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Based on record review and interview, the hospital failed to ensure the right to personal privacy of 1 of 11 patients (Patient #1). Three patients (Patients #3, #6, and #11) were allowed to witness Patient #1 hanging during a suicide attempt and/or rescue efforts.

Findings included:

Patient #1's Hospital Nursing Progress Notes dated 11/06/16 at 0800 reflected the patient "isolated in room resting in bed ..." The notes timed at 1420 and 1422 reflected the nurse observed Patient #1 "...hung from the ceiling, white sheet tied around neck ..."

Personnel #16 was telephone interviewed on 11/16/16 at 1040 and stated Patient #1 hung himself in his room with a bed sheet tightly knotted around the patient's neck. Another patient, Patient #3, grabbed Patient #1 "by the midsection and lifted him up" so that the bed sheet could be loosened.

Patient #3's Physician Progress note dated 11/07/16 reflected, "Patient reports helping in recent peer hanging..."

Patient #6's Physician Progress Note dated 11/07/16 reflected, "...was present to assist in helping the staff in resuscitating a patient who had hung himself..."

Patient #11's Physician Progress Note dated 11/06/16 at 1500 reflected the patient was depressed and anxious and had witnessed " ....another patient inflict himself ..."

Personnel #17 was telephone interviewed on 11/16/16 at 1730 and confirmed that Patient #6 and Patient #11 were in Patient #1's room during the hanging incident.

Personnel #2 confirmed during an interview on 11/17/16 at approximately 1045 that Patient #11 witnessed the hanging incident.

Hospital Patients Rights Policy # 100.20 dated 11/2015 reflected that the hospital "...supports and protects the fundamental human, civil, constitutional, and statutory rights of all patients..."

Based on record review, observation, and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for seven of eleven patients (Patient #1, #3, #6, #11, #7, #2, and #4), and failed to ensure nursing staff developed and kept current nursing care plans for 3 of 11 patients (Patient #2, #4, and #7) that addressed Patient #2's right hand/arm injury, Patient #4's falls and head injury, and Patient #7's right foot injury.


1) Patient #1 had been admitted with a previous suicide attempt by hanging. Approximately 35 hours into his hospital stay, Patient #1 hung himself with a bed sheet tightly knotted around his neck and attached to the sprinkler. Nursing failed to assess the patient's suicide risk prior to the event and the patient's physical condition after his hanging.

Refer to A395

2) Patient #3 had been admitted with a history of nine suicide attempts and suicidal ideation including the plan to hang himself. Patient #3 witnessed Patient #1 hanging and actively assisted in the rescue efforts. Nursing staff failed to assess the patient's increased vital signs and anxiety level after the event.

Refer to A395

3) Patient #6 was physician assessed to be anxious, tearful, and shaking after witnessing Patient #1's suicide attempt and required anti anxiety medications. Nursing failed to assess Patient #6's anxiety after the event.

Refer to A395

4) Patient #11 had been admitted with the suicidal plan to hang herself. The patient personally witnessed Patient #1's hanging and was noted to be highly suicidal after the incident. The day following the incident, nursing failed to complete a suicide risk assessment on Patient #11.

Refer to A395

5) Patient # 7 was observed with a swollen, discolored, and lacerated foot. The patient claimed it originated prior to his hospital admission. Nursing failed to assess the patient's feet during the initial skin assessment.

Refer to A395

6) Patient #2 sustained a right swollen hand during an aggression episode on 10/01/16. Patient #2's right hand/arm was not reassessed after the initial injury until 10/04/16 when Patient #2's right hand/arm was discolored, cold and swollen. Patient #2 was sent to the medical hospital where he was admitted with a fracture to the right arm.

Refer to A395


7) Patient #4 had multiple falls. Patient #4's post fall status was not reassessed nor documented. Patient #4 sustained a hematoma to the head. No follow-up assessment with a description of the site, size and color of the hematoma was documented. Patient #4's foot was run over by a wheelchair. No reassessment was found documented in the medical record.

