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 observations, interviews and document review, the facility failed to ensure that patient grievances were directed to the Patient Representative, who was designated by the facility as the advocate for patients related to grievances. The facility also failed to ensure that the explanation provided to patients about how to file a grievance was accurate and was understood and supported by all staff, to ensure timely involvement by the Patient Representative, the patient's designated advocate in the facility.

The failure created the potential for patient grievances to not be directed to the designated Patient Representative, in order to ensure confidentiality, thorough investigation of the grievance, and protection from retaliation when lodging a grievance.



According to the policy, Patient Rights and Responsibilities, effective December, 2012, the facility has a responsibility to inform each patient about the process for filing a grievance and whom to contact to file a concern, complaint or grievance.

According to the policy, Patient Rights, last revised 02/10/11, all patients will have access to the Patient Representative and all psychiatric units' staff will assist patients in contacting the Patient Representative if necessary.

According to the policy, Patient/Family Grievance Process, revised 12/06/13, the hospital's Patient Representative shall be involved in the investigation process of patient/family grievances and is appointed to do so by the governing body. The policy stated that a complaint that cannot be resolved by the department in which it occurred converts to a grievance. It stated the purpose of the policy was to establish a written procedure for patients or family grievances to be forwarded to hospital and nursing administration. It stated that at any time the patient had the option to submit a written grievance. Forms should be provided for this procedure. "Patient Rights Grievance Forms" are located in patient areas. It stated that a staff member named in a patient complaint would not interview the patient for investigation/resolution.

According to the Patient Grievances handout form dated 04/13, which is provided to all patients at the time of the admission, to notify patients about the process for filing a grievance and who to notify, grievance forms are available on the units and the patient can complete the form and turn it into the Patient Representative.

1. Patients had to request grievance forms from the staff and turn those forms into the staff on the unit, rather than to the Patient Representative. This process did not protect the patient's identity and confidentiality during the grievance process. The Patient Representative referred grievances, entered on the grievance forms, to the staff on the units to investigate, rather than investigating them his/herself, as required.

a) On 07/14/15 at 10:30 a.m., the Patient Representative (Employee #3) was interviewed about the process used to investigate grievances. Employee #3 stated there were Grievance boxes on the units with grievance forms and patients could place the completed grievance form in the box and s/he picked up the grievances from the boxes on a regular basis. S/he stated there was also a Grievance box in the main dining room. Employee #3 stated that s/he typically refered complaints and grievances to the unit staff for investigation. S/he stated that even if a complaint was in writing or on a grievance form, s/he still considered it as a complaint and only treated it as a grievance and sent a response letter if it was not resolved by unit staff.

Review of the complaint/grievance log generated by the Patient Representative indicated detailed documentation of the nature of the complaint or grievance and who it was referred to, but little or no evidence of investigation about whether the allegations in the complaint actually happened and action taken. When the Patient Representative did treat a complaint as a grievance that had not been resolved, a letter was sent out to the complainant, if the patient was no longer in the hospital.

b) On 07/15/15 at 2:05 p.m., a focused tour of all patient units was conducted to locate the Grievance boxes that were supposed to have blank forms available and a locked box for submitting complaints or grievances to the Patient Representative in a confidential manner. The tour was conducted with the Risk Manager (Employee #1). On the 3rd floor adult unit, Employee #1 went to the location where the Grievance box was previously located and determined that it was no longer there. The Nurse Manager, Employee #11, stated that the box had been pulled off the wall by patients and they were no longer using the box, "because patients keep pulling it off the wall." Employee #11 stated the process for submitting grievances was that the patient had to request a grievance form from staff and then turn it into staff when it was completed and then staff would investigate the complaint or grievance.

A tour of the adolescent unit on the 2nd floor revealed this unit also did not have a Grievance box and there was no explanation as to why the box was no longer being used. Employee #12 stated that the process for patients to file a grievance was that patients must request the grievance form from the staff at the desk and then return it to staff. S/he stated that staff received the grievance and then begin to investigate it on the unit to try to resolve it. S/he stated that it worked better that way, because staff could sometimes prevent issues from turning into grievances.

A tour of the adult unit on the 2nd floor revealed this unit also did not have a Grievance box and there was no explanation as to why the box was no longer being used. Employee #10 stated that the process was that patients must request the grievance form from the staff at the desk and then return it to staff. S/he stated that staff received the grievance and then begin to investigate it on the unit to try to resolve it.

