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 interview and facility policy review, it was determined the facility failed to ensure a safe environment for the patients on the adolescent girl unit within the facility when an incentive program was put in place for patients to use brooms, dustpans and bleach wipes to clean so they could earn snacks. These items were considered contraband and could harm the patients if use inappropriately.

The findings include:

Review of the facility policy titled, "Hazardous Materials Management Plan, last revised 01/2016, revealed the Hazardous Material and Waste (HazMat) Management Plan describes the methods for handling hazardous materials and waste through risk assessment, management and regulated processes. The plan assesses the risks associated with those materials, wastes, or energy sources that can pose a threat to the environment, staff, and patients. The program was also designed to assure compliance with applicable codes. The processes include education, procedures for safe use, storage and disposal, and management of spills or exposures. The program was applied to all locations where patients are treated and/or employees perform work function.

Review of the facility policy titled "Patient Rights", dated 01/2015, revealed the patient has the right to receive care in a safe setting.

Review of the facility "Contraband" list, not dated, revealed contraband was weapons or anything that could be used as a weapon or any other item deemed potentially dangerous by staff.

Interview with Mental Health Technician (MHT) #1, on 03/16/16 at 12:06 PM, revealed on 02/28/16 she had talked with the Director of Nursing (DON) about using an incentive program for chores that would result in rewards of snacks for the adolescent girls. She stated this was a voluntary program and not mandatory. She stated she did not think the items used for the chores (broom, dustpan and bleach wipes) would be considered contraband. She stated she did not have concerns with the girls using the broom, dustpan or bleach wipes as she supervised them and never had a problem or incident with the use of the items. She stated she made sure the patients using the bleach wipes washed their hands thoroughly after completing the task.

Interview with MHT #4, on 03/17/16 at 10:39 AM, revealed housekeeping was the department responsible for cleaning the units, rooms and bathrooms and the bleach wipes, brooms and dustpans were locked in the housekeeping closet. He stated he thought the brooms, dustpans, and bleach wipes would be considered contraband.

Interview with the Director of Nursing (DON), on 03/17/16 at 10:50 AM, revealed the incentive program was started by MHT #1 and she had talked to her about doing it as a pilot program with snacks as incentives for the adolescent girls. The DON stated MHT #1 had been doing this program with the patients before she talked to her about it and she had not been made of any concerns with the pilot program until recently. She revealed the patients get points as a part of the status program, and feels that this was an extension of the incentive program. The DON stated when MHT #1 talked to her about the program it did not dawn on her that the MHT was speaking of using brooms and bleach wipes; as these items are not necessarily safe items for the adolescent groups. The DON revealed the weekends tend to be a little less structured than during the week and they were trying to find ways to help the weekends be structured as well.

Interview with Risk Manager, on 03/16/16 at 9:25 AM and on 03/17/16 at 1:44 PM, revealed the snack incentive program was not being used at this time but it had started around June or July of 2015 and was used only on the girls ' adolescent unit. She stated MHT #1 would bring in snacks such as cupcakes and sodas as an incentive for the girls if they wanted to clean but the girls did not feel like they had to. She further stated brooms, dustpans, and bleach wipes were being used during the chores and the patients should not have had access to these items. She stated a broom, dustpan or bleach wipes would be for Housekeeping or staff use only, not for patients.

Interview with the facility Administrator, on 03/17/16 at 2:39 PM, revealed he started at the facility on 02/22/16 and she was unaware of the incentive program that MHT #1 was using with the girls.