Refer to A395

8) Patient #2's treatment plan did not address the patient's right hand injury that had required emergency care evaluation.

Refer to A396


9) Patient #4 fell at least twice at the hospital. Nursing noted a hematoma on the patient's head shortly afterwards. Patient #4's treatment plan did not address the falls and/or the hematoma to the head.

Refer to A396


10) Patient #7 was surveyor observed with a swollen, red, and lacerated right foot. Patient #7's treatment plan did not address the injury.

Refer to A396

Based on record review, observation, and interview, the hospital failed to ensure that a registered nurse supervised and evaluated the nursing care for seven of eleven patients (Patient #1, #3, #6, #11, #7, #2, and #4).

1) Patient #1 had been admitted with a previous suicide attempt by hanging. Approximately 35 hours into his hospital stay, Patient #1 hung himself with a bed sheet tightly knotted around his neck and attached to the sprinkler. Nursing failed to assess the patient's suicide risk prior to the event and the patient's physical condition after his hanging.

2) Patient #3 had been admitted with a history of nine suicide attempts and suicidal ideation including the plan to hang himself. Patient #3 witnessed Patient #1 hanging and actively assisted in the rescue efforts. Nursing staff failed to assess the patient's increased vital signs and anxiety level after the event.

3) Patient #6 was assessed by a physician to be anxious, tearful, and shaking after witnessing Patient #1's suicide attempt and required anti anxiety medications. Nursing failed to assess Patient #6's anxiety after the event.

4) Patient #11 had been admitted with the suicidal plan to hang herself. The patient personally witnessed Patient #1's hanging and was noted to be highly suicidal after the incident. The day following the incident, nursing failed to complete a suicide risk assessment on Patient #11.

5) Patient # 7 was observed by a surveyor with a swollen, discolored, and lacerated foot. The patient claimed it originated prior to his hospital admission. Nursing failed to assess the patient's feet during the initial skin assessment.

6) Patient #2 sustained a right swollen hand during an aggression episode on 10/01/16. Patient #2's right hand/arm was not reassessed after the initial injury until 10/04/16 when Patient #2's right hand/arm was discolored, cold and swollen. Patient #2 was sent to the medical hospital where he was admitted with a fracture to the right arm.


7) Patient #4 had multiple falls. Patient #4's post fall status was not reassessed nor documented. Patient #4 sustained a hematoma to the head. No follow-up assessment with a description of the site, size and color of the hematoma was documented. Patient #4's foot was run over by a wheelchair. No reassessment was found documented in the medical record.

Findings included:

1) Patient #1's Hospital A's Comprehensive Psychiatric Evaluation dated 11/05/16 at 1130 reflected the patient was noted to "depressed...irritable..." The patient was delusional with impaired judgement and without insight. The physician identified problems to be addressed that included the patient's danger to self, and his depressive and psychotic symptoms.

Patient #1's Hospital A's Nursing Suicide Risk Assessment dated 11/06/16 was not completed for the 0700-1500 shift.

Patient #1's Hospital A's Nursing Progress Notes dated 11/06/16 at 0800 reflected the patient "isolated in room resting in bed...unable to assess patient further ...continue on 15-minute safety checks..." The notes timed at 1420 and 1422 reflected the nurse observed Patient #1 "...hung from the ceiling, white sheet tie around neck...staff lift patient up to relieve pressure and cut sheet down...Code blue activated...started on CPR immediately...911 called...paramedics arrive...transferred to...[Acute Care Hospital B]..." There was no other nursing assessment regarding Patient 1's physical condition.

Patient #1's Acute Care Hospital B Discharge Summary dated 11/07/16 at 0744 reflected that the patient was discovered "...hanging with bed sheet...approximately 30 min[utes] before being found ...asystole by EMS [Emergency Medical Services]...as pupils fixed and dilated on arrival... patient expired..." Discharge diagnoses included Attempted Suicide, Asphyxiation by Hanging, Acute Renal Insufficiency, Anoxic Encephalopathy, and Anoxic Cerebral Edema.

