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Based on observations and staff and patient interviews, the hospital failed to ensure 1) window coverings were provided in 7 of 7 patient rooms (rooms a, b, c, d, e, f and i) out of a total of 18 rooms, and 2) failure to allow 14 of 14 patients comfort time in their rooms from 8:00 AM to 9:00 PM. Findings:

1) Observations on 2/6/13 at 1:15 PM revealed rooms a, b, c, d, e, and f have 2 windows in each room and there failed to be a curtain over both windows. These windows had an opaque covering which did not reach the edges and while the patient was in their room, they could be seen from the street and the private residents located across the street. Room i had a totally clear Plexiglass window with no curtain to provide privacy.

Interviews with S2 Program Director and S3 RN on 2/6/13 at 1:15 PM confirmed the curtains were missing in these rooms.

Further observations on 02-06-13 at 10:30AM, observation of the behavioral health unit revealed the patient rooms were locked. The patients were sitting in chairs or loveseat in the group room or the quiet room. Lunch was served in the dining room at 11:50AM. After lunch the patients continued to sit in the group room or quiet room watching television. Some patients were noted to be sleeping while sitting up in the chairs or while reclining on the love seats.

During a group interview on 02-06-13 at 4:00 PM the patients on the unit complained the doors to their rooms were locked from 8:00AM until 9:00PM. They stated they were not allowed personal time in their rooms at all during the day. They complained they were bored just sitting and watching television. At this time patient #5 complained that he had neck and back pain, and the only relief he got was to lie down flat in the bed. He stated he requested to lie down and was denied by the nurse who told him if she allowed him to go to his room, everybody else would want to also. Patient #1 was sitting in a wheelchair and had an above the knee amputation. He stated he had to sit in the wheelchair all day, and it was very uncomfortable. He stated he was not allowed to go to his room and lie down. The patients also stated that some of them took medications that made them sleepy, but there was no place to lie down.

On 02-07-13 an interview with S11 Physician confirmed the patient rooms were locked during the day, although she was unaware the patients were not allowed some personal time in their rooms during a portion of the day. S11 Physician checked with the nurse on duty, S4 LPN, and was informed the rooms remained locked during the day and patients were not allowed to go to their rooms at all unless there was a physician's order. S4LPN stated they stopped allowing patients to have personal time in their rooms about a month ago.

An interview with S14 Activity Director confirmed the patient rooms were locked each day from 8:00AM until 9:00PM. She stated it has always been policy for rooms to be locked during the day. She stated if a patient had a physical need to lie down in bed, they were supposed to ask the nurse who would get a physician's order for the patient to be allowed to go to the room and lie down. S14 Activity Director stated there were 2 planned activities scheduled each day, one in the morning and one in the afternoon each lasting about an hour. The remainder of the time the patients spent in the group room or the quiet room.

An interview with S2 Program Director and S3 RN, Nurse Manager on 02-06-13 at 12:30PM confirmed patient rooms were locked from 8:00AM until 9:00PM. S3RN Nurse Manager stated the patients were encouraged to be out of their rooms during the day, and if the rooms were left unlocked patients would stay in the bed and refuse to participate in group therapy. S2 Program Director stated there were 2 RN's on staff at night but only 1 RN during the day and confirmed there was not enough staff to monitor the patients while they were in their rooms.

An interview with S4LPN and S5RN on 02-08-13 at 10:00AM confirmed patients were not allowed in their rooms during the day. It was up to the judgment of the nurse to allow a patient who was not feeling well to rest in their room. S5RN stated there were only 2 mental health technicians to observe the patients during the day. Both S4LPN and S5RN agreed the nurses, social worker and the activity director were available to monitor patients during the day for scheduled personal time in their rooms.

Based on observations, review of the Patient Hand Book, Activity Schedule, medical records, and staff interview, the hospital failed to ensure the Registered Nurse conducted ongoing nursing assessments on each patient as evidenced by: 1) failure to assess 1 of 7 patient's (#1) for lower extremity edema who was a diabetic and lower left extremity above the knee amputee, and 2) failure to assess 5 of 7 patients (#1-#5) out of a patient population of 14, in order to determine the need for the patients to rest quietly and comfortably during the day. Findings:

Observation on initial tour on 2/6/13 at 10:30 AM revealed there was a group/activity/common room and a quiet room. Each room was equipped with straight chairs and a short sofa. There was a patient asleep on each of the sofas at that time and various times throughout the survey. Further observations from 2/6/13, 10:30 AM through 2/8/13, 1:30 PM revealed all patient rooms remained locked. Patients were not allowed into their rooms for toileting, having to use the common bathroom or the toilets in the two shower rooms. While not in group meetings, the patients were observed walking around the unit or sitting/ lying in the group room and the quiet room or sitting in the hallway.

