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.

Based on review of medical records and interviews with patients and staff, the hospital staff failed to maintain a safe environment for patients and failed to ensure all patients were not in possession of contraband on the Behavioral Health unit. The hospital staff agreed 1 of 1 patient possessed contraband on the Behavioral Health unit since January 2015 (Patient #1).

Failure to ensure patient's did not have contraband in their possession when on the in-patient Behavioral Health Unit, risked the health and safety of all the Behavioral Health patients, visitors, and staff.

Findings include:

1. The policy titled, "Contraband and Weapons" dated 12/2014 included in part..."To assist in providing that safe environment, contraband is prohibited on or in any property...maintained by the hospital...The definition of contraband ...Tobacco, including cigarettes...and lighters...For safety of patients and staff on certain units...Inpatient Behavioral Health Unit...additional steps will be taken to ensure no contraband is allowed on those units...Before entering the nit, patients and visitors will be searched by means of a handheld metal detector and the turning out of pockets..."

The policy titled, "Safety" dated 12/14 included in part, "...All members of the nursing staff are expected to keep patient, visitor, and employee safety upper most in mind at all aware regulations and policies of the...Inpatient Behavioral Health Unit...Fire Safety...Patients are not allowed to have... matches in their possession...Patients on the inpatient Behavioral unit are not allowed to smoke on the unit..."

The policy titled, "Behavioral Health Admissions and Management" dated 12/20/14 included in part, "...Patients on the Behavioral Health Unit may have visitors...All visitors will be screened for any contraband..."

2. Review of Patient #1's medical record revealed the following:

a. Documentation revealed the date of the patient's admission on 3/15/15 with the diagnosis of acute psychosis and substance abuse. The documentation showed upon admission, the patient received a body search completed by staff.

b. On 3/26/15 at 8:23 PM, the documentation by Staff A, RN, included in part, "...walking to the end of hallway D...noted the smell of cigarettes...entered D 8 and bathroom smelled heavily cigarette smoke...Room searched...2 cigarettes and book of matches found in shelf above his bathroom sink...Room and patient entirely searched with no other items found. States his old roommate had left the cigarettes and matches for him..."

c. Documentation on the patient's visitors sign in/out sheet showed the patient had a visitor on 3/23/15, 3 days prior to the date staff found cigarettes and matches in the patients room.

3. During an interview on 3/31/15 at 2:20 PM, the surveyors requested the incident report regarding Patient #1's possession of cigarettes and matches and smoking in the Behavioral Health unit from the Chief Nursing Officer (CNO). The CNO reported the staff failed to fill out a report for the incident. The CNO added that she expected the staff to fill out a report each time staff find contraband.

4. During a telephone interview on 4/1/15 at 11:50 AM, Staff A, RN, reported that Patient #1 told staff he had acquired the cigarettes and matches from his roommate.