Personnel #2 stated during an interview on 11/15/16 at 1155 that Code Blue documentation regarding Patient #1's physical condition and vital signs had not been done.

Personnel #16 stated during a telephone interview on 11/16/16 at 1040 that Patient #1 had "his eyes open in a stare...chest not moving."

2) Patient #3's High Risk Notification Alert document dated 10/29/16 timed at 2115 reflected, "History and current suicide risk factor...overdose, hanging..."

The Comprehensive Psychiatric Evaluation dated 10/30/16 timed at 1457 reflected, "Chief complaint...depressed and suicidal...positive suicidal thoughts, hallucinations commands to hurt self times three months, hopeless, worthless, paranoid...suicide attempts times 9... hanging, overdose...history of suicide attempts..."

Personnel #16 was telephone interviewed on 11/16/16 at 1040 and stated Patient #1 hung himself in his room with a bed sheet tightly knotted around the patient's neck. Patient #3 grabbed Patient #1 "by the midsection and lifted him up" so that the bed sheet could be loosened.

Patient #3's Physician Progress Note dated 11/06/16 timed at 1540 reflected, "I am a nervous wreck he was dead...patient [#3] anxious about patient [#1] that attempted suicide positive for shaking, sweating and breathing fast...Ativan...po (by mouth) now for anxiety."

Patient #3's Physician Progress note dated 11/07/16 reflected, "Patient reports helping in recent peer hanging..."

Patient #3's Nursing Progress Notes dated 11/06/16 at 1630, approximately two hours after Patient #3's active involvement in Patient #1's suicide attempt, reflected Patient #3's blood pressure was 143/73 mmHg and his heart rate was 104 beats per minute. The patient complained of anxiety level of 8 on a 1 to 10 scale (with 10 as the highest score). There is no further nursing reassessment of Patient #3's elevated vital signs and/or anxiety level.

Patient #3's Case Management Note dated 11/07/16 and timed at 1030 reflected that the patient "...still reports anxiety..."

Record review of Hospital Nursing Reassessment Policy # 1200.211 dated 10/2016 reflected "...reassessment occurs...in change in the patient's condition...[and] findings from the reassessments are documented in the patient's chart."

3) Patient #6's Integrated Intake and Psychosocial Assessment dated 10/31/16 reflected, "Bipolar...increased difficulty in sleep...has 7 voices in his head, they have their own memories, names..."

During a telephone interview on 11/16/16 at 1730 Personnel #17 stated that Patient #6 witnessed Patient #1's suicide by hanging.

Patient #6's Physician Progress note dated 11/06/16 timed at 1521 reflected, "I was a first responder...anxious...responded to patient hanging, feeling stressed...tearful...shaking...ativan 0.5 po (by mouth) times one now..."

Patient #6's Physician Progress Note dated 11/07/16 reflected, "Pushing to be discharged...was present to assist in helping the staff in resuscitating a patient who had hung himself..."

Nursing Notes dated 11/06/16 timed at 0930 and 2000, on 11/07/16 timed at 0200, 0900, and 2000, and on 11/08/16 timed at 0230 did not reflect nursing documentation regarding the patient's response to a peer patient's suicide by hanging event of 11/06/16.

4) Patient #11's Demographics reflected an 11/02/16 admission date and an 11/10/16 discharge date.

Patient #11's Comprehensive Psychiatric Evaluation dated 11/03/16 at 1130 reflected the patient had been involuntarily admitted with suicidality and the plan to hang herself.

Patient #11's Physician Progress Note dated 11/06/16 at 1500 reflected the patient was depressed and anxious and had witnessed "....another patient inflict himself..." Patient #11's judgment and insight were poor.

