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Based on observation, interview, and record review, the hospital failed to establish a process for prompt resolution of patient complaints and grievances for two of two patients (Patients #11 and #12) who were unaware of a hospital patient advocate at the time of survey. Patient #11 had personal items missing from his room, and Patient #12 did not have an identification bracelet to ensure proper patient identification and prevent treatment and/or medication errors. The patients did not file complaints.


Findings included:

Observations on 11/02/18 at 1515 reflected no information regarding patient advocacy posted in the patient area. The space for a name of the hospital's patient advocate was left blank. Personnel #6 witnessed and acknowledged the finding at that time.


Two patients (Patients #11 and #12) stated during an interview on 12/28/18 at approximately 1130 that they were unaware of a patient advocate at the hospital. Patient #11 stated that he was missing his shoes earlier that day and found them on another patient. Patient #11 stated that, earlier in his hospital stay, he had come back to his room to find another patient "naked on my bed trying to put my jeans on." Patient #12 stated she had not received a hospital issued identification bracelet. Both patients denied having filed a complaint.

Personnel #7 was surveyor asked how patients were identified for example during medication administration in case of missing ID bracelets. There was no answer.

Personnel #6 witnessed and acknowledged the patients' statements at that time.

Record review of the hospital's Patient Rights Policy RTS-02 dated 01/11/16 reflected the patient had a right to "make a complaint and to be told how to contact people who can help..."

Based on record review and interview, the hospital's nursing staff failed to ensure the right of one of one patient (Patient #6) to be involved in her care and failed to provide the patient with the opportunity to consent to her psychoactive medication administration.


Findings included:

Patient #6"s Initial Screening Form dated 06/19/17 at 1505 reflected the patients' voluntary admission status with thoughts of harming self. The patient planned to stab herself and suffered from auditory and visual hallucinations.

Physician Progress Notes dated 06/27/18 reflected the patient's diagnoses that included Schizoaffective Disorder, Bipolar Type and noted care changes to increase dosage of Prozac to 50 mg (milligram) daily for Depression on 06/21/18 and increase dosage of Zyprexa to 20 mg daily for Schizoaffective Disorder on 06/24/18.

Record review of Patient #6's medical file did not provide evidence of a medication consent for Prozac and/or Zyprexa.


Personnel #7 reviewed Patient #6's chart on 12/28/18 at 1600 and denied the patient signed consents for Zyprexa or Prozac.

Record review of hospital policy RTS-02 titled Patient Rights dated 01/11/16 reflected the patients had "...the right to explanations of...the risks, side effects, and benefits of all medications..."

Based on observation, interview, and record review, the hospital failed to ensure the right to personal privacy for one of one patient (Patient #16) who experienced an episode of sudden-onset abdominal pain during the survey. The patient was physician examined in full view of two other patients and emergently removed from the facility via a fully occupied patient dining area during lunch. A more private exit was available.




Findings included:

A male patient (Patient #16) was observed in the hospital's patient day room across the nurses' station on 12/28/18 at approximately 1205 with an ice pack on his right upper gastric area. He was grimacing in painful facial expression.

On 12/28/18 at approximately 1210, Personnel #11 was observed examining Patient #16 in the day area in view of at least two other patients (Patient #15 and an unidentified female patient) by palpating the patient's clothed abdomen and asking questions. Shortly afterwards staff called emergency services. Non-hospital emergency personnel arrived, interviewed Patient #16, placed him on a gurney, and pushed him through the dining room where multiple patients ate their lunch meal before exiting the patient care area and hospital on 12/28/18 at about 1235. Hospital. Personnel # 6 and Personnel #7 witnessed the incident at that time. Upon surveyor inquiry, Hospital Personnel #6 agreed that there would have been another way to transport the patient out of the patient care area without pushing him through the fully occupied patient dining area at lunch time.

Record review of Patient #16 reflected an admission date of 12/18/18. The patient was admitted with diagnoses that included Mood Disorder and Psychosis. He did not have any medical issues at that time.

Daily Nurse Note dated 12/27/18 at 2300 reflected the patient did not have pain.

Nursing Progress Note dated 12/28/18 at 1115 reflected Patient #16 complained of upper abdominal pain, "...ice pack offered...patient received Tylenol 650 mg..." Notes timed 1210 reflected Personnel #11 gave an order to emergently send the patient out and "...911 [was] called immediately..." Notes timed at 1236 reflected Patient #16 "left [the] unit" in transfer to emergency care.

Record review of the hospital's Patient Rights Policy RTS-02 dated 01/11/16 reflected the patient had a right to a treatment environment that "...provides privacy to as great a degree as possible...and promotes respect and dignity for each patient."

Based on observation, interview, and record review, the hospital's registered nursing staff failed to supervise and evaluate the nursing care for four of four patients (Patients #16, #8, #4, and #9).


1) Patient #16 complained to nursing staff of sudden severe upper abdominal pain and required emergency medical care. After the initial assessment, nursing failed to reassess the patient's pain and vital signs for at least 90 minutes until the patient departed per emergency services.

2) Patient #8, age 89, fell and hit his head. Despite orders for neurological tests, nursing failed to provide data to evidence the patient's vital signs, level of consciousness, size and reaction of his pupils, and speech.

