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Based on record review, observation, and interview, the hospital failed to protect and promote the rights of 11 out of 11 patients on the hospital's adult, geriatric, and adolescent patient care units (Patients #19, #20, #21, #16, #12, #14, #15, #11, #13, #6, and #5).


1) The hospital failed to protect personal health information of three of three patients (Patients #19, #20, and #21) whose protected mental health information was left accessible to Patient #18.

Cross refer: A0129


2) The hospital failed to ensure the right to receive care in a safe setting for eight of eight patients (Patients #16, #12, #14, #15, #11, #13, #6, and #5) on the hospital's geriatric and adolescent patient care units. All patients on the hospitals geriatric PCU Unit at the time of survey had access to safety hazards potentially usable for self-harm, suicide attempt, and/or elopement from the locked unit. A patient on the hospital's adolescent care unit remained on routine staff supervision although the patient was able to collect contraband including tobacco and posed a serious risk to other patients, staff, and the unit's physical environment with sexually inappropriate and aggressive-destructive behavior.

Cross refer: A0144

Based on record review and interview, the hospital failed to provide one of one patient (Patient #22) with written notice of its resolution of the patient grievance. Telephone contact only occurred thirty-six days after the patient complaint was received.


Findings included:


Record Review of Patient #22's Concern Notification provided by Personnel #16 reflected the patient's complaint that Personnel #19 talked to her "rudely" and "didn't care." The document reflected that a message was left on 02/20/17 at 1427 with Patient #22's family member "to call back."


During an interview on 02/24/17 at 1315 Personnel #16 denied that a written response was provided to Patient #22. Personnel #16 stated she did not "always get to...[patient complaints] right away."

Based on record review, observation, and interview, the hospital failed to ensure the privacy of protected patient information for three of three patients (Patient #19, #20, #21) whose mental health information was left in the unit day room accessible to another patient.


Findings included


Patient #18 was observed on the hospital's adult unit on 02/23/17 at 1105. The patient was on the sofa in the unit day room. There was no staff in the room and the patient was alone. In close proximity and accessible to Patient #18, was a stack of papers on the table that included Patient #19's Daily Goal Sheet dated 02/20/17 identifying the patient's feelings and personal relapse prevention plan.


Accessible to Patient #18 was also Patient #20's Daily Goal Sheet dated 02/16/17 which reflected personal patient information and Patient #21's undated Relapse Prevention Plan identifying that the patient took Marijuana.


Personnel #14 witnessed and acknowledged the findings at that time, stated the papers should not be there, and removed them.

Based on observation, interview, and record review, the hospital failed to ensure the patient's right to receive care in a safe setting for seven of seven patients on the hospital's PCU Unit (Patients #16, #12, #14, #15, #11, #13, and #6). These patients had access to safety hazards that included eight feet oxygen tubing pthat could be used for self-harm, a harmful liquid, and keys to unlock the unit doors. In 1 of 1 patient on the hospital's adolescent unit (Patient #5) the level of observation was not increased due to sexually acting out and aggressive behavior thereby placing the patient, hospital staff, and fellow patients at risk of harm.


1) Although Patient #16 was admitted for depression, without hope and self-worth, and made suicidal comments to hospital staff, she had access to long oxygen tubing, multiple cords, and bed side rails with spaced bars potentially usable for ligature for 42 hours and 46 minutes until surveyor intervention.


2) Patient #12 was admitted with labile mood, had a history of suicide attempts, and mourned the loss of a son to suicide. Patient #12 had access and means for self-harm with long oxygen tubing and side rails.


3) Patients #14 and #15 had been admitted with confusion and/or poor impulse control and anxiety. Both patients had access to a liquid that would require poison control contact immediately in case of ingestion.


4) Patients #11, #14, #13, and #6 had access to staff's unit keys while waiting for group therapy to start.


5) Patient #5's level of observation was not increased due to sexually acting out and aggressive behavior on the hospital's adolescent unit. Patient #5's behavior placed Patient #5, hospital staff, and other patients at risk of harm.