Patient #11's Nursing Progress Notes dated 11/06/16 at 2030, six hours after the hanging incident, reflected that the patient was "highly suicidal."

Patient #11's Nursing Assessment Notes dated 11/07/16 for the 0700 to 1500 shift reflected the patient's suicide risk assessment was left blank. In addition, there was no documented assessment of Patient #11's behavior, affect, or thought process.

Personnel #17 was telephone interviewed on 11/16/16 at 1730 and confirmed Patient #11 was in Patient #1's room during the hanging incident.

Personnel #2 confirmed during an interview on 11/17/16 at approximately 1045 that Patient #11 witnessed Patient #1's hanging incident.

5) Observations on the hospital's PICU day room on 11/17/16 at 0820 reflected Patient #7 with a red discolored and swollen right foot. In addition, a dark discolored cut approximately four centimeters in length was noted on top of the patient's right foot.

Patient #7 stated on 11/17/16 at 0820 that prior to his current admission, an acute care hospital "wrapped it too tight..."

Patient #7's Initial Nursing Skin Assessment dated 10/31/16 at 1205 reflected no skin changes on the patient's right foot.

Nursing Progress Notes dated 11/17/16 at 0530 reflected that a "medical consult [was] placed for Rt [right] foot swelling with laceration on top...no drainage noted." There was no documented further assessment of the patient's condition. Notes dated 11/17/16 at 0630 reflected that Patient #7 "reported injury to...[right] foot occurred before admission."

Personnel #13 acknowledged redness and laceration during an interview on 11/17/16 at approximately 0828 and stated that Patient #7 "...reportedly came in with it...it wasn't addressed...medical consult was ordered and completed now."

Personnel #11 stated during an interview on 11/17/16 at 0945 that he did not take Patient #7's socks off to examine the patient's feet during the initial nursing skin assessment.

Personnel #2 reviewed Patient #7's chart 11/17/16 at approximately 0828 and stated she "did not see... [the injury] on the initial nursing assessment."

6) Patient #2's Integrated Intake and Psychosocial Assessment dated 09/30/16 timed at 1900 reflected, "Diabetes, hypertension, bipolar...history of paranoia, psychosis was found walking naked with scratch marks all over his body, confused and restless...poor historian, hostile, aggressive and refused to speak to assessor."

The 10/01/16 nursing progress notes timed at 1800 reflected, "...agitated when staff trying to redirect patient made an attempt to attack patient...medication Haldol, Benadryl, Ativan..medications effective...at 2000 patient's right hand appears to be swollen and bruised..ice pack placed to subside (swelling)...Dr. notified order for med consult will assess in the morning..."

The patient activity record, undated, timed at 1800 reflected, "Patient started punching patients and staff."

The physician orders dated 10/01/16 reflected "X-ray of right hand..."

The 10/02/16 nursing progress note timed at 0200, 1100, 2130, 0620 revealed no follow-up assessment for Patient #2's right hand/arm.

The X-ray report dated 10/02/16 reflected, "There is no acute dislocation or fracture."

The 10/03/16 nursing progress note timed at 0820 and 2100 revealed no follow-up assessment for Patient #2's right hand/arm.

The 10/04/16 nursing progress note timed at 0745 and 0810 revealed no follow-up assessment for Patient #2's right hand/arm.

The 10/04/16 nursing progress note timed at 2000 reflected, "Patient's right hand swollen bruised and warm to touch...patient did not show any expression of pain when asked or palpated...physician notified...transfer to ER (emergency room)...on 10/05/16 at 0250...patient discharged to (medical) hospital..."

The physician orders dated 10/04/16 reflected, "Transfer patient to ER (emergency room) for...evaluation...10/05/16...discharge patient to...hospital."

