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Based on staff interview, medical record review, and policy review the facility failed to include documented interventions in the patient's plan of care. This affected two of five behavioral health unit medical records reviewed. The Behavioral Health Unit (BHU) census was 6 and the hospital census was 43.

Findings include:

On 02/22/16 at 11:15 while touring the Behavioral Health Unit (BHU) Floor Nurse, Staff C, stated the isolation room, located directly across from the nurse's station, was converted to a "Comfort Room" in October 2015. Staff C stated there had only been two patients since October that have used the Comfort Room. Staff C identified Patient #8 and Patient #9, both discharged, as the two patients.

On 02/22/16 at 11:20 the policy and procedure guidelines for use of the Comfort Room was requested. The BHU Nurse Manager, Staff B, stated there was no policy or procedure guidelines for use of either the Comfort Room across from the nurse's station or the Quiet Room across from the dining/day room.

1. On 02/23/16 the medical record for Patient #8 was reviewed. The medical record documented an admission on 02/05/16 with a primary diagnosis of Psychosis and a discharge on 02/18/16 (14 days). The nurse notes documented providing the quiet area to decrease stimuli and anxiety on 02/06/16 at 5:50 PM, 02/08/16 at 8:00 AM, 02/09/16 at 3:28 PM, 02/10/16 at 4:53 PM, 02/12/16 at 4:29 PM, and 02/15/16 at 3:16 PM. The notes lacked clarification as to which quiet area was used however Staff C had confirmed the Comfort Room was the room used.

2. On 02/23/16 the medical record for Patient #9 was reviewed. The medical record documented an admission on 02/11/16 with a primary diagnosis of agitation and a discharge on 02/19/16. The nurse notes documented providing the quiet area to decrease stimuli and anxiety on 02/13/16 at 8:45 AM, 02/17/16 at 3:26 AM, and 02/17/16 at 6:42 PM. The notes lacked clarification as to which quiet area was used however Staff C had confirmed the Comfort Room was the room used.

The notes from both Patient #8 and #9 also lacked documentation as to the patient's need for a quiet area, what behaviors were present, what other interventions were attempted, did the patient request the quiet area, did the nurse encourage the quiet area, did the nurse escort the patient to the quiet area, how long was the patient in the quiet area, was the patient under direct observation while in the quiet area, was the door open, was the door closed, could the patient lock the door, or how effective the intervention was for the patient. The patient care plans also lacked documentation of the Comfort Room or the Quiet Room as interventions and what criteria would guide the use of those rooms.

On 02/25/16 at 1:30 PM the Chief Nursing Officer, Staff A, confirmed the use of the Comfort Room or the Quiet Room should be documented in the patient's care plan when used and the nurse's note should document the rational before, during, and after the intervention.

Based on staff interview and policy review the facility failed to ensure all medical records were completed within 30 days following discharge. The hospital census was 43.

Findings include:

On 02/25/16 hospital policy entitled; Wilson Chart Completion Policy, revised 01/2016, was reviewed. The policy documented records would be completed and authenticated within 30 days of the patient's discharge.

On 02/22/16 at 2:00 PM the Director of Health Information, Staff D, stated in an interview that the hospital had 51 delinquent medical records with six suspended physicians.

Based on observation, interview, and record review, the facility failed to maintain the physical environment in a manner safe from fire. The facility failed to maintain a two hour barrier between the facility and a medical office building, failed to meet the requirement for building construction and type as required at 19.1.6, failed to ensure the walls of its corridors were smoke tight as rated, failed to ensure doors protecting corridor opening that had self-closing and latching hardware closed and latched the doors, failed to maintain the stated rating surrounding each of its shafts and stairways, failed to ensure each path of egress was marked with readily visible exit signs, failed to ensure each door in a smoke barrier self-closed and, where so equipped, latched, to maintain the stated rating of smoke barriers, failed to maintain the stated rating surrounding its hazardous areas and to ensure each door to a hazardous area self-closed and where so equipped, latched, to ensure each of its exit stairways were enclosed with a fire resistive rating of at least one hour, failed to maintain the width of the corridor in its geriatric psychiatric unit to at least four feet, failed to ensure its fire drills were held at unexpected times under varying conditions, failed to maintain its fire alarm system in accordance with NFPA 72, 1999 edition, failed to maintain the sprinkler system in accordance with NFPA 13 and 25, 1999 editions, to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4, and failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. (A709) The cumulative effect of these practices resulted in the facilities inability to maintain the physical environment in a manner safe from fire.

Based on observation, interview, and record review, the facility failed to meet requirements for life safety, specifically, the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. This has the potential to affect all patients receiving services at this facility.

Findings include:

The facility failed to maintain a two hour barrier between itself and a medical office building. Please refer to life safety code findings at K11.

The facility failed to meet the requirement for building construction and type as required at 19.1.6. Please refer to life safety code findings at K12.

The facility failed to ensure the walls of its corridors were smoke tight as rated. Please refer to life safety code findings at K17.

The facility failed to ensure doors protecting corridor opening that had self-closing and latching hardware closed and latched the doors. Please refer to life safety code findings at K18.

The facility failed to maintain the stated rating surrounding each of its shafts and stairways. Please refer to life safety code findings at K20.

The facility failed to ensure each path of egress was marked with readily visible exit signs. Please refer to life safety code findings at K22.

The facility failed to ensure each door in a smoke barrier self-closed and, where so equipped, latched. Please refer to life safety code findings at K27.

The facility failed to maintain the stated rating of smoke barriers. Please refer to life safety code findings at K25.

The facility failed to maintain the stated rating surrounding its hazardous areas and to ensure each door to a hazardous area self-closed and where so equipped, latched. Please refer to life safety code findings at K29.

The facility failed to ensure each of its exit stairways were enclosed with a fire resistive rating of at least one hour. Please refer to life safety code findings at K33.

The facility failed to maintain the width of the corridor in its geriatric psychiatric unit to at least four feet. Please refer to life safety code findings at K39.

The facility failed to ensure its fire drills were held at unexpected times under varying conditions. Please refer to life safety code findings at K50.

The facility failed to maintain its fire alarm system in accordance with NFPA 72, 1999 edition. Please refer to life safety code findings at K52.

The facility failed to maintain its sprinkler system in accordance with NFPA 13 and 25, 1999 editions. Please refer to life safety code findings at K62.

The facility failed to ensure its dampers were tested in accordance with National Fire Protection Association 90A, 1999 edition, section 3-4. Please refer to life safety code findings at K67.

The facility failed to ensure power strips were used in accordance with National Fire Protection Association 70, 1999 edition. Please refer to life safety code findings at K147.