Findings included:


1) Patient #16's Integrated Intake Assessment dated 02/21/17 at 1519, reflected that the patient was depressed with suicidal ideation. The patient reported a decrease in sleep and appetite, was increasingly isolative and reported "crying all the time..." The patient felt "guilty living" and "wanted her kids to be at peace without her as a burden."


Patient #16's Admission Orders dated 02/21/17 at 1725, reflected the patient was "currently depressed." Oxygen was ordered to be applied per nasal cannula because the patient was short of breath.


Patient #16's Physician History and Physical Exam dated 02/22/17 at 0730, reflected the patient had "increased depression with suicidal ideations...crying all the time...feels hopeless..."


Nursing Admission Assessment dated 02/21/17 reflected Patient #16 felt hopeless, helpless, worthless, and "very lonely."


Patient #16 was observed during group therapy on 02/22/17 at 1335. The patient was tearful on several occasions when she spoke of her past. The patient wore nasal prongs as part of her head set loop oxygen extension tubing and had a portable oxygen tank.


Patient #16 was observed by a surveyor in her bed on 02/22/17 at 1620. The patient's nasal oxygen tubing was approximately four feet long and attached to an oxygen concentrator. The concentrator was turned on and plugged into the wall outlet with an electric cord of approximately five feet length. The patient's bed had side rails with cross bars which provided a potential ligature risk.


During an interview on 02/22/17 at 1620, Patient #16 stated she had come to the hospital because "I didn't want to be around me anymore." The surveyor asked Patient #16 whether she had a plan to hurt herself and responded, "If I had the means, yes." Patient #16 asked staff for an extended oxygen tubing in order to be able to move in bed more easily. Personnel #14 witnessed the interview.


On 02/22/17 at 1625, Personnel #14 stated to the surveyor, "We have a suicidal patient with a long cord." Personnel #14 left the room at that time.


Approximately 17 hours later, on 02/23/17 at 0915, observations reflected Patient #16 was in bed with an approximately eight feet oxygen tubing set. Patient #16 invited the surveyor to a conversation. The patient was tearful and stated she had come to the hospital "wondering why I was left here...I'm tired of being sad...don't understand why I can't turn lose my sadness." The patient stated staff had provided her with an extended oxygen tubing." The patient denied that a staff member sat with her during the night.


On 02/23/17 at 0952, Personnel #27 stated he checked on Patient #16 every fifteen minutes. Personnel #27 acknowledged that the patient's oxygen tubing was "four feet plus the [four feet] extension now."


On 02/23/17 at 1005, Personnel #26 was observed on the phone asking for an order for Patient #16 to be placed on one-to-one staff observation.



2) The surveyor observed Patient #12 on 02/22/17 at 1415. The patient was in bed. Her body and face were covered with a bed sheet. Long oxygen tubing was observed attached to a concentrator. The patient's bed had side rails. Patient #12 was observed again on 02/23/17 at 0915, with long oxygen tubing connected to an electric concentrator. There was no staff in the patient's room during the time of observations.


Patient #12's Integrated Assessment dated 02/14/17 at 1825 reflected had a history of suicide attempts and wished that "God would take...[her] tonight." Patient #12 verbalized grief over the loss of a son to suicide and stated "I don't expect to live very long...one is going to do me out..."


Patient #12's Physician Psychiatric Evaluation reflected the patient's statement that she did not want to live. The physician noted the patient was "labile and hostile...insight and judgement are poor to fair..."


Physician Progress Note dated 02/21/17 at 0917, reflected the patient was at "high risk...for decompensation if not in a safe environment due to continuing severe mood instability and psychosis."


Observation Reports dated 02/14/17 through 02/22/17, reflected Patient #12 was staff monitored every fifteen minutes.


Surveyor observation on 02/22/17 at 1415, reflected that eight of eight beds on the hospital's PCU Unit had side rails.


During an interview on 02/23/17 at 1650, Personnel #1 acknowledged that oxygen tubing and cords were hospital identified as potential ligature risk on 10/25/16 but not followed up with an action plan.



3) Observations on the hospital's PCU unit on 02/22/17 at 1250, reflected an open night stand next to Bed A in Room 102 had a Accutherm insulated instant hot pack. While the liquid inside the hot pack was cool at the time of survey, the bag carried a warning "for external use only...harmful if swallowed...if accidentally swallowed, call poison control immediately..." The bag was accessible to Patients #14 and #15.


