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 record reviews, it was determined that although the facility had policies and procedures in place to protect patients from abuse, the facility failed to ensure that the policies and procedures were followed by staff for one patient (#1) in the selected sample of three patients.

Findings include:

Observations conducted during a tour of the North and East Units on 02/10/11, from 8:35 AM until 10:00 AM, revealed that staff were interacting appropriately with the patients. No problems were observed.

Review of Patient #1's medical record, the facility's investigation, time sheet records, and the facility's policies and procedures, revealed the facility failed to ensure patients were protected from further abuse while an allegation of abuse was being investigated. Patient #1 reported allegations of abuse on 10/16/10, which allegedly occurred on 10/15/10, by Mental Health Associate (MHA) #1. Review of MHA #1's time sheet records and the facility's daily assignment sheet records, revealed that MHA #1 was assigned to work on North Unit on 10/18/11, which was Patient #1's assigned living unit, while the abuse allegation was still being investigated by the facility. Further record review revealed there was no documented evidence that the Department for Community Based Services (DCBS) was made aware of the abuse allegation

Review of the facility's policies and procedures on "Abuse, Mistreatment, or Neglect" and "Administrative Leave" revealed the facility's policies and procedures were not followed. A review of the "Administrative Leave" policy revealed that "Administrative Leave" is utilized "in the event an internal investigation is being conducted on an employee for neglect or abuse of a client." The facility failed to promptly place MHA #1 on "Administrative Leave" after the allegation of abuse was made by Patient #1 on 10/16/10. Further review of the "Abuse, Mistreatment, or Neglect" policy, revealed that DCBS was to be notified of allegations of abuse and/or neglect by the facility within 24 hours of the incident. Record reviews revealed there was no documented evidence that DCBS was made aware of the abuse allegation

Interview with the Interim Director of Nursing on 02/10/11 at 9:00 AM, revealed MHA #1 should have been placed on "Administrative Leave" immediately after the abuse allegation was made on 10/16/10. She also stated that DCBS should have been notified of the abuse allegation within 24 hours of the incident. She further revealed that she had no answers as to why the policies and procedures were not followed, she stated that she was not the DON during that time.