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Based on document review, observations and interviews it was determined the facility failed to ensure complaints about the heat on the Behavioral Health Unit (BHU) were addressed and resolved within a reasonable amount of time for 2 of 2 patients, Patients #2 and 3.

The findings include:

Patient #2 had a nursing notes in their medical record dated 8/14/16 and timed 2341 (11:21 P.M.) complaining to the nursing supervisor that their (Patient #2 and 3's) room was to hot. After some discussion Patient #2 agreed to sleep in the day area (common area). On 8/15/16 at 0126 (1:26 A.M.) Patient #3 complained of being unable to sleep and requested medication which was administered.

Patient #3 had nursing notes in their medical record dated 8/14/16 and timed at 2356 (11:56 P.M.) complaining that the room was to hot. A quote in the note written by the nursing staff as being said by Patient #3 stated, "I am just telling you I am hot and need the heat to be turned down." The nurses' note then stated, "Pt has already been moved due to [his/her] need for [his/her] bed to be elevated for respiratory comfort. No other hospital bed is available. Nursing supervisor is aware." On 8/15/16 at 0527 (5:27 A.M.) Patient #3 stated, "You need to get someone up here to talk to me because I am telling you I am agitated, I am thinking about hurting myself and my thoughts are racing. I feel agitated. Pt has been up and down all night because his room is hot....Of note is that client has appeared sad, however both [he/she] and [his/her] roommate have continued to obsess about the heat when the supervisor has explained the process for having it repaired."

Based on interview, observation and document review it was determined the facility staff failed to provide 2 of 2 patients, Patients #2 and 3 personal privacy for sleeping because their bedroom was to hot.

The findings include:

Patient #2 had a nursing notes in their medical record dated 8/14/16 and timed 2341 (11:21 P.M.) complaining to the nursing supervisor that their (Patient #2 and 3's) room was to hot. After some discussion Patient #2 agreed to sleep in the day area (common area). On 8/15/16 at 0126 (1:26 A.M.) Patient #3 complained of being unable to sleep and requested medication which was administered.

Patient #3 had nursing notes in their medical record dated 8/14/16 and timed at 2356 (11:56 P.M.) complaining that the room was to hot. A quote in the note written by the nursing staff as being said by Patient #3 stated, "I am just telling you I am hot and need the heat to be turned down." The nurses' note then stated, "Pt has already been moved due to [his/her] need for [his/her] bed to be elevated for respiratory comfort. No other hospital bed is available. Nursing supervisor is aware." On 8/15/16 at 0527 (5:27 A.M.) Patient #3 stated, "You need to get someone up here to talk to me because I am telling you I am agitated, I am thinking about hurting myself and my thoughts are racing. I feel agitated. Pt has been up and down all night because his room is hot....Of note is that client has appeared sad, however both [he/she] and [his/her] roommate have continued to obsess about the heat when the supervisor has explained the process for having it repaired."

On 8/17/16 at approximately 9:20 A.M. Staff Member #1 accompanied the surveyor to room 121. Room 121 was located in the Behavioral Health Unit (BHU) of the hospital.

Staff Member #1 and the Surveyor knocked on the door of room 121 and was given permission to enter by Patient #2 and 3. Both Patient #2 and 3 were lying in the bed with the curtains drawn. They were asked if the room was to warm. Both Patient #2 and 3 responded "Yes." Patient #3 stated, "especially at night". Patient #3's bed was next to the air conditioning unit. There was a considerable difference between the common area temperature and the temperature in room 121. The common area of the BHU had a comfortable temperature. Staff Member #1 stated, "This room is very warm."

Based on document reviews and interviews it was determined the facility staff failed to ensure the record for 1 of 10 patients, Patient #6 was complete and accurate and that information was provided by an identified author.

The findings include:

On 8/18/16 the medical record of Patient #6 was reviewed with Staff Member #2. Patient #6 was initialed treated in the ED on 6/7/16 at 10:51 A.M. (1st visit) for suicidal Ideations and was released at 2:34 P.M. Patient #6 returned to the ED on 6/7/19 at 9:49 P.M.(2nd visit) was treated for the same complaint and released on 6/8/16 at 6:05 A.M. Patient #6 returned a third time via a police escort on 6/8/16 at 7:58 A.M. (3rd visit) for violent behavior and threatening to harm self and was released at 12:16 P.M.

On the first and second visits Patient #6 was seen by an in house crisis worker and notes of these assessments were found in Patient #6's medical record. The third visit Patient #6 was seen by a member of the Community Service Board (CSB) for a possible TDO (Temporary Detention Order). During the record review no evaluation by the CSB could be found. A request was made by the Surveyor to try to locate the evaluation.

