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 surveyor observations, review of hospital documents, and interviews with hospital staff, the hospital failed to provide a safe environment and care in a safe setting.


1. Upon tour of the mental health unit on the morning of 03/14/2011, they surveyors observed one patient using a Styrofoam cup scooping out ice from a bowl on a cart in the hallway. The patient had not sanitized his hand before obtaining the ice. The cart did not have a designated scoop. The bowl was uncovered and not monitored to ensure sanitary access.

2. On 03/14/2011 at 1105, Staff C and D stated that patients could get their own ice from the bowl and that staff did not monitor the ice bowl to ensure patients used safe aseptic practices when obtaining their ice.

3. Seven of nine grievances reviewed alleged staff abuse, mental and/or physical. Documentation provided and interviews did not demonstrate the hospital had followed its policy to provide care in a safe setting while investigating the allegations. (Refer to Tag A-145 for details.)
Based on the review of abuse and neglect policies and procedures, patient complaints/grievances, medical records and interviews with hospital staff, the hospital does not have mechanisms/methods defined in a policy that clearly describes the procedures to follow when a patient alleges abuse by a hospital employee.


1. On the morning of 3/14/2011, the hospital provided policies for review. The policy "patient rights: to be free from abuse, neglect, or harassment from staff, other patient, and/or visitors-dated 5/09" stipulates if there is a circumstance where there is suspected abuse, neglect , or harassment by hospital staff, other patients, and/or visitors, measures will be immediately instituted to secure the patient and investigate the allegations. The policy stipulates all staff shall have criminal background checks prior to hire. The policy also stipulates identifying events as "unexplained fearfulness of people where there had not been prior complaints and aggressive behaviors (threats, insults). The policy stipulates education will occur during initial orientation and annually thereafter. The policy indicates "for the protection of the patient in question and patients in general, the staff member will be placed on suspension without pay pending investigation.
A policy entitled "occurrence/incident reporting" stipulates an occurrence/incident is "any happening out of the ordinary which results in a potential for or actual injury to a patient, visitor or employee, or damage to facility, property or reputation will be reported through completion of occurrence/incident report." The policy also stipulates "if the occurrence pertains to a fall/other injury of a patient, examine the patient for injury, vital signs, take a subjective statement if possible and notify the physician.

2. On 3/14/2011 surveyors received mental health unit grievances from October 2010 to February 2011. Of the nine grievances filed on the Mental Health Unit only two grievances(Pt 1 and 8) were reviewed by the Staff B designated by the hospital as the grievance coordinator. Seven of nine mental health unit grievances alleged staff physical or verbal abuse. Eight (Pt's 1,4,5,6,7,9,10,11) of nine (Pt's 1, 4,5,6,7,8,9,10,11) specifically stated staff names, shifts, or physical descriptions of the alleged abuser. Of the eight grievances alleging abuse by staff, the hospital failed to follow the abuse policy. None of the staff were relieved of duty pending investigation into the allegation.

Patient # 5 filed a grievance on 10/26/11 alleging at bedtime Staff F "grabs and snatches me up so hard from behind my shirt came open. I also have a bad back from two surgeries. Patient # 5's medical record documentation during the time of the incident stipulates at 0155 "pt (patient) is in bed resting with eyes closed. Resp. (respirations) even and unlabored. No gestures self harm. Pt delusional and paranoid believes staff members are out to get her called 911 to report she was being asaulted. Pt did calm down without medication and went to bed and slep soundly. No further incident."

On the morning of 3/15/11, Staff C told surveyors an investigation had taken place but there was no documentation. Staff C told surveyors the treatment team discussed the grievance but there had been no review of the documentation of the 911 call regarding abusive treatment. There was no documentation on the grievance indicating there had been investigation into the allegations. There was no incident report filed on the 911 call. Staff C stated the patient was seeking attention and was very familiar to the unit. Staff C indicated the patient was placed in a CAPE (creating a positive environment) hold during the incident. There was no documentation in the restraint and seclusion log or the medical record the patient had been restrained. Staff C told surveyors the medical record had not been reviewed. Staff C did not indicate personnel working the night of the alleged incident had been interviewed.

