14 for resident 1 .4. There was also no evidence of documentationofprogressnotes in the medical record ofresident 1 bythe RTof his contact with theresident or his observations and riskreassessment of the resident and the resident sphone call to his wife Basedon theSRA policyMS0002, the resident s behavior andcommunication the evening of 01/01/14 indicatedthe need for reassessment of his suicide risk anddocumentation of same in the medical record.5. In interview conducted 02/06/14, the ExecutiveDirector and the Nursing Directoracknowledgedthat the medical record did not contain all of theappropriate progress notes.6. The findingswere reviewed with theExecutive Director,Medical Director and Nursing

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02/11/2014NAME OF PROVIDER OR SUPPLIERSIERRA TUCSON INC

STREETADDRESS, CITY. STATE. ZIPCODE39580 SOUTH LAGO DE OR O PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESE CHDEFICIENCY MUST BEPRECEDED BYFULLREGULATORY OR LSC IDENTIFYING INFORMATION

Continued From page 13Directorduring the exit conference.R9-10-716.A.5.a. Behavioral Health ServicesR9-10-716.A. An administrator shall ensurethat:

R9-10-716.A.5. A resident d o e s not:R9-10-716.A.5.a. Use o r h av e access to an ymaterials, furnishings, or equipment or participateinany activity or treatment that may present athreat to the resident s health or safety based onthe resident s documented diagnosis, treatmentneeds, developmental levels, social skills verbalskills, or personal history; orThis RULE is not me t as evidenced by:Based on observation, document reviews an dstaff interviews, the administrator failed to ensurethat resident 1 did not have access to equipmentthatmaypresent a threat to his health and safetybased o n t h e r es i de nt s identified treatmentneeds for safety resulting indeath byhanging.Findings included;1. uringenvironmental inspection of room 36inCrescent MoonLodge on 02/04/2014, thefollowing ligaturepointswere observed:-non break away shower heads withlongextending rods fromthe wall inthe shower;-handles on doors to th e room an d th e bathroomthat extend out from t he d oo r an d ar e not breakaway handles;-a non break away shower rod for the showercurtain;

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ADHS LICENSING SERVICESX1 PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

BH-3923


B . WING




SIERRATUCSON INC

STREETADDRESS. CITY. STATE.ZIP CODE39580 SOUTH LAGO DE ORO PARKWAYTUCSON, AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BY FULLREGULATORYOR LSC IDENTIFYING INFORMATION

Continued From page 142. Pe r the medical record, resident 1 wasadmitted to the residential facility 012/28/2013 at1:30 PM from the Level 1 Sub-acute hospitalMAS) after hewas hospitalized 012/27/2013 at3:43 PM. The nursing assessment using theSuicide Risk Scale on 12/27/2013 scored thepatient at 16which is considered very high riskrange 13-20). BasedontheSuicide Risk ScaleSRS) completed bythe psychiatrist at the timeshe ordered resident V s transfer to theResidential facility 12/28/2013 at AM, resident1 scored thirteen (13)which is in the very highrisk range 13-20). Per facility policy MS 0003titled AdmissionCriteria patients witha SRSscore of7 orgreater are to remaininthe MAS.There is no evidence of a progress note or furtherevaluation of the resident's SRS score indicatingthe rationale to support the resident wassufficiently stable to transferto the residentialprogram on 12/28/2013 wherethe aboveidentified ligature points are partofthe designofth e milieu.3. In interview conducted 02/11/2014 at 3:40 PM,staff 20 reported that he receiveda report01/01/14 between 7:15 and 7:30 PM from theresidentialtherapist RT) on dutythat resident 1reported suicidal intent to hiswife in a phoneconversation that the RThad just witnessed. Perstaff 20, the RT also reported that the residentasked his wife if she had found the suicide notehe had leftfor her priorto his admission. Staff20 reportedhe contacted the provider forordersfor a PCA or a 1:1 and to see if the residentshould be moved to the hospital. He received anorder to continue the PCA thatwas due to end at10 PM that night for the nexttwenty fourhoursand maintain the resident in the residentialprogram.

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ADHS LICENSING SERVICESSTATEMENT OF DEFICIENCIESA N D P LAN OF CORRECTION

X1 PROVIDER SUPPLIER CLIAIDENTIFICATION NUMBER:

BH-3923

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SIERRA TUCSON INC

STREETADDRESS. CITY. STATE. ZIP CODE39580 SOUTH LAGO DE O R O P A RK WA YTUCSON AZ 85739

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SUMMARY STATEMENT OF DEFICIENCIESEACH DEFICIENCY MUST BEPRECEDED BY FULLREGULATORYOR LSC IDENTIFYING INFORMATION

Continued From page 154. In interview conducted 02/11/2014 the RTconfirmed the above report of his observationsand s ta ted he believed th e resident was suicidal.He documented his account of th e encounterwiththe resident and the phone call between theresident an d hi s wife in an email to th e treatmentteam. He reported he informedthe lodge nurseand the nursing supervisor as well.5. Based on review of th e medical recordresident 1 was found at approximately 12:35 PM01/02/2014 unconscious with head and leftshoulder against the shower w ll inroom 36 witha cordwrapped tightly around his neck. He hadno pulse and was not breathing.Cardiopulmonary resuscitation (CPR) wasinitiated. An automated external defibrillatorwasapplied and order noshock times two CPRcontinued until the emergency services arrivedand took over care. The patient was transportedto the hospitalwhere he died 01/05/2014.6. Based on th e forensic exam dated01/07/2014, the cause of death is ascribed tohanging forresident 1 and the manner ofdeath is suicide .7. The findingswere reviewedwiththeExecutive Director, Medical Director and NursingDirector during the exit conference.

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PROVIDER S PLAN OF CORRECTIONEACH CORRECTIVE ACTIONSHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY

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UK5H11 If continuation sheet 16 of 16

adhs statement of deficiencies at sierra tucson

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