The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LARKIN COMMUNITY HOSPITAL 7031 SW 62ND AVE SOUTH MIAMI, FL 33143 Feb. 3, 2011
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observation, interview, and record review the hospital failed to implement appropriate administrative functions related to patient safety which could result in adverse patient outcomes. (1) in 28 out of 60 days of census data reviewed, the hospital exceeded their licensed capacity for psychiatric beds; (2) in 3 quarterly meeting minutes from fiscal year 2010, the governing body failed to address this issue which ultimately resulted in a lack of planning for the safety of psychiatric patients who are admitted to the hospital after they reached and/or exceeded the licensed psychiatric bed capacity.

The findings include:

(1) Record review of the facility ' s license, number 4288, indicates that it is permitted a total of 142 beds; 100 Acute Care and 42 Adult Psych beds. Record review of the daily census for the previous 60 days, indicated that the facility exceeded the 42 bed limit for psychiatric patients and was out of compliance for a total of 28 days.

Interview with the Vice President (VP) of Nursing on 2/3/2011 at 1:00 pm revealed that he was aware that the hospital exceeded the licensed capacity of the psychiatric area at various times. The VP of Nursing stated that the facility is the only Baker Act receiving facility in the area. He further stated that the amount of patients that are brought in to the Emergency Department by the Police is beyond control and unexpected. He stated that he believed the situation to be temporary due to pending patient discharges from the Psychiatric Department and thought by moving patients to the 3rd floor annex, the patients were safer than if they had remained within the emergency room .

(2) The governing body failed to ensure that the approved performance improvement plan, dated 5/2010, was followed assuring that all information is provided to Board of Directors as relating to the appropriateness and quality of patient care, as well as, patient safety practices as evidenced by the failure of the governing body to address the issue of placing psychiatric patients in a medical-surgical unit.

The governing body failed to address areas that affect health outcomes, patient safety, and quality of care by permitting the admission of psychiatric patients to the extent that the licensed capacity of 42 beds was exceeded for 28 out of 60 days.
The governing body, failed to perform quality assurance activities ensuring that the environment of care was safe and appropriate for the type of patients placed within its settings.

Interview with the VP-Nursing on 2/3/2011 at 1:00PM acknowledged the overcapacity of patients. He stated that it was a decision that he made and that he believed that it was going to be temporary in nature. He further acknowledged the physical differences of the rooms located within the formal psychiatric department and the 3rd floor annex. He stated that the governing body has not met to address the issue.
VIOLATION: PATIENT RIGHTS Tag No: A0115
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation, record review and interview (1) the hospital placed psychiatric patients on a medical surgical unit, that lacked adequate safety measures for their conditions, as the medical surgical 3rd floor annex area had completely different equipment and room set up than that of the 5th floor psychiatric unit; (2) Five (#1, #2, #3, #4, and #5) out of 5 sampled patients as well as a review of 60 days of the facility census reports revealed that patients who were admitted to the hospital with psychiatric conditions were placed on a medical surgical floor which lacked appropriate resources to render safe and therapeutic care; (3) Three (#1, 3, 5) out of 5 sampled patients were admitted to the hospital with suicidal ideation with plans and/or acute psychosis and were placed in environments where they could not receive appropriate care related to condition. As a result of these actions, the hospital failed to protect and promote patients rights at their facility.