A tour of the main dining room revealed a small box with attached blank forms titled "Suggestion or Compliment." In small letters on the box, it also indicated that grievances could be put in this box, but there were no blank grievance forms available. During the tour it was noted that there was a large, well-secured box on each unit that was titled "Suggestions or Compliments." There was no evidence that there was any problem with keeping the patients from removing these boxes from the wall. These boxes were not used for grievances, per clarification with staff on the units.

c) At 2:30 p.m., on 07/15/15, following the tour, Employee #1 was interviewed and stated that the Grievance boxes should not have been removed from the units and that the process was for patients to be able to write up and submit a complaint or grievance to the Patient Representatives, without staff involvement in the process.
Based on observations, interviews, and document review, the facility failed to provide a safe patient care environment by allowing missing or expired emergency supplies, a lack of monitoring of medication and patient food refrigerator temperatures, undated glucometer testing supplies, and the storage of patients' personal hygiene items with patient medications.

The failures created the potential for patient harm and an increased risk of negative patient outcomes.



According to the manufacturer's package insert for blood glucose test strips for the EvenCare G3 Glucometer, the strips are to be used within 6 months after opening.


According to the facility policy Glucometer Use and Quality Controls, last revised April, 2015, in order to ensure accurate results, manufacturer's instructions are to be strictly followed. The date that glucometer test supplies are opened is to be written on the supplies, in order to calculate the discard date recommended by the manufacturer.

The facility policy, Resuscitation Equipment, states resuscitation equipments is located throughout the hospital for use when patients, visitors, or staff members are found to be experiencing cardiac or pulmonary arrest. Emergency resuscitation equipment is located on each nursing floor and first floor.

The policy, Code Blue, states nursing will ensure crash cart is locked at all times by documenting the lock number on the narcotic sheet on Unit 1. If the lock is removed during a code blue the following procedure will be utilized to replace the lock: a. Replace all items used. b. Replacement locks for the crash cart are stored ...

The policy, Sterile, Dated and Single-Use Supplies, provides guidance to prevent the use of out-dated sterile supplies and equipment and to insure package integrity is maintained. Per policy, night nursing staff are responsible for removing out-dated supplies from the crash cart (checklist is completed nightly) and items that are outdated will be discarded and replaced.

The policy, Medication Refrigerator and Storage of Medication, states patient medications requiring refrigeration are to be stored appropriately and safely at all times in the refrigerators provided for medication on all patient units. Per policy, the refrigerator shall be maintained between 36-46 degrees Fahrenheit and a daily refrigerator temperature shall be recorded on the "Daily Temperature Monitoring Log- Medication Refrigerator". In addition, refrigerators with temperatures outside the acceptable range will be adjusted up or down depending upon the reading. A temperature recheck shall occur in 30 minutes and new temperature recorded. If the temperature remains out of acceptable range call facilities and ask that the refrigerator be evaluated by maintenance.

The policy, Personal Hygiene Supplies, defines guidelines to prevent the spread of infection through communal use of personal hygiene products. Per policy, the patient's name must be clearly marked on their personal hygiene supplies, and placed in patient lock-up to maintain unit safety.

1. The facility failed to ensure the bottles of test strips for each glucometer were dated when they were opened, to ensure the test strips were used within 6 months after being opened.

a) On 07/14/15 at 1:10 p.m., a tour of medication room for the 3rd floor adult unit revealed a bottle of glucometer test strips, located in the case with the glucometer (EvenCare G3), were opened, but the opened date was not noted on the bottle, preventing accurate calculation of the true expiration date for the strips.

b) During the tour of the 3rd floor medication room, on 07/14/15 at 1:10 p.m., the Director of Nursing, Employee #2, was interviewed and stated the bottle of glucometer test strips should have been dated when it was opened. S/he stated this was the expected practice to ensure the strips were not expired and were safe to use.

2. The facility did not supply suction catheters in the crash cart to be available for use during emergencies.

a) During a tour of the facility on 07/14/15, at 1:10 p.m., the code cart located in the staff lounge on the 3rd floor patient care unit was observed. Per the cart label, drawer #3 of the code cart was to contain: gloves- medium and large; stethoscope and blood pressure cuff; oxygen mask and nasal cannulas; suction tubing yankauer oral suction tool; suction catheters; and saline solution. A review of the contents of drawer #3 of the code cart revealed no available suction catheters. At time of observation, the Director of Nursing (DON) reviewed the contents of drawer #3 and all other crash cart drawers, and stated suction catheters were missing from the code cart.

b) A review of the document, Emergency Cart Check Sheet, July 2015, revealed the inventory requirements for the emergency code cart. The check list contained daily documentation of code cart inventory verification from 07/01/15 through 07/14/15, and included the supplies located in drawer #3 and other required resuscitation supplies.

