State inspection finds violations at Sierra Tucson

The violations were found during an investigation in July after a complaint was made earlier this year. The center, which treats people with addictions and behavioral disorders, agreed to pay a $3,500 fine Oct. 16.

The 139-bed center north of Tucson sits on 160 acres and is licensed by the state. It has numerous programs for, among other things, drug addiction, eating disorders, bipolar disorder, pain management and depression.

In a prepared statement, Sierra Tucson Executive Director Patricia Ryding said the center's officials could not discuss details surrounding specific clients or events. She said Sierra Tucson has submitted and implemented a corrective plan since the state investigation.

"Our swift response to their findings is indicative of our commitment to patient care," Ryding wrote. "In addition, we sought out ways to exceed industry and state standards of care to create the safest, most effective environment for our clients."

The state's fine structure is set by the Legislature and sets a maximum of $500 per day for a violation.

The fines were related to two patients. In those cases:

• A young adult with a history of psychosis left the facility and was gone for three hours before anyone noticed, the report says. When he was found on the road, he said he had been getting soda and chewing tobacco at a store four miles away. The report says that three days later, the patient left the property and ran into the desert barefoot and that law enforcement helped find him.

• A patient with suicidal thoughts who had reportedly threatened to rape at least one female patient was discharged after throwing a chair in a group session. The report says he was allowed to leave in his private vehicle without any documentation that he was not escorted by anyone. The patient said he was driving to admit himself to another facility in California, the report says.

There was no documentation that the patient, who had a history of impulsive traits and "anger/rage/assaultive behaviors," was safe to leave by himself or to drive to another facility.

Other findings in the state report:

• A patient with post-traumatic stress disorder, past sexual abuse and an eating disorder complained of feeling unsafe. The patient wanted to leave, but the report says her request was denied and there was no documentation that addressed any kind of a plan for her to feel safe.

• The sign-out logs for patients were not kept current or monitored.

• The practice with high-risk patients was limited to two room checks after curfew.

• Unless there was a special order of one-on-one supervision, patients identified as suicidal, psychotic, depressed or having thoughts of homicide were allowed to move around the campus without an escort.

• There was no documentation of food intake for one patient between May 14 and June 4. The patient had been admitted for an eating disorder, chemical dependency and anemia.

As a result of the investigation and fine, Sierra Tucson's agreement with the state says it will now identify and document all high-risk patients, and that those patients will have all potential safety hazards removed from their rooms.

The facility now places all high-risk patients on safety and observation checks every 15 minutes and places all other patients on hourly safety and observation checks.

Sierra Tucson also agreed to:

• Document all 15-minute and hourly checks, and maintain these as part of the patient's medical record.

• Enforce its own procedure for taking roll call at the time of groups or other activities to ensure patients' locations are known.

• Have registered nurses immediately complete assessments of patients, document the assessments, and maintain an ongoing plan of care.