ADHS Statement of Deficiencies at Sierra Tucson

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

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(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
(X5)
COMPLETE
DATE
(EACH DEFICIENCY MUST BEPRECEDED BY FULL


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
ADHS LICENSING SERVICES (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES

AND PLANOF CORRECTION

A. BUILDING:
(X3) DATESURVEY
COMPLETED
BH-3923
B.WING.
02/11/2014
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

DEFICIENCY)
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

(X1) PROVIDER/SUPPUER/CLIA

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
(X6)
COMPLETE
DATE

CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY)
D332
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

STATEMENTOF DEFICIENCIES AND PLAN OF CORRECTION

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
<X5)
COMPLETE
OATE
(EACH DEFICIENCY MUST BE PRECEDED BYFULL REGULATORY ORLSC IDENTIFYING INFORMATION)

CROSS-REFERENCEDTO THEAPPROPRIATE
DEFICIENCY)
D332
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


A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B.WING.
02/11/2014
NAMEOF PROVIDEROR SUPPLIER
STREETADDRESS,CITY. STATE.ZIPCODE
SIERRA TUCSON, INC

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ID PREFIX
TAG
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DEFICIENCY)
D332
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
ADHS LICENSING SERVICES (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:

A. BUILDING:
(X3) DATESURVEY
COMPLETED
BH-3923
B. WING.
02/11/2014
STREET ADDRESS. CITY. STATE.ZIPCODE
SIERRA TUCSON, INC

(X4)ID
PREFIX TAG

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

DEFICIENCY)
(X5> COMPLETE
DATE
D332
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
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

IDENTIFICATION NUMBER.

A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B. WING.
02/11/2014
SIERRA TUCSON, INC

(X4)ID
PREFIX TAG

ID
<X5)
COMPLETE
DATE

PREFIX
TAG

DEFICIENCY)
D729
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


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

ID PREFIX TAG
(X5)
COMPLETE
DATE


CROSS-REFERENCED TO THEAPPROPRIATE
DEFICIENCY)
D729

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

(X2)MULTIPLE CONSTRUCTION
A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B. WING
02/11/2014
39580 SOUTH LAGO DE ORO PARKWAY

SIERRA TUCSON, INC
(X4) ID
PREFIX
TAG
TUCSON, AZ 85739
ID PREFIX TAG
(X6)
COMPLETE
DATE

REGULATORYOR LSC IDENTIFYING INFORMATION)

CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY)
D814
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

A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B.WING.
02/11/2014
STREET ADDRESS. CITY, STATE, ZIP CODE
SIERRA TUCSON, INC

(X4) ID
PREFIX TAG

ID
(X5)
COMPLETE
DATE

PREFIX TAG

D814
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

<X2) MULTIPLE CONSTRUCTION

A. BUILDING:
(X3) DATE SURVEY

COMPLETED
B.WING.
02/11/2014

SIERRA TUCSON, INC
(X4) ID
PREFIX TAG
TUCSON, AZ 85739
ID PREFIX TAG
(X5)
COMPLETE DATE


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


A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B.WING.
02/11/2014
SIERRA TUCSON, INC

(X4) ID
PREFIX TAG

ID PREFIX TAG
(X5)
COMPLETE
DATE

(EACH CORRECTIVE ACTIONSHOULD BE

D1228

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


A. BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B.WING.
02/11/2014
STREET ADDRESS, CITY. STATE. ZIP CODE
SIERRA TUCSON, INC

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(X5)
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D1228
D1228
Director during the exit conference.

D1606
R9-10-716.A.5.a. Behavioral Health Services R9-10-716.A.

that:
D1606
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
PRINTED: 03/18/2014
FORM APPROVED

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TUCSON, AZ 85739
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(X5)
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D1606

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


A BUILDING:
(X3) DATE SURVEY

COMPLETED
BH-3923
B. WING
02/11/2014
SIERRA TUCSON, INC

(X4) ID
PREFIX TAG

ID PREFIX TAG
(X5)
COMPLETE DATE


D1606

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

ADHS Statement of Deficiencies at Sierra Tucson

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ADHS Statement of Deficiencies at Sierra Tucson

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PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES

<X2) MULTIPLE CONSTRUCTION

(X3) DATE SURVEY

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY. STATE. ZIP CODE

SIERRA TUCSON, INC

39580 SOUTH LAGO DE ORO PARKWAY TUCSON, AZ 85739

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(EACH DEFICIENCY MUST BE PRECEDED BYFULL

(EACH CORRECTIVE ACTION SHOULD BE

D000 Initial Comments

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

The following deficiencies werefound at the time

Atelephonic exit was conducted February 19,

Upon completion ofthecomplaint investigation, it

Dianne Roberts, RN, BSN State Licensing Surveyor

Ann Pearson, RN, BSN, MS Date

An administrator shall ensure

physical health services are established,

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES

(X2) MULTIPLE CONSTRUCTION

BH-3923 NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY. STATE. ZIPCODE

SIERRA TUCSON, INC

39580 SOUTH LAGODE ORO PARKWAY TUCSON,AZ 85739

SUMMARY STATEMENT OF DEFICIENCIES

PROVIDER'S PLAN OF CORRECTION

(EACH DEFICIENCY MUST BEPRECEDED BY FULL

(EACH CORRECTIVE ACTION SHOULD BE

Continued From page 1 documented, and implemented that:

Cover the provision of

behavioral health services and physical health

This RULE is not met as evidenced by:

procedures were implemented for behavioral

CareAssistant (PCA) and Admission Criteria.

A. Theagency policy and procedure MS0002

Management (SRA)" and dated 08/28/2013

throughout the treatment stay. These will include

(SRS), the BDI-II, and the Beck Hopelessness

"3. L2 Behavioral Health ResidentialAgency":

"A. Upon discharge from the Special Hospital

"B. At Behavioral Health Residential Agency, a

PRINTED: 03/18/2014 FORM APPROVED

ADHS LICENSING SERVICES (X1) PROVIDER/SUPPLIER/CLIA STATEMENT OF DEFICIENCIES

(X2) MULTIPLE CONSTRUCTION

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS. CITY. STATE. ZIP CODE

39580SOUTH LAGO DE ORO PARKWAY

SIERRA TUCSON, INC

REGULATORY ORLSC IDENTIFYING INFORMATION)

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

SUMMARY STATEMENT OFDEFICIENCIES

CROSS-REFERENCED TO THE APPROPRIATE

(EACH CORRECTIVE ACTION SHOULD BE

PROVIDER'S PLANOF CORRECTION

Continued From page 2

clinician or nurse will address the suicidal risk on

clinically indicated, ii. Nursing will follow Provider

safety risk every shift, v. High-risk clients will be

iv. Nursing will document narratively about client

included on the Kardex and the Nursing Daily