Staff Member #2 obtained a form from the (Name of City) CSB titled Report of Contact. The form list Patient #6's name, date of the evaluation, the time of the evaluation and the location. Patient #6 was evaluated on 6/8/16 at 8:15 A.M. and the site of the evaluation was MV ED Bed 21. There is no Disposition /Referral checked. In the Comments section is written, "doesn't meet criteria for TDO, (Name of Support Service) will do in home intervention." Notification of Attending Physician or Agency Personnel had the attending physician and 2 nurses names with the same date and time as the beginning of the evaluation. Notification was listed as face to face and the evaluator signed their name. There were no credentials listed. There was no copy of the actual evaluation provided.

Staff Member #2 stated, "We don't do a record review of psych patients who return multiple times within 24 hours or anytime they return."

Based on document reviews and interviews it was determined the facility staff failed to ensure the record for 1 of 10 patients, Patient #6 contained the support information to determine the services needed by Patient #6.

The findings include:

On 8/18/16 the medical record of Patient #6 was reviewed with Staff Member #2. Patient #6 was initialed treated in the ED on 6/7/16 at 10:51 A.M. (1st visit) for suicidal Ideations and was released at 2:34 P.M. Patient #6 returned to the ED on 6/7/19 at 9:49 P.M.(2nd visit) was treated for the same complaint and released on 6/8/16 at 6:05 A.M. Patient #6 returned a third time via a police escort on 6/8/16 at 7:58 A.M. (3rd visit) for violent behavior and threatening to harm self and was released at 12:16 P.M.

On the first and second visits Patient #6 was seen by an in house crisis worker and notes of these assessments were found in Patient #6's medical record. The third visit Patient #6 was seen by a member of the Community Service Board (CSB) for a possible TDO (Temporary Detention Order). During the record review no evaluation by the CSB could be found. A request was made by the Surveyor to try to locate the evaluation.

Staff Member #2 obtained a form from the (Name of City) CSB titled Report of Contact. The form list Patient #6's name, date of the evaluation, the time of the evaluation and the location. Patient #6 was evaluated on 6/8/16 at 8:15 A.M. and the site of the evaluation was MV ED Bed 21. There is no Disposition /Referral checked. In the Comments section is written, "doesn't meet criteria for TDO, (Name of Support Service) will do in home intervention." Notification of Attending Physician or Agency Personnel had the attending physician and 2 nurses names with the same date and time as the beginning of the evaluation. Notification was listed as face to face and the evaluator signed their name. There were no credentials listed. There was no copy of the actual evaluation provided.

Staff Member #2 stated, "We don't usually get a copy of the assessment performed by the CSB."

Based on document reviews and interviews it was determined the facility staff failed to ensure the record for 1 of 10 patients, Patient #6 contained the evaluation performed by the Community Service Board.

The findings include:

On 8/18/16 the medical record of Patient #6 was reviewed with Staff Member #2. Patient #6 was initialed treated in the ED on 6/7/16 at 10:51 A.M. (1st visit) for suicidal Ideations and was released at 2:34 P.M. Patient #6 returned to the ED on 6/7/19 at 9:49 P.M.(2nd visit) was treated for the same complaint and released on 6/8/16 at 6:05 A.M. Patient #6 returned a third time via a police escort on 6/8/16 at 7:58 A.M. (3rd visit) for violent behavior and threatening to harm self and was released at 12:16 P.M.

On the first and second visits Patient #6 was seen by an in house crisis worker and notes of these assessments were found in Patient #6's medical record. The third visit Patient #6 was seen by a member of the Community Service Board (CSB) for a possible TDO (Temporary Detention Order). During the record review no evaluation by the CSB could be found. A request was made by the Surveyor to try to locate the evaluation.

Staff Member #2 obtained a form from the (Name of City) CSB titled Report of Contact. The form list Patient #6's name, date of the evaluation, the time of the evaluation and the location. Patient #6 was evaluated on 6/8/16 at 8:15 A.M. and the site of the evaluation was MV ED Bed 21. There is no Disposition /Referral checked. In the Comments section is written, "doesn't meet criteria for TDO, (Name of Support Service) will do in home intervention." Notification of Attending Physician or Agency Personnel had the attending physician and 2 nurses names with the same date and time as the beginning of the evaluation. Notification was listed as face to face and the evaluator signed their name. There were no credentials listed. There was no copy of the actual evaluation provided.

Staff Member #2 stated, "We don't usually get a copy of the assessment performed by the CSB."

