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 interview, medical record review and document review there was no evidence that the patient or legal guardian was involved in the development of the patients care plan.
This was evident in four (4) of four (4) medical records reviewed. (Patient #6, #11, #16 &

Findings include:

During a tour of the Unit 6B on 6/7/16 at approximately 11:20 PM, Patient # 16 was asked about his plan of care and whether or not the staff discussed his plan of care with him. He expressed concern about not knowing what his plan of care was and how it would affect his present living arrangement. He stated that "I have no idea what they are going to do with me, I do not know if I am going from point A to point B."

Patient #17 on Unit 6B was asked about his plan of care and whether or not the staff discussed the plan of care with him. He stated that the staff never discussed a plan of care with him or his wife. He stated that he believed that he was readmitted to the hospital because the staff failed to review the previous plan of care prior to discharge.

During interview on 6/7/16 at 11:40 AM, Staff R , Registered Nurse, Unit 6B, stated that she was assigned to the above patients. She was asked whether or not patients are involved in their care plan. She stated that she was "not sure."

During interview on 6/7/16 at 1:30 PM, Staff Q, Charge Nurse, Unit 6 B was asked to describe the patient care planning process. He stated that the patient plan of care was done in the computer at the Nurse's station and that patients were not involved in the process.

During interview of patients on Unit 8C, on 6/8/16 at approximately 12:00 PM, Patient #11 stated that a plan of care was never discussed with her. She added, "I guess they will do it tomorrow before I leave."

Patient #6 on Unit 8C stated that the staff did not discussed a plan of care with her and she did not know what it was.

During interview on 6/8/16 at 12:31 PM, Staff S, Attending Physician for Patient #6 and Patient #11, was asked about patient's involvement in their plan of care. He stated that he "explained the diagnosis" to patient #6. He did not state if he had similar discussion with Patient #11."

Review of the medical records for Patient #6, #11, #16 & #17 showed no documented evidence that these patients participated in their plan of care.

Hospital Policy and Procedure titled: "Criteria and Guidelines For The Interdisciplinary Treatment and Discharge Plan" states: The patient/family will be involved in the care planning process.

The hospital failed to adhere to their own guidelines for patient care planning.
Based on medical record review, document review, review of a video surveillance tape and interview, it was determined the staff failed to follow the facility's policy to provide patient care, free from physical abuse. This was found in one (1) of 15 medical records reviewed. (Patient #5).

Findings include:
Review of medical record for Patient #5 revealed the following: Patient #5 presented to the emergency department (ED) on May 30, 2016 at 1:22 AM because of his erratic and irrational behavior. The triage documentation noted patient was alert and oriented; patient was sweating, pacing around, had pressured speech, and appeared to be responding to internal stimuli.
Documentation in the medical record at 4:00 PM that day, revealed the patient alleged he was hit by a member of staff at the right side of his ear during an earlier incident in the ED.

A review of the hospital's ED video surveillance tape revealed, on May 30, 2016 at 9:11 AM, Staff N, a Behavioral Health Associate, was seen talking to the patient, who had a cup in his hand that he had picked up from the floor. At 9:11:50, the patient tossed the liquid that was in the cup at Staff N, hitting Staff N into his face and upper torso. Staff N immediately punched the patient on the right side of his head by using his right fist.

During an interview with Staff B, Associate Executive Director on June 8, 2016 at 10:00 AM, he confirmed that Staff N did punch the patient on his head after the patient threw toilet water in Staff N's face.

The staff's action was not in compliance with the policy titled "Patient Abuse and Neglect," effective in 11/15, states "every patient has the right to receive care free from neglect; exploitation; and verbal, mental, and physical abuse."
Based on document review and staff interview the hospital failed to developed an effective Quality Assurance and Performance Improvement (QAPI) program to track, trend, and analyze data collected for the facility's patient complaint/grievance process.

Findings include:

Review of the "Summary of Complaints/Grievance" for January to March 2016 showed that the hospital summarized the total number of complaints/grievances for this three (3) month period, however there was no evidence that this information was analyzed to determine the effectiveness of care/service provided.

During interview on 6/8/16 at 10:25 AM, Staff T, Department Chief of Operations, stated that the hospital has a grievance committee that meets weekly to review whether or not patients complaints/grievance were closed within the 7 days required time frame. She also stated that the hospital was collecting the number of patient complaints/grievances, however, it was not trended, analyzed, nor was a plan developed for improvement.
When asked for a QAPI plan for complaints/grievances, she was not able to produce one.

The hospital provided no evidence that the department developed and implemented an on-going QAPI program that measures, and analyzes patient complaints/grievances to identify trends and develop a plan for improvement.