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 policy review, record review and interview, 2 of 5 current employees (staff E & F) had not been trained in the facility's physical restraint protocol, resulting in increased risk of improper restraint application for all 16 current patients. Finding include:

Policy Review:
On 8/7/14 at approximately 1445, the policy titled, Restraints, dated "1/13," was reviewed. The policy stated:
"All staff which have direct patient contact must have ongoing education and training in the proper and safe use of restraints; application techniques; and alternative methods for handling behavior, symptoms and situations that traditionally may have been treated through the use of restraint."

Record Review:
On 8/7/14 at 1430, the physical restraint training records of 5 current employees were reviewed. Staff E, hired 4/7/14, and staff F, hired 3/31/14, had not received training in CPI (Crisis Prevention Intervention).

On 8/7/14 at 1435, staff A stated that staff, who work on the Psychiatric Unit are expected to complete CPI training and use CPI techniques in managing patients. Staff A confirmed that training records for staff E and F revealed that they had not completed CPI training.
Based on interview and record review, the hospital failed to establish a process for prompt resolution of patient grievances, resulting in increased risk of all 16 current patients losing the right to file grievances. Findings include:

On 8/6/14 at approximately 1500, staff G stated that patients are encouraged to place written complaints in a complaint box located on the unit. Staff G confirmed that there was no documentation of patient complaints being filed or reviewed since 7/16/14. Staff G confirmed that one patient neglect complaint, dated 7/24/14, found in the box today (8/6/14), had not been addressed.

Policy Review:
On 8/6/14 at 1530, a policy titled, Recipient Rights Complaint and Appeal Process, dated "08/13", was reviewed. The policy stated:
-"It is the policy of (hospital name) to ensure that: 1) a mechanism is provided for prompt reporting, review, investigation, and resolution of suspected recipient rights violations..."
-"The Rights Office will check the contents of the box frequently, at least one time/week."

On 8/6/14 at approximately 1545, a policy titled Abuse and Neglect of Recipients of Mental Health Services, dated "8/28/13". The policy stated:
-"(Hospital name) will insure prompt and thorough review of charges of abuse and/or neglect..."

A policy specifying a timeframe that ensures prompt review of written abuse and neglect allegations was not found.
Based on observation, record review and interview, the facility failed to follow protocols for post-fall interventions for 1 of 1 current patients who sustained multiple falls (patient #1), resulting in increased risk of falls for all 16 current patients. Findings include:

Policy Review:
On 8/7/14 at approximately 1300, a policy titled, Fall Prevention, dated "6/11," was reviewed.
The policy stated:
-"Implement fall risk interventions for patients scoring-'Moderate Fall Risk':
-Locate patient in a close as possible to the Nurse Station."
-"Implement fall risk interventions for patients scoring-'High Fall Risk':
-Remain with patient while toileting and during ambulation."

On 8/7/14 at approximately 1315, a review of a policy titled, Treatment Planning, dated "1/13," was completed.
The policy stated:
-"Team conferences and development of the 'Master Treatment Plan' will be completed according to the following schedule:
a. Progress, review and update of the 'Master Treatment Plan'..."

1. On 8/6/14 at 1015, patient #1 was observed sitting in a wheelchair in the Day Room.
2. On 8/6/14 at 1030, a walker was observed at patient #1's bedside. The patient's room (221) was located 3-4 rooms beyond the nurse's station.
3. On 8/6/14 at 1405 patient #1's name was observed on a white board at the nurse's station, listed under the heading "High Risk for Falls." Staff A stated the listing means that patient #1 receives the interventions for "High Fall Risk" patients listed in the facility's Fall Prevention policy.

Record Review:
1. On 8/6/14 at approximately 1100, a review of patient #1's History & Physical (H & P), dated 7/8/14, was reviewed. The H & P, written by Physician I, stated, "Cognition was not tested ." (A 5/12/14 H & P included in patient #1's record lists dementia as a diagnosis.) The dementia diagnosis was not listed on the 7/8/14 H & P.
2. On 8/6/14 at approximately 1445, a review of facility Incident Report records revealed that patient #1 had sustained falls on: 7/12/14, 7/16/14, 7/17/14, 7/19/14, 7/21/14, 7/26/14, and two falls on 7/31/14. In the 7/21/14 fall, patient #1 was found in a puddle of urine on a bathroom floor. In a 7/31/14 fall, patient #1 received facial lacerations from falling on a walker.
3. On 8/7/14 at approximately 1100, a review of patient #1's "Master Treatment Plan for Falls" revealed that the plan was not updated after the "Target Date of 7/14/14." The "Master Treatment Plan" did not specify types of assistive devices or levels of staff assistance needed. "Weekly Team Progress Notes" did not include new interventions for fall prevention, except for one brief period of 1:1 monitoring noted on "7/17/14." The date 1:1 monitoring was discontinued was not noted in the "Master Treatment Plan."

1. On 8/7/14 at approximately 1130, staff A confirmed that patient #1 had not been moved to a room near the nurse's station after sustaining multiple falls during July 2014. Staff A also confirmed that patient #1's "Master Treatment Plan" did not include a provision for staff assistance with toileting.
2. On 8/6/14 at approximately 1410, a Behavioral Health Technician (staff H) was asked if patient #1 is allowed to use a walker. Staff H stated that he did not know. Staff A confirmed that patient #1's "Master Treatment Plan" does not specify the type of equipment and level of staff assistance needed.
Based on interview and record review, 1 of 1 current patients (patient #6) was physically restrained as a means of coercion or discipline, resulting in increased risk of improper use of restraints for all 16 current patients. Findings include:

On 8/7/14 at 1530 patient #6 stated that staff E told her that she could not be in the TV room one night in June 2014. Patient #6 stated, "I was sitting. He took me by my arm and leg and dropped me in the hall."

Record Review & Interview:
On 8/7/14 at 1620 staff A confirmed the following "progress note" by staff E, dated "6/27/14" at "0118: Staff requested (patient #6) return to her room because the television room was off limits after 2300, she refused and was assisted to her room. Halfway to her room (patient #6) refused to walk and was dragged into her room and placed on her bed." Staff A stated that this incident had not been reported and that an investigation would be started immediately.