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 interview with staff, it was determined the hospital failed to ensure adequate RN supervision of care occurred for at least one (1) of ten (10) records reviewed of a patient who was identified to be at risk for harm (patient #1). This has the potential to negatively affect the quality of care and safety of all patient's who may be at risk.

Findings include:

Review of the medical record for patient #1 revealed the female patient was admitted to the Behavioral Sciences Center (BSC) on 6/12/2013. The patient's surrogate signed consents for the patient's admission, as she was not competent at the time. The patient had a new onset of confusion and hallucinations. Nursing, counselor and physician assessments noted the patient to be somewhat oriented at times, with intermittent confusion.

Review of the medical record for patient #2 revealed he is a male patient who was admitted on [DATE] at about 4:30 p.m. to the BSC for complaints of depression. The patient was noted to be alert and oriented and he signed his own admission papers.

A staff LPN was interviewed on 6/19/2013 at 1:15 p.m. She stated she was working on the the B-Adult unit on the 7 a.m. to 7 p.m. shift on 13. She stated she was not assigned to patient #1, but she was observing her closely and noted the patient was "seemingly confused and was wandering into other (patient) rooms." The LPN stated a family member of patient #1 had been in "earlier in the day" (prior to the incident) and had been "concerned" about the patient's mental status.

The nursing assistant who was assigned to patient #1 on 6/16/2013 was interviewed on 6/19/2013 at 10:30 a.m. She stated earlier in the day on 6/16/2013, patient #1 was doing very well and she had a conversation with the nursing assistant. She stated that later on, patient #1 was acting more confused and was wandering in the hallway. She stated she observed patient #1 entering a male patient's room (not patient #2) and she redirected her out of the room both occasions. She stated patient #1 was easily redirected and she was not concerned because she was trying to watch her closely.

The RN who assumed charge duties at 2 p.m. on 6/16/2013 was interviewed by telephone on 6/19/2013 at 1:45 p.m. She stated she was not familiar with patient #1 until the shift on 6/16/2013. She stated the patient's family member had called to the unit early in the day and had spoken to another RN. The family member told the other RN he had spoken with the patient on the phone and he was concerned that she was "talking crazy". She stated the other RN had conveyed that information to her prior to the other RN leaving at 2 p.m. She stated the patient's family member came at about 3 p.m. to visit with the patient. The patient's family member spoke with the RN before he left the unit and he again expressed concern. He stated he could not carry on a coherent conversation with the patient. The RN stated the unit was becoming "swamped with admissions", and she was also transferring a patient to the medical floor. She stated patient #2 was admitted on [DATE] and she completed his nursing admission assessment in the treatment room. She stated she took him to his own room at about 5:45 p.m. on 6/16/2013. She stated it was "about 10 minutes later", when the nursing assistant called for help from the room of patient #2, when patient #1 and patient #2 were discovered in the bed together in a sexual position.

The Nurse Manager was interviewed throughout the investigation. She stated on 6/18/2013 at about 2:30 p.m. that patient #1 was placed on 1:1 observation after the incident and it is planned the patient will continue with 1:1 observation until the time of discharge in order to protect her. She stated the patient had not been on increased observation prior to the incident. She stated all patient's are observed every fifteen (15) minutes as per policy.

Review of the medical record for patient #1 revealed there had been no orders for 1:1 observation prior to the time of the incident. It was documented the patient was observed every fifteen (15) minutes on the day of the incident. There had been no updates to the treatment plan prior to the incident for increased observation to protect the patient from harm when it was noted she was wandering into another male patient's room. The nursing staff failed to document or note there had been incidents of the patient wandering into another patient's room or her increased confusion on the day of the incident or that the patient's family member had expressed concern on the day of the incident on more than one occasion prior to the incident occurring.