3) Although Patient #4's systolic blood pressure readings significantly fluctuated at night by up to 56 mmHg, and the patient complained of lightheadedness during the evening shift on 08/22/18, nursing failed to recheck the patient's low blood pressure until twelve hours later on 08/23/18 at 0700.

4) Although Patient #9 was initially assessed to be without bruising. routine skin assessments during the first week of his hospitalization reflected a bruise on the patient's left upper leg. Two weeks into his hospital stay, Patient #9 was noted to have multiple bruises on both arms and legs and scraped skin on his left leg. The skin changes were not reassessed for 39.5 hours when the patient had bruising and a suspected toe injury that required x-rays.



Findings included:

1) Patient #16 was observed in the hospital's patient day room across the nurses' station on 12/28/18 at approximately 1205 with an ice pack on his right upper abdominal area. He was grimacing with a painful facial expression. Shortly afterwards, staff called emergency services. The patient left the hospital with emergency medical personnel on 12/28/18 at about 1235 per surveyor observation.

Record review of Patient #16 reflected an admission date of 12/18/18. The patient was admitted with diagnoses that included Mood Disorder and Psychosis. He did not have any medical issues at that time.

Daily Nurse Note dated 12/27/18 at 2300 reflected the patient did not have pain.

Nursing Progress Note dated 12/28/18 at 1115 reflected Patient #16 complained of upper abdominal pain, "...ice pack offered...patient received Tylenol 650 mg..." The note did not reflect quality and/or severity of pain. Initial vital signs were noted. The notes dated 12/28/18 at 1245 reflected the patient left the hospital with emergency personnel. There was no evidence of nursing reassessment of vital signs and/or pain severity and/or quality of pain between 1115 and 1245.




2) Record review of Patient #8's Multidisciplinary Notes dated 08/22/18 at 1353 reflected nursing staff "found" the 89-year old patient on the floor during routine checks. The patient stated he had "lost his balance...tumbled ...went to the floor hitting his head ...neuro check was performed ..."


Record review of Patient #8's Internal Medicine Progress Note dated 08/22/18 at 1810 reflected the patient was examined after an "unwitnessed fall ...reports hitting [his] head ..." The notes concluded "neuromuscular checks per protocol."

Personnel #7 provided Patient #8's neurological flow sheet ("protocol") during an interview on 12/27/18 at 1610. It was left blank. Personnel #7 acknowledged the finding at that time.





3) Patient #4's Physician Discharge Summary dated 08/23/18 at 1213 reflected the patient's 08/15/18 date of admission. The patient had been admitted with suicidal thoughts.

Record review of Patient #4's Admission Nursing Assessment dated 08/15/18 at 1845 reflected a blood pressure of 144/85 mmHg.

Patient #4's Physician completed evaluation dated 08/16/18 at 1101 and the History and Physical Examination dated 08/16/18 at 1920 reflected the patient had a medical history of high blood pressure. The patient's blood pressure at the time of the History and Physical Examination was noted to be 125/76 mmHg.

Patient #4's graphic record flow sheets reflected the patient's blood pressure to be 94/60 mmHg (millimeter mercury) on 08/20/18 at 1900. Twenty-four hours later, on 8/21/18 at 1900, the patient's blood pressure was measured to be 150/85 mmHg, and on 08/22/18 at 1900, nursing documented the patient's blood pressure to be 97/57 mmHg. There was no evidenced recheck of the patient's blood pressure until twelve hours later on 08/23/18 at 0700.

Daily Nursing Note dated 08/22/18 at 2241 reflected the nurse assessment that the patient complained of "light-headedness ...was assessed ...vitals were within normal limits."

Personnel #7 was interviewed on 12/28/18 at 1040 and acknowledged the findings.

Record review of the hospital's Patient Reassessment Policy #1200.211 dated 10/2018 reflected the expectation that patient reassessments were conducted by the RN routinely and when a patient's condition changed.

The American Heart Association warned that "fluctuations in blood pressure, blood sugar, body mass index and cholesterol could put people at higher risk for heart attack or stroke" (https://www.heart.org/en/news/2018/10/01/big-fluctuations-in-bp-and-cholesterol-increase-heart-disease-stroke-risk).


4) Record review of Patient #9's Physician Discharge Summary dated 09/21/18 at 1434 reflected the patient's 08/14/18 admission and 09/19/18 discharge date. The patient had been admitted for aggression and combative behaviors and required one-to-one staff supervision.

Record review of Patient #9's initial Skin Assessment dated 08/15/18 at 0900 reflected "no significant findings." Skin assessment documentation dated 08/19/18 at 1125 and 08/22/18 at 1150 reflected the patient had a "purple bruise" on his left upper thigh. Nursing assessed the patient with "multiple bruises on both arms and bilateral lower extremities...[and] 2 abrasions...on skin of left leg" on 08/27/18 at 2000. On 08/29/18 at 1130 nursing noted the patient's "multiple bruising to upper and lower extremities of different stages of discoloration ...left pinky toe red..." and ordered x-ray examination.



Personnel #3 acknowledged the above findings during an interview on 12/27/18 at approximately 1620 and denied further documentation on the patient bruising was available.