Personnel #3 acknowledged the finding at that time and removed the instant hot pack.


Record review of Patient #14's Physician Psychiatric Evaluation dated 02/21/17 reflected the patient was "confused and disoriented to time and place." Admitting diagnoses included Major Depressive Disorder with Psychotic Features.


Record review of Patient #15's Psychiatric Evaluation, undated, untimed, reflected the patient was admitted on 02/21/17 with "aggressive violent behavior...free floating anxiety...impulse control problems..." Admission diagnoses included Bipolar Disorder; the patient was noted to be manic.



4) The surveyor observed Patients #11, #14, #13, and #6 on 02/22/17 at 1312 in the unit's day room. No staff member was present. A set of keys was observed on the table. After approximately three minutes, Personnel #29 returned and sat down close to the keys. The surveyor asked Personnel #29 about leaving the unit keys on the table and stated, "I was just trying to get someone else to come to therapy." Personnel #29 was observed later using the keys to open the unit door.



5) Patient #5's Admission Orders dated 01/19/17 timed at 1710, reflected, "Observation level...close observation with Q15 minute checks..."


The Psychiatric Evaluation dated 01/22/17 timed at 0900, reflected, "14 year old...in school suspension...stealing...refusing to do his work...truant, patient along with other boys vandalized the school...anxiety and panic attacks had grown and he had begun to entertain thoughts of taking his own life...continued to have problems with bullying and other people harassing him..."


The Daily Nursing Assessment-Flow Sheet dated 01/22/17 timed at 1430, reflected, "Patient caught "snorting" sugar on 3-11 shift yesterday...multiple contraband items found including 50 plus packets of sugar...broken hollowed out markers, cigarette butts and tobacco in Styrofoam cups..."


The Daily Nursing Assessment-Flow Sheet dated 01/22/17 timed at 1200, reflected, "During lunch a patient reported hearing Patient #5 and [female peer] had been sexually inappropriate and female performed oral sex...discussed with both parties...admitted him and female peer had kissed last night while staff were dealing with another situation...advised we would have to keep both of them separated..."


The Observation Report dated 01/22/17 reflected, "Patient is being sexually inappropriate and touching others...redirected several times...at 1820...becoming increasingly aggressive and cussing at female patients...sent to room remains hostile..."


The Daily Nursing Assessment-Flow Sheet dated 01/23/17 for 7-3 reflected, "Has required redirection regarding unit rules and boundaries...admits to tearing a hole in wall that was patched by maintenance...verbally aggressive and threatening peers to "kill them" making obscene hand gestures to peers patient appears to get other patients to "gang up" on other peers..."


The 01/24/17 Daily Nursing Assessment-Flow Sheet timed at 1100 reflected, "After class patient came out to nurses station with a female peer...talking with BHT [behavioral health technician] and began rubbing peers leg...immediately separated...advised patient and peer no longer allowed to interact...patient became upset ran into room, slammed door and kicked wall..."


The 01/25/17 Daily Nursing Assessment-Flow Sheet reflected, "Arrived on unit at 0645...agitated with staff [for not] being allowed to leave unit for breakfast...has to alternate with female peers because SAO [sexually acting out], inappropriate touching when other patients left unit, patient threw hygiene buckets sitting on nurses station at BHT, hitting BHT in the face...then went to room, slammed the door, kicked wall, tearing sheets off bed...took shower curtain off and used shower rod to slam against the A/C unit in room..."


The 01/25/17 Daily Nursing Assessment-Flow Sheet timed at 0740 reflected, "Patient roommate went into room...argument over patient tearing up the room...patient shoved peer into the wall in room...roommate became upset...
[Patient #5] shoved him, roommate punched [Patient #5] in the face...[Patient #5] ran out of room while BHT was on the way to the room...[Patient #5's] nose bleeding, right eye redness and swollen scab on forehead reopened...ice applied...at 1000 asked to change room...refused to leave room...became compliant and went to new assigned room...then shoved new roommate into wall...cursing at staff, verbally aggressive...does not take responsibility for behavior...at 1230 decreased swelling to right eye..."


