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Based on record review, observation, and interview, the hospital failed to ensure the right of 3 of 3 patients (Patients #10, #13, #5) to participate in the development and implementation of their care plan.


1) Although assessed to have a high fall risk on admission, Patient #10 experienced a fall four days into her hospitalization and suffered a head injury that required emergency medical care interventions. After the patient's return from emergency care, hospital staff failed to revise the plan of care to reflect the needs of the patient following the fall incident, as well as the related injuries, and did not explain care interventions related to the incident to the patient.


2) Patient #13 had been admitted for homicidal and illogical thoughts. During his treatment, staff became aware that the patient took plastic spoons during meal times and hid them in his pocket. Patient #13 also announced his plans to elope from the facility. The patient's treatment plan did not reflect a revision with patient participation to meet Patient #13's needs.


3) Patient #5's skin assessment on admission was not completed. Nursing staff noted a deep tissue injury to the patient's lower back nine days into his hospitalization and two pressure ulcers on the patient's hips sixteen days after his admission. Patient #5 plan of care dated the eighteenth day of his hospitalization did not address his skin injuries.


Findings included



1) Patient #10 was observed on 09/05/17 at 1715 in the hospital's dining room. Patient #10 had extensive bruising on her left eye and on the left side of her face.

Patient #10's Integrated Inpatient Nursing Assessment dated 08/26/17 at 2354 reflected the patient was a high fall risk. Factors contributing to the high fall risk assessment included the patient's recent fall history, use of assistive devices, impaired mental status, and use of psychotropic medications. However, staff failed to initiate nursing care interventions to address the patient's fall risk.

Progress Notes dated 08/30/17, at 2100, reflected Patient #10 fell in the dining room at 2020 and hit her head. The patient had a "large hematoma [bruise] on her left temple...[and complained] of allover pain...unable to straighten legs out..." Patient #10 was transferred to a medical hospital for emergency medical care. Progress Notes dated 08/31/17, at 0120, reflected the patient returned to the hospital at that time.

Daily Nursing Assessment and Progress Note dated 08/31/17 at 0530 reflected Patient #10 had a hematoma (bruising) on the left side of her head and "multiple skin tears."

Record review of Patient #10's Inpatient Master Treatment Plan dated 08/27/17 at 1815 did not reflect a revision to address the needs of the Patient #10 following the fall incident. There was no evidence that staff explained interventions to reduce further incident of falls with the patient or address care issues related to her bruising and/or skin tears with the patient.

Hospital Personnel #9 was interviewed on 09/06/17 at 1050 regarding Patient #10's treatment plan. Hospital Personnel #9 stated the patient's fall and bruising were not on the treatment plan.


2) Record review of Patient #13's Complete Psychiatrist Evaluation dated 08/24/17, at 1229, reflected the patient was admitted to the hospital after he walked into traffic, threatened people, and assaulted a police officer. The patient was homicidal, delusional, paranoid, and had illogical thinking. He required "...continuous observation in a safe and secure environment...prevention of injury to self or others..."

Patient #13 was observed in the hospital's dining room on 09/05/17, at 1745, in a conversation with Patient #16. Patient #13 emptied the content of his right pant pocket onto the table. It included two plastic spoons. After a brief moment, Patient #13 picked up the two plastic spoons and a third one he used during the meal and returned them to his right pant pocket. After surveyor inquiry, Hospital Personnel #30 approached Patient #13 who denied having spoons in his pocket.

During an interview on 09/05/17, at 1750, Hospital Personnel #19 stated Patient #13 eventually turned four spoons over to staff. Hospital Personnel #19 stated at that time that Patient #13 and Patient #16 had made plans to elope from the hospital.

Patient #13 was interviewed on 09/05/17, at 1830, and stated he and Patient #16 would be leaving the hospital that night. The patient was asked about plastic spoons and stated he got them "every day."

Record review of Patient #13's Inpatient Master Treatment Plan dated 08/24/17 at 1230 and the patient's Treatment Plan Review dated 08/31/17 did not reflect a revision of care with interventions to address the patient's behavior of hiding plastic ware and elopement plans. There was no evidence that staff explained interventions to address Patient #13's potential elopement and/or self-harming behavior.

During in interview on 09/06/17 at 1100, Hospital Personnel # 30 acknowledged the above findings and stated plastic ware was contraband.


3) Record review of Patient #5's Integrated Nursing Assessment dated 07/12/17, at 2120, reflected nursing staff was "unable to complete" a skin assessment.

Daily Nurse Assessment and Progress Note dated 07/21/17, at 1552, reflected Patient #5 had a "blister dark area...possibly DTI [deep tissue injury]..." on his right lower back.

Progress Notes dated 07/28/17 at 0428 reflected the patient had "received wound care for a Stage 2 wound to right ischial tuberosity [lower back part of the hip bone]...observed now Stage 2 [wound] to left ischial tuberosity...stage 2 to left ischial tuberosity...[is] 3 cm [centimeter] in diameter..."

Patient #5's Interdisciplinary Treatment Plan Problem Page dated 07/30/17 reflected the patient had pressure sores. There was no evidence that interventions to address the skin break-down were explained to Patient #5.

