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 record review, and staff interviews, it was determined the hospital failed to ensure 1 of 8 patients, whose records were reviewed, was included in the development and implementation of her plan of care. This resulted in care decisions without the input of the patient. Findings include:

Patient # 6 was a [AGE] year old female who was admitted to the facility on [DATE], at 9:38 AM for suicidal ideation. She was discharged on [DATE], with diagnoses of Posttraumatic stress disorder, and borderline personality disorder.

Patient # 6's record included telephone orders on a form titled "MEDICATION ORDERS & RECONCILIATION RECORD," dated 12/16/17 at 7:46 PM, 14 hours prior to admission. The orders were signed by the psychiatrist who gave them on 12/18/17 at 9:15 AM. The form listed all the patient's current medications from home. The form stated Patient #6 took Dilaudid 2 mg, 3 times a day as needed for pain, and Percocet 5/325 mg, every 4 hours for severe pain. Both medications were stopped on admission to the facility. Plain Acetaminophen (Tylenol) was ordered instead. No assessment of Patient #6 by a physician or nurse practitioner was conducted before making the decision to stop the narcotic pain medications.

Patient # 6's medical record included an "INTAKE ASSESSMENT," dated 12/17/18, at 11:50 AM that stated Patient # 6 rated her pain with an intensity of 8 out of 10. The intake assessment also stated she had a history of chronic pain. Under the section of "Stressors & Precipitants" it listed chronic pain as one of the most significant stressors to the current hospitalization and past suicide attempts for the patient.

Patient #6's record included a nursing assessment, dated 12/17/18, at 1:00 PM. Under the section titled "PAIN ASSESSMENT" it was documented the patient is currently having pain with an intensity of 7 out of 10. The documented assessment of pain did not include an objective evaluation of pain by the nurse, the duration of Patient #6's pain, or how long the patient had been taking opioid pain medications prior to admission to the facility. There was no documentation of interventions attempted for her current pain or notification to the physician of her complaints.

Patient #6's record included a nursing flow sheet, dated 12/17/17, at 5:30 PM. It stated Patient #6 had a pain level of 7 out of 10 and the patient was upset about not receiving her pain medications. The nurse documented that she explained to the patient some of her medications were held as ordered by the physician until they could be reviewed. The note stated Patient #6 was focused on her pain management. There was no documentation the nurse contacted the physician regarding Patient #6's concerns of pain management.

During an interview with the day shift RN, beginning on 1/23/18 at 11:25 AM, the RN stated Patient #6 complained of pain all morning on 12/17/17. She stated she did not contact the Physician or Nurse Practitioner for additional orders to address the patients pain.

A nursing flow sheet dated 12/17/17, included a nursing note timed at 9:00 PM. It stated Patient # 6 was found on the floor in her room, unresponsive. It also stated her roommate found the patient on the floor but did not hear her fall. The nurse assessed the patient and documented that she was responsive within 5 min of discovery, could bear weight, and was assisted to the bathroom. The nursing note, timed 11:00 PM stated that the patient was angry and said she had reported auras (a perceptual disturbance experienced by some with migraines or seizures before either the headache or seizure begins) to the day shift nurse. The note stated the patient complained the day shift nurse had ignored her complaints. The note stated the nurse called the physician, who placed Patient #6 on a detoxification protocol.

Patient #6's medical record included a psychiatric evaluation by the patients Physician, dated 12/18/17 at 9:49 AM. The evaluation included a list of the patient's current medications which stated, "She is on various opiates as well". The evaluation stated the patient also had nonspecific pain issues in multiple areas, and that the physician was hesitant to keep her on opiates. It also stated, the patient had an unobserved seizure in her room and then was put on a detoxification protocol. The evaluation did not include a pain history or what Patient #6 thought about the plan for pain.

A history and physical dated 12/18/17, at 12:01 PM, signed by Nurse Practitioner A, stated that the patient had chronic pain issues, the Nurse Practitioner gave an order to stop the detoxification protocol and start patient on Percocet 10/325 mg every 6 hours as needed for pain and Ativan as needed for seizures.

During an interview with Patient #6's physician on 01/23/18, at 10:30 AM, when asked if he saw the patient on 12/17/17, he stated that he rounds daily. He stated he did not examine Patient #6 on 12/17/17. He said he most likely rounded before the patient was admitted to the facility on [DATE]. He also stated, he received a call from the nurse on the night of 12/17/17 about Patient #6's seizure and he then put her on a detoxification protocol. When asked why the detoxification protocol was stopped the next morning he stated Nurse Practitioner A stopped the detoxification protocol and started her on Percocet without consulting him. Patient #6's physician confirmed that he did not see the patient or discuss her pain management plan of care with her on 12/17/17.

During an interview with Nurse Practitioner B on 1/23/18, at 11:50 AM, he stated he rounded on patients on 12/17/17, and ordered a Tegretol level, a laboratory test, for Patient #6. He stated he but did not see Patient #6 or assess her for pain. He stated Patient #6 was not on his list of patients to see.

There was no documentation Patient #6 was included in the development and the implementation of her pain management plan of care.