The findings include:
(1) On 2/1/2011 at 2:45pm observation of the 3rd floor medical surgical, accompanied by the Vice President (VP) of Nursing, reveals the main hallway with various levels of patient care. Environmental services were also noted in the area cleaning various areas of the unit. According to the VP of nursing, the patients on this unit have a variety of medical diagnosis. At the east end of the hallway was a locked unit. The VP of nursing called this area the 3rd floor annex. The VP of nursing unlocked the door in order to gain entry. Observation of this area includes a small desk at the entry, which the VP of nursing called the nurses ' station. There was a small common hallway area which branched out into 4 patient rooms, 2 rooms on each side of the small unit. Rooms 319 and 320 were to the left of the nurses ' station and rooms 321 and 322 were to the right of the nurses ' station. Outside of each room was 1 bathroom, so that each side had a bathroom. Upon entry into this area Sampled Patient (SP) # 2 was in a wheelchair and being escorted out of room 320 by a Mental Health Technician (MHT). The VP of nursing reported that SP#2 was being transferred from this area to the psychiatric unit on the 5th floor as there is a bed now available. Further observation of this 3rd floor annex area revealed the following: room 319 had a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; the garbage contained a red plastic bag labeled biohazard. Room 320 contained: a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; the garbage contained a brown paper bag. Room 321 contained a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; negative pressure generator was observed in the center of this room, which also had a black cord coming from it. Room 322 had a flat screen television protruding/hanging from the wall, with black and which electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; there was a clear plastic bag in the closet. Each of the rooms 319, 320, 321, and 322 had hospital beds with 4 side rails and the electric controls for elevating and lowering. Each bed had a white electrical cord which was plugged into the wall.


At the south end of the hallway was another locked unit, which per the VP of nursing is the Immigration Customs Enforcement (ICE) unit that house federal prisoners with psychiatric illnesses. Tour of this unit revealed there were 10 patients, and a ratio of 2 guards to 1 patient. Per the VP of nursing this unit is operated by the ICE correction officers and the clinical staff includes 1 Registered Nurse (RN) and 2 Mental Health Technicians (MHT). He further reports that the clinical staff is managed by the manager of the psychiatric unit. Observation of each rooms revealed the beds were the appropriate ones for psychiatric units with a solid base and a mattress on top. There were no cords observed in any of the rooms on this unit. Interview with Sampled Employee (SE) #5 at 2:55pm revealed that the unit is staffed with 1 RN and 2 MHT ' s. She revealed that the patients have a schedule of activities which was posted near the nurses ' station. During this interview a MHT was escorting a patient from the break area with 2 guards.


On 2/1/2011 at 2:45pm interview with the VP of nursing confirms that there were a total of 7 psychiatric patients assigned to 3rd floor annex today and each were, currently, being transferred to the psychiatric unit on the 5th floor as beds had recently opened up. The VP of nursing reports that the 3rd floor annex area is used for psychiatric patients when their 5th floor psychiatric unit is full, and that the patients are transferred to the psychiatric unit as beds there open up. The VP of nursing confirms that the 3rd floor annex area does not have the safety environment necessary to house suicidal and/or aggressive patients.


Interview with Director of the 3rd floor Medical Surgical Unit at 2:50p.m. revealed that the 3rd floor annex can also be used for medical patients. She reveals that if the 3rd floor annex has psychiatric patients, her staff does not provide the care there. She reports that in that scenario, the manager of psychiatry would staff the area. She reports that her responsibility is the 3rd floor medical patients.

On 2/1/2011 at 3:10 pm, observation of the 5th floor psychiatric unit reveals various levels of patient care occurring. The unit is busy with patients free to move about, use the phone in the main hallway adjacent to the nurses ' station. Each room observed to have the appropriate beds for psychiatric patients with the solid base and mattress at the top. Each room observed to have no cords dangling from any appliances. Current census on the unit was 33 patients. Observation of the white board at the nurses ' station revealed room #; patient initials; nurse assigned; technician assigned; attending physician; and social worker assignment. There were 7 patients on the board that had only their initials annotated.

On 2/1/2011 at 3:30p.m.interview with Sampled Employee (SP) #1 reveals that the 7 patients on the white board with no assignment data noted was due to the patients recent arrival to the unit. SP#1 confirms that the 7 patients were moved from the 3rd to the 5th floor within the last couple of hours and the staff was going through their medical records to find out the pertinent information. SP#1 confirms that the 3rd floor does not have adequate safety measures for psychiatric patients.