Please see tag 0701 for detailed information related to this condition.

Based on observations, document review and interviews it was determined the facility failed to ensure they maintained the environment in a comfortable and safe manner for all patients including those in the Behavioral Health Unit (BHU) and the Emergency Department (ED).

The findings include:

On 8/17/16 at approximately 9:20 A.M. Staff Member #1 accompanied the surveyor to room 121. Room 121 was located in the Behavioral Health Unit (BHU) of the hospital.

Staff Member #1 and the Surveyor knocked on the door of room 121 and was given permission to enter by Patient #2 and 3. Both Patient #2 and 3 were lying in the bed with the curtains drawn. They were asked if the room was to warm. Both Patient #2 and 3 responded "Yes." Patient #3 stated, "especially at night". Patient #3's bed was next to the air conditioning unit. There was a considerable difference between the common area temperature and the temperature in room 121. The common area of the BHU had a comfortable temperature. Staff Member #1 stated, "This room is very warm."

Staff Member #11 was interviewed on 8/17/16 at approximately 9:40 A.M. and stated, "I did not know there was a problem until yesterday (8/16/16). I walked around the unit but no one told me a problem in a specific room until today when (Name of Staff Member #1) told me the room number. We never received a work order for room 121."

Staff Member #3 was interviewed several times during the days of the survey and provided the following information: On 8/17/16 at 1:30 P.M., "The patient in room 121 complained to the staff Monday (8/15/16) and they (the staff) called maintenance. They did not fill out a work order. On Tuesday I spoke with someone from your office and told them we were repairing the chiller."

Staff Member #1 provided copies of emails related to the function of the air conditioning unit on the BHU. Email dated 7/26/16 from (Name of Staff Member #11) to (Name of Staff Member #3) "The (Initials of Hospital) chiller has experienced a failure of one-half of the cooling system resulting in only limited cooling to the entire unit (BHU). We are working to identify a strategy to relieve the heat and repair the chiller."

Emails dated 8/16/16; First email from Staff Member #3 to Staff Member #11 at 10:32 A.M. stated, " Office of licensure received a call from a patient regarding the hot temperature in the rooms. Can someone please take a look at it. Pt. Did not identify themselves or the unit so I cannot tell you where the issue is." Second email from Staff Member #3 to Staff Member #11 on 8/16/16 at 11:59 A.M. stated, "I have rounded on all units. All STU (a locked adult treatment area for patient who need much closer monitoring for their safety and the safety of others) rooms and some ADCD (adult chemical dependency treatment) rooms have no AC. I have assured licensure we are taking care of it."
Email from person in maintenance to Staff Member #3 dated 8/17/16 at 1:55 P.M. Subject: Your Work Request has been completed. The work order was generated on 7/25/16 stating the room is warm and the AC in not working.

On 8/18/16 at approximately 11:30 A.M. Patient #11 was randomly interviewed about the temperature of the room. Patient #11 on the BHU resides in room #125. Patient #11 stated, "The air conditioning unit is not cooling the room." The surveyor walked from the door way into Patient #11's room the room was warm. The room was approximately 12 feet by 12 feet with the air conditioning (AC) unit on the wall farthermost from the door and under the window. The vent of the AC was on the top surface of the unit. When the Surveyor placed their hand directly on the unit the air could be felt and was cool. When the Surveyor lifted their hand approximately 6-8 inches above the vent no air could be felt coming from the vent.

Staff Member #11 was interviewed on 8/18/16 at approximately 4:00 P.M. and stated, "In July we were aware of the air conditioning issues. The air conditioner is over 18 years old and we can't get parts anymore they have to be made. The fan coils in each patient's room is over 45 years old. If one of those get damaged we have to replace the unit."

Per Timeanddate.com the weather for August 15, 2016 had a high temperature of 91 degrees and a low of 81 degrees; August 16, 2016 had a high temperature of 91 degrees and a low of 79 degrees; August 17, 2016 had a high temperature of 91 degrees and a low of 79 degrees; August 18, 2016 had a high temperature of 86 degrees and a low of 79 degrees.

During the initial tour of the Emergency Department on 8/17/16 at 10:30 A.M. with Staff Member #2 the following environmental observations were made:
The counter in several vacant rooms had broken/missing parts of the counter tops leaving exposed wood and jagged protrusions of counter top (Formica like covering);
The nurses' station in numerous places had broken/missing counter tops leaving exposed wood and jagged edges.
The wall by the Pyxsis machine was cracked.
Staff Member #2 stated, "Replacing the counter top at the nurses' station has been budgeted for and approved, we just don't know when it will be done."