Interview on 2/6/13 at 1:00 PM with S3 RN Nurse Manager revealed the patient doors are locked at 8:00 AM and unlocked at 9:00 PM. When asked if patients were allowed to lie down, S3 RN Nurse Manager answered that the decision was made by the nurse on whether to allow a patient to lie down, if they ask.

Review of the Patient Hand Book that was provided to each patient on admission revealed under Safety Issues: during scheduled activities, the doors to patient rooms will remain locked. Review of the Behavioral Health Unit Rules-#11: Patient's rooms will be locked during the day. Patients are expected to attend all scheduled groups. Patients may be granted access to their rooms with the approval of the charge nurse, nurse manager, program director or physician only.

Review of the Behavioral Health Unit Weekday Activity Schedule revealed "personal time" was scheduled for 7-7:30 AM, 12:15-1:00 PM, 6:00-7:00 PM. Review of the weekend schedule revealed personal time was allowed from 8:00- 8:45 AM, 11:30 -12:30 AM, 1:00-1:30 PM, 3:30-4:30 (relaxation), 4:30-5:00 PM, 5:30- 6:00 PM, 9:00-9:30 PM.

A patient group interview was held on 2/6/13 at 4:15 PM. Among the issues discussed (dietary, environment) having the patient rooms locked was a great concern for several of the patients. Patient # 5 expressed he had a lot of neck and pain following past surgeries in those areas. Patient #5 stated he had requested to lie down in his room because that helped relieve his back pain but was denied access to his room by the nursing personnel who told him "if we let you, everybody will want to".

Interview on 2/8/13 at 9:10 AM with S14 Activity Therapist revealed she was on site daily. When asked where patients spent their personal time she stated, in the group room or quiet room because the patients were not allowed back into their room to rest which had always been the policy.

Review of the medical record for patient #5 revealed he was admitted 01/29/13 with an Axis III diagnosis of chronic neck and back pain. Further review revealed his routine home pain medication was discontinued upon admission. Review of Nurse Notes dated 2/3/13 revealed documentation that patient #5 complained to the nurse that his "neck and back had been painful and had dizziness associated with the neck pain. Worse when just sitting or standing around and not being able to lie down a few times a day". Further review revealed the documentation addressed his mental health but no other mention of allowing him to lie down.

Interview on 2/8/13 at 10:00 AM with S5RN and S4LPN revealed the staff that day consisted of the RN, the LPN, 2 MHTs (mental health tech), the social worker and the activity director. The surveyor asked these nurses about locking the patient rooms for the entire day, and S5RN replied if the patient was depressed they would want to stay in their room all day and not attend group activities. S5RN also stated there were times when there was not a problem with patients attending group activities. When asked if the patient population was active and exhibited no intention of wanting to stay in bed, were the patients allowed back in their room even for 1 hour to rest, S5RN and S4LPN replied they were not. S5 RN further stated that allowing a patient to lie down was a nursing judgement based on if a patient complained of not feeling well. S4 LPN stated that if you let one patient lie down, they all want to lie down and then there was the problem of patients going to other patients rooms. S5RN and S4LPN were asked if patients were routinely assessed following admission, with medication changes, diagnosis needs, etcetera, if the nurse determined if patients needed to lie down to rest. They stated "No". Both nurses confirmed medication changes can make patients sleepy and that patients were asleep on the love seat couches at all times of the day. S5RN was asked about the documentation in patient #5's chart that indicated he complained of neck and back pain and needed to lie down a few times a day. S5 RN stated he had never complained to her and the nurse who documented that worked on Tuesday only and could not answer for her.

On 2/8/13 at 11:40 AM, the surveyor observed patient #1, who is a left above the knee amputee, sitting in the wheelchair with his right leg propped up on a chair. Interview with patient #1 during the observation revealed the right ankle/foot area was swollen because he had been sitting in the wheelchair all day and the foot "has been hanging down". Patient #1 further stated he had concerns about the swelling because he was a diabetic and had already "lost my other leg". The surveyor asked S5RN if she was aware of the patient #1's right lower extremity edema and she replied "no". S5RN then proceeded to remove the patient's sock, assess the lower extremity and confirmed the ankle area was edematous. S5RN stated there was an assessment sheet located in the patient's medical record that was completed at the beginning of every shift and confirmed there was no documentation regarding edema of the patient's ankle or foot.