On 02/24/17 at approximately 1304, Personnel #2 and #14 were interviewed and asked to review Patient #5's medical record. Personnel #2 and #14 were asked if Patient #5's level of observation such as a LOS [line of sight], one-to-one staff observation was ordered due to Patient #5's aggression, behavior and sexually acting out. Personnel #2 verified the physician changed the patient level on the unit but no new orders were obtained to increase Patient #5's observation level. Personnel #2 stated she agreed the observation level should have been increased.


The policy and procedure titled, "Provision of Care, Treatment and Services Observation Rounds" with a revision date of 03/2013 reflected, "It is the policy...to provide a safe and therapeutic environment for all patients...hospital provides a general level of security and supervision commensurate with the needs of the patients....1:1 observation...ordered if the patient is in imminent danger of harming himself/herself...maintains visual contact and remains within arms length at all times...Line of sight...patient who is unable to maintain personal safety due to psychosis or confusion...patient who requires frequent re-direction due to psychosis or confusion..."


The Patient Bill of Rights with a revision date of 02/2017 reflected, "You have a right to a clean and humane environment in which you are protected from harm, have privacy with regard to personal needs...you have the right to be free from mistreatment, abuse, neglect, and exploitation..."

Based on record review, interview, and observation, the hospital failed to set priorities for its performance improvement activities that focus on problem-prone areas. Oxygen tubing together with side-rail equipped hospital beds had been identified as safety risk to patients four months prior to survey without a follow-up action plan which left two of two suicidal patients (Patients #16, #12) at risk for self-harm.


1) Patient #16 was admitted depressed, without hope and self-worth, and made suicidal comments to hospital staff. The patient had access to long oxygen tubing, multiple cords, and bed side rails with spaced bars potentially usable for ligature for 42 hours and 46 minutes until surveyor intervention.


2) Patient #12 was admitted with labile mood, had a history of suicide attempts, and mourned the loss of a son to suicide. Patient #12 had access and means for self-harm with long oxygen tubing and side rails.


Findings included:


1) Patient #16's Integrated Intake Assessment dated 02/21/17 at 1519, reflected the patient was depressed with suicidal ideation.


Patient #16's Admission Orders dated 02/21/17 at 1725, reflected the patient was "currently depressed." Oxygen was ordered to be applied per nasal cannula because the patient was short of breath.


Patient #16's Physician History and Physical Exam dated 02/22/17 at 0730, reflected the patient had "increased depression with suicidal ideations...crying all the time...feels hopeless..."


Patient #16 was surveyor observed in her bed on 02/22/17 at 1620. The patient's nasal oxygen tubing was approximately four feet long and attached to an oxygen concentrator. The concentrator was turned on and plugged into the wall outlet with an electric cord of approximately five feet length. The patient's bed had side rails with cross bars which provided a potential ligature risk.


During an interview on 02/22/17 at 1620, Patient #16 stated she had come to the hospital because "I didn't want to be around me anymore." Patient #16 was surveyor asked whether she had a plan to hurt herself and responded, "If I had the means, yes." Patient #16 asked staff for an extended oxygen tubing in order to be able to move in bed more easily.


On 02/22/17 at 1625, Personnel #14 stated, "We have a suicidal patient with a long cord."


Approximately 17 hours later, on 02/23/17 at 0915, observations reflected Patient #16 was in bed with an approximately eight feet oxygen tubing set. The patient stated staff had provided her with an extended oxygen tubing for increased mobility.



2) Patient #12 was surveyor observed on 02/22/17 at 1415. The patient was in bed. Her body and face were covered with a bed sheet. Long oxygen tubing was observed attached to a concentrator. The patient's bed had side rails. Patient #12 was observed again on 02/23/17 at 0915, with long oxygen tubing connected to an electric concentrator. There was no staff in the patient's room during at the time of observations.


Patient #12's Integrated Assessment dated 02/14/17 at 1825, reflected had a history of suicide attempts and wished that "God would take...[her] tonight." Patient #12 verbalized grief over the loss of a son to suicide.


