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 a review of facility documentation and staff interviews, the facility failed to ensure well-organized nursing services were provided to all types of patients admitted to the facility as critical nursing service patient care policies had not been adopted and enforced by the director of nursing service and the hospital.

Findings were:

Facility policy entitled Medically Compromised: Early Identification, Observation/Precautions, Interventions and Response & Notification, date issued 5/2013, stated in part:
"Exclusionary Criteria:
The facility Medical and Nursing Staff identify Exclusionary Criteria that describes medical conditions that cannot be managed/treated in the facility, including: ...
2. Total ADL assistance required ...
Director of Nursing/Designee and/or Medical Staff:
Evaluates any patient referred with a serious physical disability or medical condition to determine if the condition can be safely and appropriately managed within a free-standing psychiatric hospital.
Assesses for history of and/or current risk factors/conditions and places patient on 'Medically Compromised' Precautions including, but not limited to: ...
Patients are continually assessed/reassessed throughout their admission to identify medical risk factors or changes in condition that prompt the initiation of/change in Medically Compromised Precautions and level of monitoring ... "
Patient #6 was a patient at the facility from 5/27/14 through 6/23/14.
A Braden Scale for Predicting Pressure Sore Risk performed on 5/27/14 for Patient #6 revealed the following:
A Moisture score (degree to which skin is exposed to moisture) of 4 - the highest score possible score and described as "4. Rarely Moist - skin is usually dry, linen only requires changing at routine intervals."
A Mobility score (ability to change and control body position) of 4 - the highest possible score and described as "4. No Limitation - makes major and frequent changes in position without assistance."
A Friction Score of 3 - the highest possible score and described as "3. No Apparent Problem - moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair."

The highest score possible on the Braden Scale is a 23. Patient #6, a wheelchair bound patient with [DIAGNOSES REDACTED], received a score of 23.

The clinical record of this patient included the following nursing progress notes:
6/2/14 AT 7:00 p.m. - "Pt. was given a full body shower & peri-care. Pressure sore noted to Rt buttock 4 cms long (dark reddish). MD was notified & zinc oxide was ordered ...Attending groups. Pericare given at 1840 prn. Pt placed in bed at this time monitor pt..."
6/22/14 at 6:45 p.m. - "Pt continues [with] a stage II pressure ulcer to L buttock. Approximately 1 cm in diameter. No drainage or foul smell to site. Zinc oxide applied to buttocks..."

Between these dates, nursing documentation of skin care provided Patient #6 was sporadic and minimal. She was discharged on [DATE].

Staff #7, an LVN who provided care to Patient #6 during several hospital admissions, was interviewed on the afternoon of 6/30/15 in the small facility meeting room. She stated, "I remember this patient. She's been here several times - she was here not that long ago. She's in a wheel chair. She can't walk. If I remember, she has [DIAGNOSES REDACTED] and needs complete, total care ...I think it's usually that we turn patients every two hours if they need it ...I think we document that in a progress note ... "

In an interview with the facility Performance Improvement/Risk Management Director on the afternoon of 6/30/15 in the small facility meeting room, she confirmed the patient had been admitted to the facility a number of times. When asked to provide nursing policies regarding care of patients requiring total assistance, skin care provision, maintenance of skin integrity, or of pressure sore assessment or risk assessment, or of nursing documentation of skin care, she stated the facility did not have policies regarding these topics.

These findings were again confirmed in an interview with the facility administrator and other administrative staff on the afternoon of 6/30/15 in the facility conference room.