Patient #4 filed a grievance on 10/26/11 alleging staff were verbally abusive. Pt #4 documented "Sunday night and Monday night will curse and yell and people and (sic) be rude and hateful . Didn't happen to me but seen it happen to a lot of people." Staff C told surveyors she had interviewed Patient #1. Documentation on the grievance stipulates "spoke with patient. She states there was a "blonde female" that acted like she owned the place. Monday night was an Indian guy (sic) was screaming - another tech was yelling and screaming at patients - was cussing at patients stated "shut the fuck up, get this damn dayroom cleaned up or you're not going out to fucking smoke!"
Staff C documented follow up conversations with the staff alleged involved. No other staff listed as working the night of the incident were interviewed. The investigation of the grievance did not follow the hospital policies.

Patient #6 filed a grievance on 2/3/11. Patient #6 documented "against (name withheld) for making me take off my clean scrubbs (sp) with little diapers on to try and put on my jeans and t-shirt that I was told to hol on to and not let go off (sp) while other people were left alone with there (sp) scrubs left on. Patient #6 also documented on another grievance report "jumpin on me when they should be jumpin (sp) on some one else-don't know there (sp) names".

Staff C documented "patient iillogical and paranoid". There was no investigation of the complaint documented. Later on 3/15/11 Staff C told surveyors the treatment team reviewed allegations but there was no documentation of the meeting. The investigation of the grievance did not follow the hospital policies.

Patient #10 filed a grievance on 1/3/11. Pt #10 alleged staff had asked patient's to remind staff when they needed or wanted medications but when patients asked for their medications they were accused of being drug seekers. Patient also stated in the grievance "please don't hold this against me". There was no investigation documented on the grievance. There was no indication the patient's allegation had been reviewed.

3. Hospital staff (Staff C and D) the morning of 3/14/11, told surveyors various ways they would handle an allegation of abuse or neglect of a patient or witnessed abuse and neglect. These staff could not identify exactly and verbalize what to do if they witnessed an incident of abuse or neglect of a patient by a staff member.

4. On 3/14/11 surveyors reviewed staff meeting minutes dated 1/26/11. Items reviewed in the staff meeting include "12. There have been many complaints made about staff attitudes., i.e. talking rudely to the patients and lack of compassion. 13. In appropriate force used to take the patients in cape holds, etc. Not trying verbal intervention, prns, and etc. first. 16. All cape holds have to have the same paperwork pulled and completed by the nurses. The debriefment must be signed by all witnesses. Make sure that the care plan is put in the chart.

5. Surveyors toured the mental health unit 3/14/11. During the tour, surveyors were were shown where patient's could submit written grievances. The "inbox" (basket stipulated for grievances) was out on the unit and a open wire basket. The grievance inbox was not locked and could be accessed by all patients and staff. Later Staff C told surveyors patient's could put grievances under the door of the manager's office if the patients wanted.
Based on review of hospital policies and procedures, staffing schedules and personnel files, and interviews with hospital staff, the hospital failed to ensure staff, working on the mental health/psychiatric (psych) unit, were trained and kept current in the safe implementation in CAPE (Creating a Positive Environment), the facility's approved method to hold/restrain patients, and application of restraints before patient care were assigned. This occurred for nine of nineteen (Staff # F, K, L, N, O, P, Q, R, and T of Staff #C, E, F, G, H, I, J, K, L, M, N, O, P, Q, R, S, T, U and V) personnel files reviewed for CAPE competency.


1. State Licensure Chapter 667 Hospital Standards, Subchapter 33, 310:667-33-2(b)(2), stipulates, "All staff providing active treatment or monitoring patients shall be trained in facility methods approved to physically hold or restrain patients before patient care responsibilities are assigned. These staff members shall be reoriented regarding these policies annually or when policies are revised."

2. On the morning of 03/14/2011, staff told the surveyor that CAPE was the approved method to physically hold/restrain patients. This was confirmed by policy review and personnel file review.