3. The facility allowed emergency resuscitation supplies to remain in place in the code cart, available for use, beyond the manufacturer's recommended expiration dates.

a) During a tour of the facility on 07/14/15, at 1:10 p.m., the code cart located in the staff lounge on the 3rd floor patient care unit was observed. Noted hanging on the side of the code cart was a packaged resuscitation bag with a manufacturer's expiration of 06/2011. Located in drawer #3 were three bottles of sterile saline solution labeled with a manufacturer's expiration date of 05/2015. An emergency eye wash station mounted on the wall near the code cart contained 2 bottles of eye flush solution, both labeled with manufacturer's expiration date of 04/2015.

At time of observation, the DON reviewed the supplies and manufacturer's expiration dates and stated, per policy, code cart checks were completed nightly by the night shift and all expired supplies were to be removed from service and replaced once the manufacturer's expiration dates were reached.

4. The facility did not monitor the patient medication refrigerator and medication room temperatures and did not document actions taken when temperatures were noted as beyond the acceptable range.

a) During a tour of the facility on 07/14/15, at 1:35 p.m., the medication room located on the 3rd floor patient care unit was observed. Upon review of the medication refrigerator/freezer temperature log, dated July 2015, no temperature documentation was noted in the corresponding box for 07/05/15 and 07/11/15.

A review of the document titled, Controlled Room Temperature Log: July 2015, revealed missing temperatures for 07/05/15 and 07/11/15. The room temperature entry for 07/08/15 was noted at 79 degrees Fahrenheit, two degrees above the acceptable range of 68-77 degrees, Fahrenheit. No documentation of corrective action taken or recheck within the acceptable range were noted.

b) An interview at the time of observation, conducted with Registered Nurse (RN) #2, revealed temperature logs required daily documentation and repeat temperatures should be taken following any attempt to bring the refrigerator or room temperatures back within range. RN #2 confirmed missing dates and required documentation when temperatures were noted beyond the acceptable range.

5. The facility allowed patient personal belongings and clean patient supplies to be stored in the same location, increasing the risk of cross-contamination and the possible spread of infectious disease.

a) During a tour of the 3rd floor medication room on 07/14/15, at 1:45 p.m., personal hair care product and a bottle of shower gel body wash were noted to be stored adjacent to medical supplies, tubing, and glycerin sticks on the lower shelf of a cabinet located in the medication room. The personal hair care product and shower gel body wash both contained patient identifying labels.

b) An interview with RN #2 at time of the observation revealed patient owned personal hygiene items were not normally stored in the supply cabinet and were usually placed on the top of the area where the individual drawers containing patient medication was located.

c) On 07/14/15, at 11:15 a.m., an interview with the Director of Pharmacy reviewed the storage of patient owned personal hygiene items on top of the area where individual patient medication drawers were located. S/he did not see a concern unless the patient owned personal hygiene items were leaking. The Director of Pharmacy then stated it was not appropriate for patients' personal hygiene items to be stored in the medication preparation area.

6. The facility did not consistently monitor patient food refrigerator and freezer temperatures.

a) During a tour of the facility on 07/14/15, at 1:40 p.m., the patient refrigerator/freezer temperature log located in the 3rd floor medication room was reviewed. The refrigerator log was missing temperature entries for the dates of 07/03/15, 07/04/15 and 07/11/15. The freezer temperatures were noted to be out of acceptable range at ">= 8" on 07/05/15 and 07/06/15. The freezer was missing temperature checks on 07/03/15, 07/04/15, 07/11/15, and 07/12/15. Per the temperature log instructions, if the temperature is found to be outside of the acceptable temperature range, remove all items and store in an alternative location until corrective action is taken.

b) An interview with Registered Nurse (RN) #2 at the time of observation confirmed the missing temperature checks and out of range temperatures. RN #2 stated patient refrigerator checks were completed by the night shift staff and was unable to determine if corrective action was taken when freezer temperatures were noted outside of the acceptable temperature range.