Patient # 12's Physician Psychiatric Evaluation reflected the patient's statement that she did not want to live.


Patient #12's Physician Progress Note dated 02/21/17 at 0917, reflected the patient was at "high risk...for decompensation if not in a safe environment due to continuing severe mood instability and psychosis."


Record Review of the hospital's Safety Risk Assessment dated 10/25/17 reflected oxygen tubing and hospital beds were a potential ligature risk to the patient.


During an interview on 02/23/17 at 1650, Personnel #1 acknowledged that oxygen tubing and cords were hospital identified as potential ligature risk on 10/25/16 but not followed up with an action plan.

Based on record review, interview, and observation, the hospital failed to ensure that a registered nurse supervised and evaluated the care for 5 of 5 patients (Patients #16, #6, #17, #3 and #4) and assessed/reassessed the patients according to their needs.


1) Nursing failed to assess Patient #16's traumatic two-finger amputation and its effect on the patient's functional status and/or physical and emotional well being.


2) Patients #6 and #17 were admitted with chronic severe back pain. Nursing failed to reassess the patients' pain levels at regular intervals according to hospital policy.


3) Patient #3 sustained a bruised eye injury during a patient altercation incident on the unit. Nursing failed to reassess the extent of the injury for three days prior to the patient's discharge.


4) Patient #4 had a bruise on her left hand and experienced a fall incident while hospitalized. The patient complained of hip pain. Nursing failed to complete reassessments of the patient's hip. Within a week, the patient experienced a change of condition and was noted to be sleepy, drowsy, and lethargic. The patient was not sent to medical inpatient treatment for another four days.


Cross refer: A0395

Based on observation, interview, and record review, the hospital registered nursing staff failed to supervise and evaluate the nursing care for 5 of 5 patients (Patient #16, #6, #17, #3 and #4) and assess/reassess the patients according to their needs.


1) Patient #16 had two fingers of her right hand missing. Nursing did not assess the patient's functionality or effect of the missing digits on the patient's physical and/or mental health.


2) Patient #6 was admitted with chronic pain requiring an opioid pain medication. On 12 out of 19 hospital days, nursing staff failed to document the patient's pain according to hospital policy.


3) Although Patient #17 had been admitted with a back injury and severe pain, the patient's pain level was assessed only twice during the first 48 hours post admission.


4) Patient #3 sustained a black eye at the hands of a fellow peer. Nursing personnel did not reassess Patient #3's black eye on 01/18/17, 01/19/17, and prior to discharge on 01/20/17.


5) Patient #4 had a bruise to the left hand and sustained a fall and complained of hip pain. No follow-up reassessments were completed. Patient #4 further had a change of condition which started 01/08/17. The hospital did not send Patient #4 to the medical hospital until 01/12/17 for further inpatient medical treatment.


Findings included:


1) The surveyor observed Patient #16 on 02/22/17 at 1335. The patient had only three fingers on her right hand. Her right ring finger and little finger were missing.


During an interview on 02/22/17 at approximately 1620, Patient #16 stated that the two missing fingers were due to an industrial accident during her previous employment at a tool shop.


Patient #16's Initial Nursing Assessment dated 02/21/17 at 2030, and the Daily Nursing Assessments dated 02/22/17 timed at 0645 and 1515, did not reflect that the patient had two fingers missing.



2) Patient #6's Integrated Nursing Assessment dated 02/01/17 reflected the nurse removed four Fentanyl pain patches from the patient's chest. Patient #6 stated she had continuous back pain which she rated as worst pain possible.


During an interview on 02/22/17 at 1415, Patient #6 stated she had broken her back and also experienced a fall in the hospital "a week ago." The patient stated she had pain from her "left hip across the back to...[her] right hip."


Record review of 19 Daily Nursing Assessment Flow Sheets (02/02/17, 02/03/17, 02/04/17, 02/05/17, 02/06/17, 02/07/17, 02/08/17, 02/09/17, 02/11/17, 02/12/17, 02/13/17, 02/14/17, 02/15/17, 02/16/17, 02/17/17, 02/18/17, 02/19/17, 02/20/17, and 02/21/17) reflected 12 days where one or more shift pain assessments were left blank (02/02/17, 02/03/17, 02/05/17, 02/06/17, 02/07/17, 02/08/17, 02/09/17, 02/012/17, 02/14/17, 02/15/17, 02/16/17, and 02/17/17).