Record review of the hospital census reports reveal that on the following dates the hospital housed psychiatric patients on the medical surgical 3rd floor annex area: 12/17/2010 - 5 patients; 12/19/2010 - 1 patient; 12/20/2010 - 1 patient; 1/31/2011- 8 patients; 1/30/2011 - 4 patients; 2/1/2011- 1 patient.

(2) The hospital admitted patients with psychiatric conditions and placed them in medical surgical unit, which lacked appropriate resources to render safe and therapeutic care. Observation of the 3rd floor annex area revealed that it was not equipped with a medication dispensing unit. According to the VP of nursing, if the annex is being used for psychiatric patients and staffed with 1 RN and 2 MHT ' s, the nurse must leave the locked unit, and go down the hallway to the medical surgical nursing station to utilize their medication dispensing machine for patient care. The lack of resources needed to care for patients and location of medications, puts the patients at clinical risk. This can also create a safety risk for the staff and other patients if there is a need for an emergency medication for a combative psychiatric situation. Additionally the physical environment on the 3rd floor annex is not conducive to safety for psychiatric patients that may need to be protected from themselves or others as the environment is not equipped to be a psychiatric unit. Finally this unit does not have access to groups or any other therapeutic interventions that is present on the psychiatric unit.

On 2/1/2011 at 3:45pm, interview with Employee #5 reveals that she normally works on the 5th floor but has been staffed on the 3rd floor annex to care for psychiatric patients. She confirms that the 3rd floor is not adequate for psychiatric patients and has felt that she did not have the resources she needed for safe patient care. She confirms that she does not feel safe working in the 3rd floor annex with psychiatric patients. She further confirms that she has had to leave them 2 mental health technicians in the annex area to obtain medications for patients.
Clinical record review of 5 (#1, #2, #3, #4, #5) out of 5 sampled patients reveals that each patient was cleared medically and admitted to the psychiatric unit. The care plans for each patient reveals that portions of the care plan cannot be carried out on the 3rd floor annex area. Particularly the interventions of providing a safe and therapeutic environment for the problem areas of potential for violence, which was care planned for SP#1, #2, #3, #4, and #5.

Review of hospital policy and procedure revealed that the policy for behavioral health admission procedure guidelines confirms that whenever possible, psychiatric patients are to be admitted directly to the behavioral health unit, 5th floor. The policy does not state what is to be done in the event that the 5th floor psychiatric unit is full.

(3) Three (#1, #3, and #5) out of 5 patients were placed in an environment where they could not receive appropriate care related to their current suicidal ideation and/or aggressive behavior. Clinical record review of SP#3 was brought to the hospital ' s emergency room via ambulance on 1-30-2011 at 11:25 am. According to the emergency room ' s nurses and physician ' s notes the patient was suicidal and had a plan in place to carry out the suicide. The patient, as an emergency treatment order, was administered Ativan 2mg; Haldol 5mg; and Benadryl 50mg, each medication was given intramuscularly. SP #3 was cleared medically and evaluated by a psychiatric physician who then gave orders to admit patient to psychiatric unit and place on special precautions. According to the emergency room ' s nurse ' s notes, the patient was admitted to room 321 on the medical surgical floor in the annex area. Room 321 does not have the physical safety environment for a patient who is suicidal with a plan. Room 321 is a medical surgical room, as already observed on tour, with cords and various items that could be potentially dangerous to a patient in the mental state of SP#3.

SP #1 was brought to the hospital ' s emergency room on [DATE] at 12:25 am, by the Miami Dade Police Department. The police notes reveal that the police found SP#1 in a car and SP#1 reported to them that she had been in the car for 9 hours and she had not taken her medication. According to the emergency room physician notes, the patient was extremely paranoid, delusional and aggressive. The patient, as an emergency treatment order, was administered Ativan 2mg; Haldol 5mg; and Benadryl 50mg, each medication was given intramuscularly. SP#1 was cleared medically and evaluated by a psychiatric physician who then gave orders to admitted and placed on special precaution for aggression. On 1-31-2011 SP#1 was admitted to room 322 on the medical surgical floor in the annex area. Room 322 does not have the physical safety environment for a patient who is in an acute psychosis state. Room 322 is a medical surgical room, as already observed on tour, with cords and various items that could be potentially dangerous to a patient in the mental state of SP#1.

