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, interview, and observation, the facility failed to ensure the patients' rights to receive care in a safe setting for three of three patients (Patients #8, #5, #6) in that

1) Patient #8's wrist wounds were dressed with long gauze wrap which provided a ligature risk for the suicidal patient. The gauze wrap was not hospital identified as contraband and

2) Patient #5 and Patient #6 were involuntarily exposed to cigarette smoke during a scheduled group activity and Patient #6 suffered from a headache afterwards.

Findings included:

1) Patient #8 was observed on 06/11/15 at 13:01 on the hospital's adult unit with both her wrist wounds covered with Kerlix gauze wrap. The patient stated she had cut both of her wrists prior to coming to the hospital.

Hospital Employee #1 was informed of the surveyor's observation of Patient #8 on 06/11/15 at 13:45 and denied that Kerlix gauze wrap was on the contraband list. Hospital Employee #1 stated that, earlier that week, a nurse had refused to dress Patient #8's wounds with Kerlix gauze due to ligature risk.

Hospital Employee #5 stated during an interview on 06/11/15 at 14:01 that she had declined using the Kerlix gauze wrap on Patient #8 earlier that week because "it was a ligature risk" and Patient #8 had made a suicide attempt prior to her hospital admission. Instead of the gauze, Hospital Employee #5 used a dressing pad and paper tape to dress the wounds. At that time Patient #8 took the tape off and stated she would "wait for the night shift, they will use the gauze." Hospital Employee #5 was asked about the length of the gauze used to dress Patient #8's wounds and she responded it was "long enough to hang oneself."

Record review of Patient #8's MOT (Memorandum of Transfer) Physician Note dated 06/06/15 at 13:59 reflected the patient's involuntary admission status after she had attempted suicide by an overdose on sleeping pills and cutting both wrists.

Record review of Patient #8's Nursing Progress Note dated 06/08/15 at "07:35" reflected gauze wrap was used.

2) During observational rounds on the hospital's adult unit on 06/11/15 at 12:35 Patient #5 told the surveyor that the nurse-led education group earlier that morning had been held outside and patients were allowed to smoke during the group. Patient #5 stated the non-smokers had to be separated so far from smoking patients that it was difficult to follow what was said in the group session. Patient #5 stated when she had heard that the group would be conducted outside, she "crinched and almost did not want to go [to group]."

Patient #6 stated on 06/11/15 at 13:18 that she developed a headache from cigarette smoke when patients during the nurse-led education group were allowed to smoke.
Patient #6's Psychiatric Evaluation dated 06/06/15 at 14:11 noted the patient had a history of allergies.

Hospital Employee #6 acknowledged on 06/11/15 at 12:40 that she had led an educational group earlier that morning. The group had been held outside and patients were allowed to smoke during the group session.

Hospital Employee #4 stated on 06/11/15 at 13:10 that patients should not smoke during scheduled group sessions but during unit scheduled smoke breaks.

The hospital's Patient Rights' Policy dated 10/15/11 reflected the policy for patients to have "the right to a humane treatment environment that ensures protection from harm...promotes respect and dignity for each individual."

Based on record review and interview the facility failed to supervise and evaluate the nursing care for one of one patient (Patient #3), an adult, whose admission weight was 84 pounds. Although multiple initial admission assessments acknowledged the patient's low weight and loss of appetite, a nursing nutritional screening was not completed. Daily nursing assessments did not include the patient's weight and the patient's low blood pressure was not rechecked. Daily meal intake documentation was incomplete.

Findings included:

Patient #3's Physician Preadmission Examination Orders dated 10/02/14 at 13:59 reflected the patient reported poor appetite and had daily suicidal thoughts.

History and Physical Exam dated 10/03/14 at 10:15 noted the patient's height of 5 feet 4 inches. The patient's weight was 84 pounds. The medical diagnosis included Scoliosis.

Psychiatric Evaluation dated 10/03/14 noted multiple suicidal thoughts. The patient complained about poor appetite. Admission diagnoses included Mood Disorder and Chronic Mental Illness. The plan of care did not address the patient's low weight.

Inpatient Nursing Admission assessment dated [DATE] reflected the patient's weight of 84 pounds. The nurse nutrition assessment was left blank. The nursing admission summary note reflected the patient "appears to be severely underweight" and "order placed for dietary consult."

Review of physician's orders for Patient #3's hospital stay did not reflect an order for a dietary consult or dietary consult documentation.

The daily meal flow sheet documentation reflected the patient meal intake was not documented on 10/04/14 and 10/05/14. Dinner meal intake was not documented on 10/06/14, 10/07/14, and 10/08/14.

Nursing shift assessments noted Patient #3's blood pressure was 73/50 (on 10/04/14), 95/65 (on 10/05/14), 94/58 (on 10/07/14) and 89/53 (on 10/08/14). There was no documented follow-up to the low blood pressure readings.

On 06/11/15 at 11:45 Hospital Employee #1 stated during an interview that Patient #3 was "very ill, suicidal and emaciated." During a telephone interview on 07/24/15 at around 16:00, Hospital Employee #1 stated she could not find an order for a dietary consult or documentation that a consult was completed.

During a phone interview on 07/28/15 around 09:55 Hospital Employee #8 acknowledged the incomplete meal intake documentation and low blood pressure readings for Patient #3.

Nutritional Support and Assessment Policy dated 11/15/10 noted that "nutritional support is provided to patients based on an initial nutrition screen during the assessment process." The procedure included that "all patients during the preadmission evaluation, initial nursing assessment and physical exam will be screened for evidence of nutritional risk..."