Hospital pain management Policy POC 136 dated 03/2013 reflected "all patients will be assessed for pain control...at regular intervals..."


3) The surveyor observed Patient #17 was on 02/23/17 at 1250 on the hospital's Substance Use Unit. The patient stated that staff had "messed up her meds [medication]" and was "disorganized."


Integrated Nursing Assessment dated 02/21/17 at 0130, reflected Patient #17 complained of a pain severity level of "8 out of 10 (worst possible)...fractured sacrum [large wedge shaped vertebra at the inferior end of the spine] possibly refractured 2 weeks ago."


The Daily Nursing Assessment Flow Sheets dated 02/21/17 for the 1500-2300 and the 2300 to 0700 shifts did not assess the patient's pain. The Daily Nursing Assessment Flow Sheets dated 02/22/17 for the 1500 to 2300 and the 2300-0700 were left blank for pain assessments and the narratives did not address pain.


Personnel #14 witnessed and acknowledged the findings at that time.


4) Patient #3's Daily Nursing Assessment Flow Sheet dated 01/15/17 (1500 to 2300 shift) reflected, "Patient was attacked by Patient #2 while standing in line for cigarette...was hit on left side of face...received small red mark to corner of left eye and minimal swelling to cheek...ice pack..."


The 01/17/17 Daily Nursing Assessment-Flow Sheet (0700 to 1500 shift) reflected, "Has black left eye from being punched by peer..."


The 01/18/18, 01/19/17 and 01/20/17 Daily Nursing Assessment-Flow Sheets revealed no documentation and/or follow-up assessment regarding Patient #3's black eye.


On 02/22/17 at approximately 1554, Personnel #14 was interviewed. Personnel #14 was asked to review Patient #3's medical record. Personnel #14 verified no follow-up assessment was completed for 01/18/17, 01/19/17 and for 01/20/17 prior to discharge from the hospital.



5) Patient #4's Daily Nursing Assessment Flow Sheet dated 12/31/16 and timed at 0740, reflected, "4 ½ inch by 3 inch bruise noted to top of right hand..." No follow-up assessment and/or documentation was found for Patient #4's right hand bruise.


The Daily Nursing Assessment-Flow Sheet dated 01/01/17 for the 1500-2300 shift reflected, "1530 patient sitting in floor...wheel chair away from resident...complains of left hip pain...initial assessment...did not hit head...observed left leg shorter with mild to moderate external rotation...complains of pain...ER [emergency room]...at 1830...patient returning to hospital no fractures...no concerns voiced except hip pain...at 1850...return to unit...says hip is better..." No further follow-up assessment and/or documentation was found for Patient #4's hip.


The 01/08/17 the Observation Report timed at 0730 reflected, "Patient is very sleepy and threw all of her breakfast on the floor...sleeping in front of nurses station...at 0815...patient could not sit up in her chair, kept falling forward...charge said to lay her down..."


The 01/08/17 Daily Nursing Assessment Flow Sheet timed at 1045 reflected, "Very difficult to wake, ignores us and sleeps...assisted to wheel chair...slumping forward sleeping...assisted back to bed..."


The Daily Nursing Assessment Flow Sheet dated 01/09/17 (0700 to 1500 shift) timed at 1400 reflected, "Patient lethargic this shift, not sitting up at lunch...at 1230 remains in a lethargic state, mucus membranes dry, attempted to push fluids however she was resistant..."


The Daily Nursing Assessment Flow Sheet dated 01/10/17 timed at 1420 reflected, "Slept most of morning ...slept through medications...lethargic this shift..."


The Observation Record dated 01/11/17 timed at 0750, reflected, "Attempted to wake up patient multiple times...patient had very little response...at 1100...attempted to wake patient up multiple times...01/11/17 non timed note...patient placed on oxygen...oxygen saturation 90 percent...patient on 2 liters of oxygen...at 1630 attempted to wake up patient for dinner...very little response..."