Hospital Personnel #30 acknowledged the above findings during an interview on 09/05/17 at 1540.

The hospital's Patient Right Policy dated 02/01/17 reflected the patient's right "...to participate in the development and implementation of his or her plan of care."

Based on record review, observation, and interview, the hospital failed to ensure that of 3 of 3 patients (Patients #10, #13, #5) had a comprehensive treatment plan.


1) Although assessed to be a high fall risk, Patient #10 fell four days into her hospital stay and suffered a head injury that required emergency medical care interventions. After the patient's return from emergency care, hospital staff failed to revise the plan of care with the patient's fall incident and related injuries.


2) Patient #13 had been admitted for homicidal and illogical thoughts. During his treatment, staff became aware that the patient took plastic spoons during meal times and hid them in his pocket. Patient #13 also announced his plans to elope from the facility. The patient's treatment plan did not reflect the patient's behavior and elopement plans.


3) Patient #5's skin assessment on admission was left uncompleted. Although the patient was noted to have a deep tissue injury nine days into his hospital stay and two pressure ulcers on his hips approximately two weeks into his stay, a care plan to address his skin injuries was not initiated until the eighteenth day of his hospitalization.



Findings included



1) Patient #10 was observed on 09/05/17 at 1715 in the hospital's dining room. Patient #10 had extensive bruising on her left eye and on the left side of her face.

Patient #10's Integrated Inpatient Nursing Assessment dated 08/26/17 at 2354 reflected the patient was a high fall risk. Factors contributing to the high fall risk assessment included the patient's recent fall history, use of assistive devices, impaired mental status, and use of psychotropic medications.

Progress Notes dated 08/30/17, at 2100, reflected Patient #10 fell in the dining room at 2020 and hit her head. The patient had a "large hematoma [bruise] on her left temple...[and complained] of allover pain...unable to straighten legs out..." Patient #10 was transferred to a medical hospital for emergency medical care. Progress Notes dated 08/31/17, at 0120, reflected the patient returned to the hospital at that time.


Daily Nursing Assessment and Progress Note dated 08/31/17 at 0530 reflected Patient #10 had a hematoma (bruising) on the left side of her head and "multiple skin tears."


Record review of Patient #10's Inpatient Master Treatment Plan dated 08/27/17 at 1815 did not reflect a revision to address the Patient #10's fall incident.


Hospital Personnel #9 was interviewed on 09/06/17 at 1050 regarding Patient #10's treatment plan. Hospital personnel #9 stated the patient's fall and bruising were not on the treatment plan.


2) Record review of Patient #13's Complete Psychiatrist Evaluation dated 08/24/17, at 1229, reflected the patient had been admitted after he walked into traffic, threatened people, and assaulted a police officer. The patient was homicidal, delusional, paranoid and had illogical thinking and required continuous observation in a safe and secure environment...prevention of injury to self or others..."


Patient #13 was observed in the hospital's dining room on 09/05/17, at 1745, in a conversation with Patient #16. Patient #13 emptied the content of his right pant pocket onto the table. It included two plastic spoons. After a brief moment, Patient #13 picked up the two plastic spoons and a third one he used during the meal and returned them to his right pant pocket. After surveyor inquiry, Hospital Personnel #30 approached Patient #13 who denied having spoons in his pocket.


During an interview on 09/05/17, at 1750, Hospital Personnel #19 stated Patient #13 eventually turned four spoons over to staff. Hospital Personnel #19 stated at that time that Patient #13 and Patient #16 had made plans to elope from the hospital.


Patient #13 was interviewed on 09/05/17, at 1830, and stated he and Patient #16 would be leaving the hospital that night. The patient was asked about plastic spoons and stated he got them "every day."


Record review of Patient #13's Inpatient Master Treatment Plan dated 08/24/17 at 1230 and the patient's Treatment Plan Review dated 08/31/17 did not reflect the patient's behaviors of hiding plastic ware and plans to elope.


During in interview on 09/06/17 at 1100, Hospital Personnel # 30 acknowledged the above findings.


3) Record review of Patient #5's Integrated Nursing Assessment dated 07/12/17, at 2120, reflected nursing staff was "unable to complete" a skin assessment.


Daily Nurse Assessment and Progress Note dated 07/21/17, at 1552, reflected Patient #5 had a "blister dark area...possibly DTI [deep tissue injury]..." on his right lower back.

Progress Notes dated 07/28/17 at 0428 reflected the patient had "received wound care for a Stage 2 wound to right ischial tuberosity [lower back part of the hip bone]...observed now Stage 2 [wound] to left ischial tuberosity...stage 2 to left ischial tuberosity...[is] 3 cm [centimeter] in diameter..."


Patient #5's Interdisciplinary Treatment Plan Problem Page dated 07/30/17 reflected the patient had pressure sores.


Hospital Personnel #30 acknowledged the above findings during an interview on 09/05/17 at 1540.


Hospital Policy titled Interdisciplinary Treatment Planning Documentation dated 02/01/17 noted that treatment plan reviews occurred in cases of "significant change" in the patient's condition or following a qualifying event."