3. On 03/14/2011 at 1100, Staff C and D told surveyors that Security was often on the unit every day and did participate in CAPE holds and restraints.

4. Four of five psych unit staff (Staff # F, L, R and T of Staff # F, L, R, T and V), hired within the last year and whose personnel files were reviewed, did not have CAPE training before working on the psych unit.
a. Staff F - date of hire was 05/12/2010; CAPE training was 06/25/2010.
b. Staff L - date of hire was 07/09/2010; CAPE training was 08/16/2010; schedule review confirmed worked on unit before CAPE.
c. Staff R - date of hire was 07/15/2010; CAPE training was 08/16/2010; schedule review confirmed worked on unit before CAPE.
d. Staff T - date of hire was 10/05/2010; CAPE training was 12/28/2010; schedule review confirmed worked on unit before CAPE.

5. Three of three Security staff (Staff #O, P and Q), hired within the last year and whose personnel files were reviewed, did not have CAPE training before helping on the psych unit.
a. Staff O - date of hire was 08/12/2010; CAPE training was 09/09/2010; schedule reviewed confirmed worked and was available to help on the unit before CAPE.
b. Staff P - date of hire was 02/25/2011; has not had CAPE training; seen on unit with patients on 03/15/2011.
c. Staff Q - date of hire was 01/14/2010; CAPE training was 09/25/2010; schedule review confirmed worked and was available to help on the unit before CAPE.

6. Security Staff N did not have current CAPE training. Security Staff N's last CAPE training was 12/10/2003.

7. Staff K did not have current CAPE training. Staff K's last CAPE training was 12/__/2009.

8. These findings were reviewed with administrative staff on the afternoon of 03/15/2011.
Based on record review and interviews with hospital the hospital does not ensure patient grievances are investigated and the hospital's grievance process is implemented. Seven ( #'s 2,3,4,5,6,7 & 9) of nine patient grievances filed on the hospital's mental health unit were not investigated and the hospital's grievance process was not implemented.


1. Seven of the nine grievances reviewed from the hospital's mental health unit during the months October 2010 through February 2011 did not have review by the hospital's grievance coordinator as required by the hospital's grievance policy. The hospital's grievance policy states "The individual receiving the grievance will initiate a written Grievance Management form, completing as much information as is available. The person who initiated the grievance will be advised that the grievance will be directed to the hospital's COO or designee for prompt resolution."

2. Mental health unit staff keep a separate grievance log and this log is not integrated into the hospital's grievance process. This was verified on 03/14/11 in the morning by Staff C and A.

3. On 03/15/11 Staff A stated that Staff B was responsible for the grievance process and was the only person reviewing the grievances. Mental health unit grievances are not "usually" investigated by Staff B according to both Staff A & B. Most of the grievances filed in the mental health unit are reviewed and investigated by the mental health unit staff not by the hospital's designated grievance individual. Documentation provided to the surveyors did not contain evidence the grievances had been investigated.
Based on review of the hospital's grievance policy, selected grievances from the mental health (paych) unit and interviews with hospital staff, the hospital failed to provide a written response to the complainant with the required information. This occurred for nine of nine grievances reviewed filed for the psych unit patients (Patients #1, 4, 5, 6, 7, 8, 9, 10 and 11).


1. Patient #1 - On 03/15/2011 at 1030, Staff B stated she investigated the complaint filed by the patient's representative, but did not send a written response, with all the required information, to the complainant.

2. Patient #8 - On 03/15/2011 at 1035, Staff B stated she investigated the complaint referred by another source. Documentation provided did not show a written response was provided to the actual complainant, but a written response was provided to the referral source. Staff stated she responded to the referral source because that was the person who had contacted her about the problem.

3. Documentation for complaints/grievances filed for Patients #2, 3, 4, 5, 9, 10 and 11) did not demonstrate a written response, with the required information, was provided to the complainants. Staff B stated she did not investigate these complaints. Staff A stated that psych complaints were handled on the unit. Staff C stated they were "handled" in Treatment Team and that a written response was not provided to the complainant.