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Base on record review, interview and observation, the hospital failed to provide a safe environment for 5 of 21 patients (Patients #18, #19, #20, #9, #2).

1) Patients #18, #19, and #20 occupied rooms with metal framed beds and electrical cords which could potentially pose a safety hazard and/or ligature risk for those patients who required inpatient psychiatric treatment for their mental illness.

2) Patient # 9 was bit by Hospital Personnel #14 during a restraint incident on 01/14/16. Although Hospital Personnel #14 did not follow hospital policy of emergency behavior management, the employee was allowed to continue his shift for additional four hours on a different unit before administration suspended him.

3) Elderly Patient #2 was ambulatory on admission. Two days into her hospitalization, the patient fell twice within seven hours and required emergency medical evaluations. Although unable to bear weight, unresponsive and shaking for a brief period of time, and noted to be with a dangerously low blood pressure after her second fall, Patient #2 had to wait for approximately 105 minutes to be transported to the medical center.

Findings included:

1) Observations on 03/21/16 between 16:30 and 17:20 reflected patients occupied Rooms #119, #120, and #121 that had metal framed beds and electrical cords. The rooms were assigned to Patients #18, #19 and #20.

Pants with strings and a plastic spoon were observed in Room 121 on 03/21/16 at 16:40. Hospital Personnel #3 stated at that time that those items were "not supposed to be there."

Patient #18's Inpatient Admission Orders dated 03/18/16, untimed, reflected admission diagnosis of Mood Disorder. Intake screening documentation, undated, timed at 19:25 reflected an involuntary admission. Patient #18 was noted to be a danger to herself.

Patient #19's Inpatient Admission Orders dated 03/17/16 at 22:05 noted diagnoses including Bipolar Disorder, manic, with psychotic features. Admission staff was unable to assess Patent #19's suicidality. The patient was too psychotic.

Patient #20's Intake Assessment dated 03/18/16 at 16:02 reflected a patient statement that she was "severely depressed...drinks because of depression..."

Hospital Personnel #3 and/or #15 accompanied the surveyor during the tour and acknowledged the observations. Hospital Employee #3 stated on 03/21/16 at 16:40 that the hospital had eight metal-framed beds.


2) Patient #9's Physician Discharge Summary reflected an admission date of 01/14/16 and a 01/19/16 discharge date. Admission and discharge diagnoses included Major Depressive Disorder.

Progress Notes dated 01/14/16 at 23:00 noted that Patient #9 "...received a bite mark during the admission process."

Hospital Personnel #8 stated during an interview on 02/10/16 at 16:40 that a patient "bit a tech [mental health technician] and the tech bit the patient."

Hospital Personnel #3 stated on 02/10/16 at 16:40 that Patient #9 was restrained in the Intake Department's lobby on 01/14/16 at 19:40. Patient #9 during the restraint bit Hospital Personnel #14 who "bit back."

Hospital Personnel #7 stated on 02/10/16 at 17:00 that Hospital Personnel #14 did not follow the hospital's emergency behavior management procedures and bit Patient #9 on the right shoulder during a restraint. Pictures showed bruises on Patient #9's right shoulder. After the incident Hospital Personnel #14 "was sent back to his unit and continued his shift." The employee was then suspended and did not return to work.

Record review of Hospital Personnel #14's time card reflected he started his 01/14/16 shift at 16:00 and left at 23:50. There was no time recorded for Hospital Personnel #14 after 01/14/16.


3) Patient #2's Pre-Admission Exam and Certification dated 12/10/15 at 16:43 noted the patient was admitted with a chief complaint of "delusional."

Multidisciplinary Progress Notes dated 12/10/15 at 20:37 reflected Patient #2 "arrived on the unit, ambulatory, with upright gait."

Multidisciplinary Progress Notes dated 12/12/15 at 15:25 reflected Patient #2 wandered the halls "where she bent to pick up items from the floor in front of another patient...[who] came out of his room, hollering, and pushed ...[Patient #2] to the floor...[physician on unit] gave order for...[Patient #2] to be sent to ER [Emergency Room] for evaluation ..."

Multidisciplinary Progress Notes dated 12/12/15 at 17:07 reflected that nursing staff gave report to the acute care hospital ED [emergency department] and "...EMS [emergency medical services] left unit with...[Patient #2]" approximately 102 minutes after the incident.

Multidisciplinary Progress Notes dated 12/12/15 at 20:20 noted the patient returned to the unit "from ED due to injury."

Three hours and twenty minutes later, on 12/12/15 at 23:40 nursing staff noted the patient fell, had a blood pressure of 82/57, was "unable to bear weight...there was a period where [Patient #2] did not respond to staff and began to shake for 5 seconds ...EMS called ..." The notes reflected that EMS were "on the unit for transport" on 12/13/15 at 01:25, approximately 105 minutes after the patient fell. Patient #2 returned from the acute care hospital ED about four hours later on 12/13/15 at 05:35.

Multidisciplinary Progress Notes dated 12/13/15 at 09:30 reflected Patient #2 left the hospital per her family's request. The family had informed nursing staff that Patient #2 was "not safe" at the hospital.

During an interview on 03/21/16 at 14:45 Hospital Personnel #3 reviewed Patient #2's chart and acknowledged the findings.