SP#5 was brought to the hospital ' s emergency room on [DATE] at 6:35 pm, by ambulance. According to the emergency room physician ' s notes, the patient was severely agitated with hallucinations. The emergency room nurses notes that SP#5 was very aggressive. The patient, as an emergency treatment order, was administered Ativan 2mg; Haldol 5mg; and Benadryl 50mg, each medication was given intramuscularly. SP#5 was cleared medically and evaluated by a psychiatric physician who then gave orders for the patient to be admitted to psychiatry. On 12-16-2010 at 11:25pm, SP#5 was admitted to the medical surgical floor in room 321, in the annex area. Room 321 does not have the physical safety environment for a patient who is in an acute psychosis state. Room 321 is a medical surgical room, as already observed on tour, with cords and various items that could be potentially dangerous to a patient in the mental state of SP#5.

On 2-2-2011 at 1:00pm the Vice President of Nursing confirms that he gave the direction for the hospital to exceed their psychiatric bed capacity on a few occasions. He admits that it is not a normal occurrence to admit psychiatric patients to the medical surgical units and it is only done when there are no beds on the 5th floor psychiatric unit. He confirms that the hospital has not applied for a waiver, nor have they come up with an answer to this issue. The Vice President of Nursing admits that he made the decision to use the 3rd floor annex area for psychiatric patients because it appeared to be a more appropriate setting than the emergency room . He further admits that the staffing, environment, and resources for use of this area for psychiatric patients could have been planned better.

On 2-3-2011 at 11:06am, interview with Employee #1 confirms that on 12-16-2010, there was a psychiatric patient inappropriately admitted to the medical surgical annex area. She further reports that she hopes that the 3rd floor annex area not be used for psychiatric patients any more. She reports that the 3rd floor annex area simply do not have the physical conditions for any psychiatric patient. She reports that if a psychiatric patient is on the 3rd floor annex area and becomes combative, aggressive or decompensate, the staff is advised to call a code " Mr. Strong " which is the hospital ' s code to have a certain team of mental health professionals and security show up to the area. She reports that the psychiatric unit is where these patients should be for their safety, the safety of other patients, and the safety of the staff.
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on observation, interview and record review the facility failed to ensure the plan of care was implemented for 5 (#1, #2, #3, #4, #5) out of 5 sampled patients which denies patient rights, delay patient care and can potentially have negatives effects on patient outcomes.

The findings include:

The hospital admitted patients with psychiatric conditions and placed them in medical surgical unit, which lacked appropriate resources to render safe and therapeutic care. Observation of the 3rd floor annex area revealed that it was not equipped with a medication dispensing unit. According to the Vice President (VP) of nursing, if the annex is housed with psychiatric patients and staffed with 1 Registered Nurse (RN) and 2 Mental Health Technicians (MHT ' s), the nurse must leave the locked unit, and go down the hallway to the medical surgical nursing station to utilize their medication dispensing machine for patient care. The lack of resources needed to care for patients and inability to readily access to medications puts the patients at clinical risk. This can also create a safety risk for the staff and other patients if there is a need for an emergency medication for a combative psychiatric situation. The 3rd floor annex unit does not have access to groups or any other therapeutic interventions that is present on the psychiatric unit.
On 2/1/2011 at 3:45pm, interview with Employee #5 reveals that she normally works on the 5th floor but has been staffed on the 3rd floor annex to care for psychiatric patients. She confirms that the 3rd floor is not adequate for psychiatric patients and has felt that she did not have the resources she needed to implement patient care. She further confirms that she had to leave the 2 mental health technicians in the annex area to obtain medications for patients.