On 11/15/16 at 1411 Personnel #5 was interviewed. Personnel #5 stated she was on duty on 10/04/16 on the adult unit. Personnel #5 stated the nurse came to her and asked if she could speak with Patient #2's family. Personnel #5 stated she spoke with Patient #2's family who was upset about Patient #2's hand and arm. Personnel #5 stated she assessed Patient #2's arm. Patient #2's arm and hand was swollen, bruised and purple. Personnel #5 stated Patient #2 did not appear to be in pain. Personnel #5 stated the patient was sent to the hospital where he was admitted and was determined to have a fracture to his right arm and had to have surgery.

On 10/17/16 at approximately 1203 Personnel #9 was interviewed. Personnel #9 was asked to review Patient #2's medical record. Personnel #9 reviewed the nursing notes for follow-up assessment documentation regarding Patient #2's right hand/arm. Personnel #9 stated no documentation was found until the evening of 10/04/16 when the patient was sent to the emergency room for an evaluation. Personnel #9 verified the treatment plan did not address Patient #2's right hand injury.

7) Patient #4's Integrated Intake and Psychosocial Assessment dated 11/01/16 timed at 1701 reflected, "86 year old...spitting, hitting staff and peers...Major Depressive Disorder, Dementia with Behavioral Disturbances."

The Initial Nursing Assessment dated 11/02/16 timed at 1845 under the section titled "Fall Assessment for Adult" reflected "Level II Fall Risk with a score of 5 to 9."

The 11/03/16 Fall Risk Assessment for Adults reflected, "Glaucoma, assistive devices wheelchair...total score 13...greater than 10 level III Fall Risk..."

The nursing progress notes dated 11/03/16 timed at 1705 reflected, "Agitated...patient found twice on the floor...will monitor." No documentation was found which indicated the patient was assessed..."

The nursing progress note dated 11/04/16 timed at 0100, 0800, 1100, 1820 revealed no documentation which indicated Patient #4 was assessed post being found on the floor the previous day 11/03/16.

The 11/07/16 nursing progress notes timed at 0900 (late entry) reflected, "Patient was taken to bathroom...patients' right foot was run over by wheelchair...refused nurse to examine her foot...at 1600...compliant..." No further documentation was found which indicated Patient #4's foot was assessed after initially refusing at 0900.

The 11/08/16 nursing progress notes timed at 0100, 0800 and 1715 documentation did not address the condition of Patient #4's foot.

The 11/11/16 nursing progress notes timed at 0800 reflected, "Hematoma...persists on occipital...denied pain...will have skull x-ray (secondary) to being on the floor..." No documentation was found for how large the hematoma, color and size.

The 11/12/16 nursing progress notes timed at 0920 and 1820 revealed no documentation which addressed the hematoma to Patient #4's head.

On 11/17/16 at 1130 Personnel #9 was asked to review Patient #4's medical record. Personnel #9 verified no nursing documentation and/or reassessment was documented in regard to the above falls, hematoma to the head and Patient #4's foot.

The Hospital's Patient Reassessment Policy # 1200.211 dated 10/2016 reflected the procedure that "...reassessment occurs in...change in the patient's condition...physical complaint..."

Based on interview and record review the hospital failed to ensure 3 of 11 patients' (Patient #2, #4, and #7) care plans addressed

1) Patient #2's right hand/arm injury,
2) Patient #4's falls and hematoma to the head, and
3) Patient #7's right foot injury.

Findings included:


1) Patient #2's Integrated Intake and Psychosocial Assessment dated 09/30/16 timed at 1900 reflected, "Diabetes, hypertension, bipolar...history of paranoia, psychosis was found walking naked with scratch marks all over his body, confused and restless...poor historian, hostile, aggressive and refused to speak to assessor."

The 10/01/16 nursing progress notes timed at 1800 reflected, "Agitated when staff trying to redirect patient made an attempt to attack patient...medication Haldol, Benadryl, Ativan..medications effective...at 2000 patients right hand appears to be swollen and bruised..ice pack placed to subside (swelling)...Dr. notified order for med consult will assess in the morning..."


