HospitalInspections.org

Based on observation, medical record review, and review of facility policies, the facility failed to inform patients of their Patients' Rights, and to post Patients' Rights information as directed by their policy.

Findings include:

During a facility tour on 2/17/16 at 11:30 AM with the Nurse Manager (Employee #6), it was observed:
Unit C- No patient rights information posted
Unit E- No patient rights information posted

Review of ten (10) medical records (#s 1-10) revealed that medical record #2 and #3 did not contain evidence that Patients' Rights information had been provided.

Review of facility policy #RI.005, Patients' Rights and Responsibilities, date 1/10, last reviewed/revised 01/14, revealed that at the time of admission, voluntary/involuntary patients or the parent or legal guardian of minor patients would be provided a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language.
A copy of the Patient's Bill of Rights form would be displayed prominently at all times in patient common areas, and other areas frequented by persons receiving services.

Based on observation and review of facility policies, the facility failed to provide patients the right to privacy in two (2) unit E rooms viewed (#105 and 109)

Findings include:

During a tour with the Nurse Manager (Employee #6) on 2/17/16 at 11:30 AM, the following was observed:
Unit E
No patients' rights information posted
Room 105: large bedroom window without shade or film for privacy
Room 109: large bedroom window without shade or film for privacy

Review of facility policy #RI.005, Patient's Right and Responsibilities, date 1/10, last reviewed/revised 01/14, revealed that at the time of admission, voluntary/involuntary patients or the parent or legal guardian of minor patients would be provided a copy of the Patient's Bill of Rights form and a verbal explanation of those rights in their primary language.
A copy of the Patient's Bill of Rights form would be displayed prominently at all times in patient common areas, and other areas frequented by persons receiving services.
ll. List of Rights include:
Personal privacy (unless immediate and serious risk to harm self or others exists)

Based on observation and staff interview, the facility failed to provide care in a safe setting.

Findings include:

During a tour with the Nurse Manager (Employee #6) on 2/17/16 at 11:30 AM, the following was observed:
SCU-
Room D106: air conditioner unit detaching from wall
Room D110: wall damage to left of the sink, ceiling tile damage
Room D112: oxygen compressor with cord approximately six (6) feet long and plastic oxygen tubing approximately six (6) feet long.

Unit E
Laundry room with clothes and shoes on the floor. Floor very dirty.
Community restroom next to seclusion room with missing base boards and four (4) large screw holes in wall
Room 105: water damage around the shower
Room 106: restroom with base boards damaged and/or missing, and water damage to wall. Room ceiling grids with heavy dust
Room 107: restroom with water damage to walls, very dirty floor
Room 109: restroom with water damage to walls

Main Dining Room with twenty (20) tables and ninety medium-light weight chairs which could be easily picked up.

The Nurse Manager acknowledged the above findings at the time of discovery.

Based on observation, and staff interview, the facility failed to assure the physical environment was maintained to assure the safety and and well-being of patients.

Findings include:

During a tour with the Nurse Manager (Employee #6) on 2/17/16 at 11:30 AM, the following was observed:
SCU-
Room D106: air conditioner unit detaching from wall
Room D110: wall damage to left of the sink, ceiling tile damage
Room D112: oxygen compressor with cord approximately six (6) feet long and plastic oxygen tubing approximately six (6) feet long.

Unit E
Laundry room with clothes and shoes on the floor. Floor very dirty.
Community restroom next to seclusion room with missing base boards and four (4) large screw holes in wall
Room 105: water damage around the shower; large bedroom window without shade or film for privacy
Room 106: restroom with base boards damaged and/or missing, and water damage to wall. Room ceiling grids with heavy dust
Room 107: restroom with water damage to walls, very dirty floor
Room 109: restroom with water damage to walls, large bedroom window without shade or film for privacy

The Nurse Manager acknowledged the above findings at the time of discovery.