Clinical record review of the care plans for 5 (#1, #2, #3, #4, #5) out of 5 sampled patients reveals that each patient was cleared medically and admitted to the psychiatric unit. The care plans for each patient reveals that portions of the care plan could not be implemented on the 3rd floor annex area. The interventions of providing a safe and therapeutic environment for the problem areas of potential for violence, was care planned for SP#1, #2, #3, #4, and #5. Observation on the initial tour of the 3rd floor annex area reveals that this area is not equipped for providing a safe environment for psychiatric patients. Further the 3rd floor annex area does not have room for group meetings, which is also care planned for SP#1, #2, #3, #4, and #5. These patients had to wait for a room on the 5th floor psychiatric unit to open up before they could have portions of their care plans implemented.

Review of hospital policy and procedure revealed that the policy for behavioral health admission procedure guidelines confirms that whenever possible, psychiatric patients are to be admitted directly to the behavioral health unit.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, interview, and record review the hospital failed to ensure that 5 (#1, #2, #3, #4, and #5) out of 5 sample patients (SP) patients receive care in a safe setting by admitting psychiatric patients to medical surgical unit/rooms. The hospital did not plan to ensure adequate resources for patient care was present. The hospital failed to ensure the equipment in the medical surgical rooms were safe for psychiatric patients. The hospital also failed to ensure the skill mix of the staff in the 3rd floor annex area was adequate for optimal patient care and safety.

The findings include:
(1) On 2/1/2011 at 2:45pm observation of the 3rd floor medical surgical, accompanied by the Vice President (VP) of Nursing, reveals the main hallway with various levels of patient care. Environmental services were also noted in the area cleaning various areas of the unit. According to the VP of nursing, the patients on this unit have a variety of medical diagnosis. At the east end of the hallway was a locked unit. The VP of nursing called this area the 3rd floor annex. The VP of nursing unlocked the door in order to gain entry. Observation of this area includes a small desk at the entry, which the VP of nursing called the nurses ' station. There was a small common hallway area which branched out into 4 patient rooms, 2 rooms on each side of the small unit. Rooms 319 and 320 were to the left of the nurses ' station and rooms 321 and 322 were to the right of the nurses ' station. Outside of each room was 1 bathroom, so that each side had a bathroom. Upon entry into this area Sampled Patient (SP) # 2 was in a wheelchair and being escorted out of room 320 by a Mental Health Technician (MHT). The VP of nursing reported that SP#2 was being transferred from this area to the psychiatric unit on the 5th floor as there is a bed now available. Further observation of this 3rd floor annex area revealed the following: room 319 contained a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; the garbage contained a red plastic bag labeled biohazard. Room 320 contained a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; the garbage contained a brown paper bag. Room 321 contained a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; negative pressure generator was observed in the center of this room, which also had a black cord coming from it. Room 322 had a flat screen television protruding/hanging from the wall, with black and white electrical cords, which were coiled up and hanging from it; a nurse call bell was on each bed which both contained white cords plugged into the wall; blinds on the window with a cord hanging from it; there was a clear plastic bag in the closet. Each of the rooms 319, 320, 321, and 322 had hospital beds with 4 side rails and the electric controls for elevating and lowering. Each bed had a white electrical cord which was plugged into the wall.

On 2/1/2011 at 2:45 interview with the VP of nursing confirms that there were a total of 7 psychiatric patients assigned to 3rd floor annex today and each were, currently, being transferred to the psychiatric unit on the 5th floor as beds had recently opened up. The VP of nursing reports that the 3rd floor annex area is used for psychiatric patients when their 5th floor psychiatric unit is full, and that the patients are transferred to the psychiatric unit as beds there open up. The VP of nursing confirms that the 3rd floor annex area does not have the safety environment necessary to house suicidal and/or aggressive patients.