The 10/04/16 nursing progress note timed at 2000 reflected, "Patient's right hand swollen bruised and warm to touch...patient did not show any expression of pain when asked or palpated ...physician notified...transfer to ER (emergency room)...on 10/05/16 at 0250 ...patient discharged to (medical) hospital..."


The physician orders dated 10/04/16 reflected, "transfer patient to ER (emergency room) for...evaluation...10/05/16...discharge patient to...hospital."


The Interdisciplinary Master Treatment Plan and update/clinical staffing worksheet dated 09/30/16 to 10/04/16 revealed no documentation which addressed Patient #2's swollen right hand and arm.


On 10/17/16 at approximately 1203 Personnel #9 was interviewed. Personnel #9 was asked to review Patient #2's medical record. Personnel #9 verified the treatment plan did not address Patient #2's right hand injury.


2) Patient #4's Integrated Intake and Psychosocial Assessment dated 11/01/16 timed at 1701 reflected, "86 year old...Type II Diabetes, Anemia...spitting, hitting staff and peers...Major Depressive Disorder, Dementia with Behavioral Disturbances."

The 11/03/16 Fall Risk Assessment for Adults reflected, "Glaucoma, assistive devices wheelchair...total score 13...greater than 10 level III Fall Risk..."

The nursing progress notes dated 11/03/16 timed at 1705 reflected, "Agitated...patient found twice on the floor...will monitor."

The 11/11/16 nursing progress notes timed at 0800 reflected, "Hematoma...persists on occipital...denied pain...will have skull x-ray (secondary) to being on the floor..."

The 11/08/16 Master Treatment Plan Update reflected in the section entitled, "Chronic/Stable Medical Problems (includes monitoring for status change and med teaching, any exacerbation of symptoms needs)..." no documented medical condition for falls and hematoma to the head.

On 11/17/16 at 1130 Personnel #9 was asked to review Patient #4's medical record. Personnel #9 verified Patient #4's Treatment Plan did not address falls and/or the hematoma to the head.

3) Observations on the hospital's PICU day room on 11/17/16 at 0820 reflected Patient #7 with a red discolored and swollen right foot. In addition, a dark discolored cut approximately four centimeters in length was noted on top of the patient's right foot.

Patient #7 stated on 11/17/16 at 0820 that prior to his current admission, an acute care hospital "wrapped it too tight..."

Patient #7's Interdisciplinary Master Treatment Plan and/or Problem List dated 11/05/16 reflected "Heartburn" as the patient's only medical problem.

Nursing Progress Notes dated 11/17/16 at 0530 reflected that a "medical consult [was] placed for Rt [right] foot swelling with laceration on top...no drainage noted." Notes dated 11/17/16 at 0630 reflected that Patient #7 "reported injury to...[right] foot occurred before admission."

Personnel #13 acknowledged redness and laceration during an interview on 11/17/16 at approximately 0828 and stated that Patient #7 "...reportedly came in with it...it wasn't addressed...medical consult was ordered and completed now."

Personnel #2 reviewed Patient #7's chart 11/17/16 at approximately 0955 and stated there was "nothing related to...[Patient #7's] foot in the treatment plan...just his heart burn."


The hospital's Master Treatment Plan Policy # 300.106 dated 03/2012 reflected the purpose to "...ensure that care is planned and provided in an interdisciplinary, collaborative manner..." The update process noted that the treatment team reviewed current symptoms.

Based on interview and record review the hospital failed to ensure 3 of 11 patients' (Patient #2, Patient #4, and Patient #7) individual treatment plan addressed

1) Patient #2's right hand/arm injury,
2) Patient #4's falls and hematoma to the head, and
3) Patient #7's right foot injury.

Findings included:

1) Patient #2's Integrated Intake and Psychosocial Assessment dated 09/30/16 timed at 1900 reflected, "Diabetes, hypertension, bipolar...history of paranoia, psychosis was found walking naked with scratch marks all over his body, confused and restless...poor historian, hostile, aggressive and refused to speak to assessor."