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Based upon observations, review of the diet list, and interviews, the hospital failed to ensure: 1) patient meals were served hot, 2) 5 of 5 patients were provided diabetic diets during the lunch meal on 02/06/13 at 11:40 AM, 3) evening snacks were provided to 14 of the 14 patients on 02/05/13, and 4) failure to provide patient #2 with fluid during the noon meal on 02/08/13. Findings:

Observation of the noon meal on 02/06/13 at 11:40 AM, revealed all 14 patients were called to the dining area. S8 and S9, from the dietary department at the main hospital, transported the meals in a soft insulated bag from the dietary department to the behavioral unit. Inspection of the bag revealed all the patient meals were inside and the Velcro strips located on the side of the bag were open allowing the heat of the bag to escape. When asked about the temperatures of the meals, S8 replied the temperatures were taken in the dietary department at the hospital; however, there was no temperature testing done once the meals reached the behavioral unit, even though the patients complained of the food being cold.

Further observations of the noon meal on 02/06/13 revealed S8 and S9 removed the meal containers from the insulated bag and placed the meals in front of the patients. The patients were then asked what they wanted to drink and then offered regular soft drinks (Cokes, Dr. Peppers). Interview with S9 during the observation revealed when asked if all the diets were the same, S9 replied "yes, everyone can eat the meals".

Interview with S2, the Behavioral Unit Program Director, on 02/06/13 at 1:30 PM, revealed when asked how the dietary department was notified of the patient diets, S2 replied every morning the list of patient diets was faxed to the dietary department. Review of the diet list revealed it was identified there were 5 diabetic diets listed. Further interview with S2 revealed the behavioral unit could not verify the list of diets had been faxed to the main hospital on the morning of 02/06/13.

Interview with patient #1 on 02/06/13 at 2:50 PM, revealed he was an insulin dependent diabetic and was suppose to receive a snack before bedtime; however, on the evening of 02/05/13, no evening snacks were provided. Observation of the nutritional area on 02/06/13 at 3:00 PM, revealed there were 4 cans of soup, crackers and peanut butter, 5 muffins, and 8 small containers of juice. Interview with S3RN during the observation revealed when asked about snacks for the patients, S3RN replied when the dietary department delivered the meals, they failed to bring the patient snacks with them. S3RN further stated she was not aware the patients did not have snacks available for the evening of 02/05/13.

During a telephone interview on 2/7/13 at 3:00 PM with S10 RD revealed the main hospital dietary department provided meals to the BHU according to what was faxed. If nothing was faxed, that meant that all of the diets sent were regular diets. S10 RD stated the courier S9 dietary worker informed her there were no special diets currently.

Observations on 02/08/13 at 12:00 Noon, revealed patient #2 was sitting at the dining table eating her noon meal; however, the patient had no drink. Interview with S4LPN during the observation revealed when asked about the patient not having any fluids provided with her meal, S4LPN replied the patient was not offered any juice because she would drink only the juice and not eat her meal. S4LPN was then asked if the patient was offered any other type of fluids, and she replied the patient would not drink anything else. At 12:10 PM, S4LPN had provided patient #2 with water of which the patient was drinking.

Based on observation and staff interviews, the hospital failed to maintain or ensure the leasing hospital maintained, the condition of the environment as evidenced by cold water in the shower area, dirty walls, and furniture in disrepair. Findings:

Observation of the group activity room during initial tour on 2/6/13 revealed furniture that had fabric and padding missing down to the wood frame of a chair; torn and split seat coverings of the straight back chairs and cloth covered couches that had dark stains. One of 2 showers had soap/debris accumulated in the safety hand rail that required removal with a tool to scrape the debris out. Further observation during tour revealed the bathroom available to all patients during the time the bedrooms were locked had a very strong urine odor. Further observation revealed the bottom of the doors and walls outside of the dining area and quiet rooms were dirty and stained.

During a group meeting with 11 patients on 2/6/13 at 4:15 PM it was revealed only cold water was available in one of the two showers. One random patient stated that he had to "jump in and out of the cold water in order to rinse off." Another random female patient stated this was the only shower available for the female patients. Several of the patients stated they had used the cold shower and had reported it to staff; however, the shower had not been fixed.

Interviews with S2 Program Director and S3 RN on 2/6/13 at 1:15 PM revealed the building was leased from the adjoining Rehab Hospital. S2 Program Director also confirmed the building had not had the attention required to keep it up to standard since he had been very involved in the operation of the Senior Care Unit and the preparation of the new adult psychiatric unit that was to open in March 2013. S2 Program Director also stated that he had made requests for new furniture but was denied since any new furniture bought was going to the new unit. S2 Program Manager and S3RN stated they were unaware of the cold water until the surveyors brought it to their attention.

Interview on 6/7/13 at 9:15 AM with S1COO (Chief Operating Officer) revealed he was unaware there was no hot water in one of the showers. S1COO explained leasing this building was only temporary. When questioned when patients were admitted here, S1 COO stated June 2011. S1COO made observations of the torn/stained furniture and confirmed the condition of the building was unacceptable and the furniture was of substandard quality.