On 2/1/2011 at 3:10 pm, observation of the 5th floor psychiatric unit reveals various levels of patient care occurring. The unit is busy with patients free to move about, use the phone in the main hallway adjacent to the nurses ' station. Each room observed to have the appropriate beds for psychiatric patients with the solid base and mattress at the top. Each room observed to have no cords dangling from any appliances. Current census on the unit was 33 patients. Observation of the white board at the nurses ' station revealed room #; patient initials; nurse assigned; technician assigned; attending physician; and social worker assignment. There were 7 patients on the board that had only their initials annotated.

On 2/1/2011 at 3:30 interview with Sampled Employee (SP) #1 reveals that the 7 patients on the white board with no assignment data noted, was due to the patients recent arrival to the unit. SP#1 confirms that the 7 patient were moved from the 3rd to the 5th floor within the last couple of hours and the staff was going through their medical records to find out the pertinent information. SP#1 confirms that the 3rd floor does not have adequate safety measures for psychiatric patients.

Record review of the hospital census reports reveal that on the following dates the hospital housed psychiatric patients on the medical surgical 3rd floor annex area: 12/17/2010 - 5 patients; 12/19/2010 - 1 patient; 12/20/2010 - 1 patient; 1/31/2011 - 8 patients; 1/30/2011 - 4 patients; 2/1/2011- 1 patient.

Record review of the hospital staffing for the medical surgical unit 3rd floor annex area was staffed with Staff #4 from the psychiatric unit on the following dates: 12-17-2010; 1-29-2011; 1-30-2011; and 2-1-2011. Review of employee files reveals that Staff #4 is a new nurse to the facility. Staff #4 hire date is 9-20-2011. This nurse has 4 months on the unit and was left alone to care for patients in the 3rd floor annex area.

On 2-1-2011 at 3:10pm, interview with Staff #4 reveals that she has just recently graduated from nursing school. She admitted that she has only 4 months of professional nursing experience.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on observation, interview, and record review, the facility failed to set performance improvement activities for 5 of 5 sample patients (SP #1, #2, #3, #4, #5) that addressed the issue of placing psychiatric patients in a medical-surgical unit. The governing body failed to address areas that affect health outcomes, patient safety, and quality of care by permitting the admission of psychiatric patients beyond the licensed capacity.

The Findings include:
Record review of the facilities daily patient census, revealed that the licensed capacity of 42 beds was exceeded for 28 out of 60 days.
Record review of the governing body minutes and the performance improvement minutes on 2/1/2011 at 3:30PM revealed that the governing body did not address issues related to the licensed capacity to ensure that it was not exceeded, as well as, the environment of care was appropriate and safe for the type of patients placed within its setting.
Record review on 2/1/2011 at 3:30PM revealed that the governing body did not ensure quality of care for patients admitted to the 3rd floor annex and that the plans of care were followed for 5 out of 5 sample patients (SP#1, #2, #3, #4, #5) that were unable to participate in group therapeutic activities.
Interview with the Director of Psychiatric Nursing on 2/3/2011 at 11:05AM revealed that there was no system in place to allow the patients that were located within the 3rd floor annex to leave the unit and participate in the group activities that were conducted on the 5th floor psychiatric department.
Performance improvement activities did not address the issue of placing psychiatric patients in a medical-surgical unit. The health outcomes, patient safety, and quality of care were compromised by permitting the admission of psychiatric patients to the extent that the licensed capacity of 42 beds was exceeded for 28 out of 60 days. Record review of the governing body minutes on 2/1/2011 at 3:30PM revealed that the governing body did not ensure that the environment of care was appropriate and safe for the type of patients placed within its setting.
VIOLATION: EXECUTIVE RESPONSIBILITIES Tag No: A0309
Based on observation, interview and record review, the governing body failed to ensure that the hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care and patient safety and that all improvement actions are evaluated.
The findings include:
The governing body failed to ensure that the approved performance improvement plan, dated 5/2010, was followed assuring that all information is provided to Board of Directors as relating to the appropriateness and quality of patient care, as well as, patient safety practices as evidenced by the failure of the governing body to address the issue of placing psychiatric patients in a medical-surgical unit.