The 10/01/16 nursing progress notes timed at 1800 reflected, "Agitated when staff trying to redirect patient made an attempt to attack patient...medication Haldol, Benadryl, Ativan..medications effective...at 2000 patients right hand appears to be swollen and bruised..ice pack placed to subside (swelling)...Dr. notified order for med consult will assess in the morning..."


The 10/04/16 nursing progress note timed at 2000 reflected, "Patient's right hand swollen bruised and warm to touch...patient did not show any expression of pain when asked or palpated ...physician notified...transfer to ER (emergency room)...on 10/05/16 at 0250 ...patient discharged to (medical) hospital..."


The physician orders dated 10/04/16 reflected, "transfer patient to ER (emergency room) for...evaluation...10/05/16...discharge patient to...hospital."


The Interdisciplinary Master Treatment Plan and update/clinical staffing worksheet dated 09/30/16 to 10/04/16 revealed no documentation which addressed Patient #2's swollen right hand and arm.


On 10/17/16 at approximately 1203 Personnel #9 was interviewed. Personnel #9 was asked to review Patient #2's medical record. Personnel #9 verified the treatment plan did not address Patient #2's right hand injury.


2) Patient #4's Integrated Intake and Psychosocial Assessment dated 11/01/16 timed at 1701 reflected, "86 year old...Type II Diabetes, Anemia...spitting, hitting staff and peers...Major Depressive Disorder, Dementia with Behavioral Disturbances."

The 11/03/16 Fall Risk Assessment for Adults reflected, "Glaucoma, assistive devices wheelchair...total score 13...greater than 10 level III Fall Risk..."

The nursing progress notes dated 11/03/16 timed at 1705 reflected, "Agitated...patient found twice on the floor...will monitor."

The 11/11/16 nursing progress notes timed at 0800 reflected, "Hematoma...persists on occipital...denied pain...will have skull x-ray (secondary) to being on the floor..."

The 11/08/16 Master Treatment Plan Update reflected in the section entitled, "Chronic/Stable Medical Problems (includes monitoring for status change and med teaching, any exacerbation of symptoms needs)..." no documented medical condition for falls and hematoma to the head.

On 11/17/16 at 1130 Personnel #9 was asked to review Patient #4's medical record. Personnel 9 verified Patient #4's Treatment Plan did not address falls and/or the hematoma to the head.
3) Observations on the hospital's PICU day room on 11/17/16 at 0820 reflected Patient #7 with a red discolored and swollen right foot. In addition, a dark discolored cut approximately four centimeters in length was noted on top of the patient's right foot.

Patient #7 stated on 11/17/16 at 0820 that prior to his current admission, an acute care hospital "wrapped it too tight..."

Patient #7's Interdisciplinary Master Treatment Plan and/or Problem List dated 11/05/16 reflected "Heartburn" as the patient's only medical problem.

Nursing Progress Notes dated 11/17/16 at 0530 reflected that a "medical consult [was] placed for Rt [right] foot swelling with laceration on top...no drainage noted." Notes dated 11/17/16 at 0630 reflected that Patient #7 "reported injury to...[right] foot occurred before admission."

Personnel #13 acknowledged redness and laceration during an interview on 11/17/16 at approximately 0828 and stated that Patient #7 "...reportedly came in with it...it wasn't addressed...medical consult was ordered and completed now."

Personnel #2 reviewed Patient #7's chart 11/17/16 at approximately 0955 and stated there was "nothing related to...[Patient #7's] foot in the treatment plan...just his heart burn."

The hospital's Master Treatment Plan Policy #300.106 dated 03/2012 reflected the purpose to "...ensure that care is planned and provided in an interdisciplinary, collaborative manner..." The update process noted that the treatment team reviewed current symptoms.