HospitalInspections.org

Based on record review and interview, the hospital failed to ensure notice of patient rights for five (Patients # 1, 2, 3, 4, and 5) of five records reviewed.

Findings:

A Review of a facility document titled, "Welcome Packet" (page 8) located in the admissions paperwork showed an incorrect address and telephone number for the State Survey Agency (SSA). The address provided was for a location vacated by the SSA in November 2020. The telephone number was disconnected.

On 03/12/25 at 11:58 am Staff B stated the address and phone number was not correct on the form provided to patients.

Based on observation and interview, the hospital failed to ensure one (Pt #6) of six patients were safe from possible accidental or purposeful injury.

Findings:

On 05/12/25 at 1:23 pm the surveyor observed a patient ouside the dining area in an enclosed area (fenced) with a concrete floor. The surveyor observed what appeared to be pieces of wood in varying sizes which could have caused an accidental or self injury or could have been used to injure another person.

Pt #6
05/12/25 at 1:24 Pt #6 was observed to be pacing around the enclosed area with only socks on his feet.

After Staff A and B were made aware of what appearted to be pieces of wood on the ground, they had patients removed from the area and placed a sign on the door for it to be locked.

On 05/12/25 at 1:25 pm, Staff A stated it was a safety risk.

On 05/12/25 at 1:25 pm, Staff B stated it was a safety risk to have a patient walking in an area with something on the ground.

Based on record review and interview, the hospital failed to meet the nutritional needs of one (Pt #3) of five patients
.
Findings:

Pt #3
1) A review of the weight flowsheet showed Pt #2 had a weight loss at the hospital. A review of weekly weights showed the following:
a. Initial weight 3/10/25 was 133 lbs,
b. 3/17/25 134 lbs,
c. 3/24/25 130.4 lbs,
d. 3/31/25 125 lbs,
e. 4/7/25 refused weight;

2) 3/14/25 the patient had a dietary evaluation with the recommendation that Glucerna be administered if the patient failed to eat less than 50% of meals. Meal intake:
a. 3/14/25 breakfast refused - no supplement documented;
b. 3/15/25 breakfast 35% - no supplement documented;
c. 3/16/25 lunch 25% - no supplement documented;
d. 3/17/25 lunch 10% - no supplement documented;
e. 3/18/25 breakfast 25% - no supplement documented;
f. 3/19/25 breakfast refused - no supplement documented;
g. 3/20/25 breakfast 5% - no supplement documented;
h. 3/21/25 breakfast 2 bites, lunch 25%, dinner 30% - no supplement documented;
i. 3/22/25 breakfast 25% - no supplement documented;
j. 3/23/25 breakfast 30%, dinner 15% - no supplement documented;
k. 3/24/25 breakfast 20%, lunch 25% - supplements documented twice;
l. 3/25/25 breakfast 20%, lunch 25% - no supplements documented;
m. 3/26/25 no documentation
n. 3/27/25 no documentation
o. 3/28/25 no documentation
p. 3/29/25 no documentation
q. 3/30/25 no documentation
r. 3/31/25 dinner 25% - no supplement documented;
s. 4/1/25 no documentation
t. 4/2/25 no documentation
u. 4/3/25 no documentation
v. 4/4/25 breakfast 25%, lunch 25%, dinner 25% - no supplement documented;
w. 04/5/25 no documentation
x. 04/6/25 breakfast 25%, lunch 25%, dinner 25% - no supplement documented;
y. 04/7/25 no documentation
z. 04/8/25 no documentation (was discharged this date)

On 05/13/25 1:40 pm at 9:40 AM Staff E stated Glucerna was not offered each time the patient ate less than 50% of a meal.