Record review of the governing body ' s meeting minutes for the last year (2010) failed to address areas that affect health outcomes, patient safety, and quality of care by permitting the admission of psychiatric patients beyond the licensed capacity of 42 patients. Record review of the daily patient census for December 2010 and January 2011 revealed that the Psychiatric patient licensed capacity was exceeded for 28 out of 60 days.

Record review of the minutes of the governing body meeting in November 2010, revealed the issue of exceeding the licensed capacity of psychiatric patients, as well as, failure to perform quality assurance activities ensuring that the environment of care was safe and appropriate for the type of patients placed within its settings were not addressed.

Interview with the Vice President-Nursing on 2/3/2011 at 1:00PM acknowledged the overcapacity of patients. He stated that it was a decision that he made and that he believed that it was going to be temporary in nature. He further acknowledged the physical differences of the rooms located within the formal psychiatric department and the 3rd floor annex. He stated that the governing body has not met to address the issue.
VIOLATION: PROVIDING ADEQUATE RESOURCES Tag No: A0315
Based on observation, interview and record review, the governing body failed to ensure that adequate resources are allocated for reducing risk to psychiatric patients admitted to the medical surgical unit.

The findings include:

The governing body failed to ensure that the appropriate resources were allocated to ensure that psychiatric patients that were admitted to rooms were safe and appropriate for the type of patients that occupied the room. Tour of the facility on 2/3/2011 at 2:45PM revealed the distinct safety differences between the rooms located in the Psychiatric Unit and the Medical Surgical Unit.
The aspects of rooms 319, 320, 321, 322 were noted. The rooms contained 8 electro-mechanical beds that could permit entrapment of the patient. The rooms contained corded call light devices, televisions mounted to the walls that had exposed electrical and cable television wiring; and window blind cords that presented a choking hazards. The 2 common bathrooms contained a hosed sprayer and fixed shower curtains that could permit choking. The patients ' rooms had standard fire doors with exposed hinges and standard wardrobes with rods in place for hangers.


The tour of the 5th floor psychiatric department with the Director of Psychiatric Nursing revealed the differences between the two areas. The patient rooms located within the Psychiatric Department had special features that promoted patient safety and took in to consideration the specific type of patient to be treated and the possible hazards that may be present within the environment.
The rooms had heavy furniture and low beds with solid bases made of wood that were bolted to the floor to prevent movement. The mattresses on each bed were specially designed for psychiatric patients to prevent it from being ripped open and tampered with. The lighting in the rooms was specially encased to prevent tampering and getting access to the glass bulb and electricity. The shower head was small and set in to the wall to prevent tampering and tying anything to it. The shower curtain was a breakaway type that could not support any weight and prevents choking. The wardrobe had shelving; no hangers or rod. There were no televisions in the rooms. No exposed wiring. No window shades. No medical gasses. The windows were covered with a locked metal screen to prevent accident and elopement. The hinges securing each door to a patient ' s room were of the piano type that was attached to the door from top to bottom; to prevent the patient from getting their body part entrapped in a closing door.


Interview with the Director of Psychiatric Nursing on 2/3/2011 at 2:55pm, revealed that she did not consider the 3rd floor annex located in the Medical Surgical area to be a safe environment for psychiatric patients since the area did not have the same safety features as the Psychiatric Unit. She stated that all of the safety measures in place in the Psychiatric Unit she demonstrated during the tour were implemented for a reason and that the safety of the patient is the primary concern.


Record review of the minutes of the governing body meeting in November 2010, revealed that the issue of exceeding the licensed capacity of psychiatric patients, as well as, failure to perform quality assurance activities ensuring that the resources to provide an environment of care that was safe and appropriate for the type of patients placed within its settings were not addressed.

The licensed capacity of 42 beds in the Psychiatric Unit was exceeded for 28 out of 60 days. By failing to address to overcapacity within the Psychiatric Department, the governing body did not allocate adequate resources to assure that those patients were in a safe environment of care and reduce the risk of harm to the patient.