The Daily Nursing Assessment-Flow Sheet dated 01/11/17 timed at 2015, reflected, "Sleeping all shift responsive to verbal stimuli but very drowsy oxygen on at 1.5 liters per minute drank approximately 240 milliliters ate only a few bites...at 2300...came on shift heard about patient's status....respirations 20 labored...2.9 liters oxygen...blood pressure 92/60...lethargic and minimal response...shakes head when asked if thirsty but hardly opens eyes and does not speak..."


The Daily Nursing Assessment-Flow Sheet dated 01/12/17 at 0015, reflected, "Sent to ER...nurse to nurse done...at 0230...called ER to check on patient...nurse...stated WBC [white blood cell] was 23.2, potassium was 5.5, and CO 2 was 19...stated that her blood gases were bad and that she was still only responding to pain [sternal rub]...patient discharged to hospital at 0230."


On 02/24/17 at approximately 1311, Personnel #14 was interviewed. Personnel #14 was asked to review Patient #4's medical record. Personnel #14 verified the bruise to Patient #4's hand was not reassessed, no follow-up regarding hip and verified the patient should have been sent out before 01/12/17 for a change of condition. Personnel #14 stated the continuity of care was not followed.


The policy and procedure titled "Provision of Care, Treatment and Services Patient Assessment and Treatment Process" with a revision date of 09/2011 reflected, "Hospital provides assessments to determine what type of care is required to meet a patient's initial needs as well as his/her needs as they change in response to care...the assessment process is individualized...goal of assessment is to determine the appropriate care, treatment, and services to meet the patient's needs as well as his/her changing needs while inpatient..."

Based on interview and observation, the hospital failed to maintain the overall hospital environment in such a manner that the safety and well-being of patients were assured. Patient occupied areas displayed evidence of missing wall paint and/or sheet rock; broken or missing ceiling tiles exposed attic or other building material, and lose and broken air conditioner units exposed sharp wires.


Findings included


Observations on the hospital's PCU Unit on 02/22/17 at 1210, reflected paint was scraped off the wall in the unit's day room and on the wall between the fire extinguisher and the nurses' station.


Personnel #14 stated at that time that the hospital maintenance crew was "painting on the CAPS [Children and Adolescent] Unit right now." Personnel #14 was asked for documentation that maintenance was aware of the peeled off paint. None was provided.


Observations on 02/22/17 at 1340, on the PCU (geriatric) Unit's group therapy room reflected paint and sheet rock the size of a fist were missing from the window sill behind a three-seat sofa.


The hospital's CAPS Unit was observed on 02/23/17 between 1200 and 1243. The surveyor was accompanied by Personnel #14.


A missing base board of approximately two and one-half feet was observed in Room 305.


The base board was missing in Room 306 on the wall identified by Personnel #14 as located on the east side. The statement "love me for good" was written in red color on the ceiling. The casing around the room's air conditioner unit was loose, and the fan cover on the top was gone which exposed sharp-edged wires. The door frame to Room 306 was lose which left a gap between the frame and the wall.


The window sill in Room 302 was observed with a hole the size of a big fist on the west side of the room. The sheet rock was removed in three places and exposed the metal frame of the window. Approximately two feet of the room's base board were missing as observed on 03/23/17 at 1211.


The west side of the CAPS Unit Day room was observed on 02/23/17 at 1220 with an air conditioning unit's casing broken and pulled away from the wall which left a gap that opened up to the outside and potentially provided an entry for small rodents and/or insects. Personnel #14 witnessed and acknowledged the findings at that time.


Five ceiling tiles on the CAPS Unit Day Room were observed broken or missing, exposing pink attic insulation material and electric wiring on 02/23/17 at 1225. The brown wood laminate flooring had white scratches in multiple places. A more than 6 feet high crack in the wall was observed at the east side of the Day Room close to the nurses' station. A blood pressure meter located inside the nurses' station was observed dusty and grimy; an approximately five centimeter long strand of hair was observed on its base.


Personnel #14 acknowledged the findings at that time and initiated cleaning of the equipment.