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 record review the Registered Nurse failed to follow hospital policy and evaluate 7 of 7 patients (Patient #8, #10, #13, #14, #12, #11, #3) according to their needs.

1) Patient #8's vital signs were not obtained prior to being administered emergent medication Benadryl 25 mg [milligrams] and Haldol 5 mg IM [Intramuscular]. Patient #8 fell two hours and five minutes after receiving the medication.

2) Patient #10 fell and sustained an head injury. Neurological checks were ordered and subsequently left incomplete. In addition, Patient #10 was administered Ibuprofen for a headache several hours prior to discharge. No reassessment was completed.

3) Patient #13 was underweight and was surveyor observed to refuse food. The patient complained of nausea and vomiting to nursing staff. Vital signs were not taken until 41 minutes later.

4) Patient #14 was surveyor observed with a swelling and red discoloration on his forehead. Nursing did not assess the patient's head for injuries.

5) Patient #12 had a history of a rare digestive disorder, Superior [DIAGNOSES REDACTED], or SMA. Nursing failed to observe the patient's dietary and fluid intake to prevent dehydration and malnutrition related SMA. A facial wound was left unassessed for healing.

6) Patient #11 was noted to be diabetic on admission. Nursing failed to obtain the ordered blood glucose samples.

7) Patient #3 fell and hit her head on the floor. Ninety minutes passed before the patient was emergently transferred. Nursing did not assess for vital signs, injuries, or neurological deficits during that time. The first assessment of vital signs was completed nine hours after the patient's fall, four hours after her return from emergency care. Although hypertensive at that time, nursing did not reassess the patient's vital signs for another 15 hours until the next morning.

Findings Included:

1) Patient #8's Psychiatric Evaluation dated 12/19/16 timed at 1400 reflected, "admitted to inpatient psychiatric unit for evaluation and management of worsening depression...patient reported that she has not been sleeping well...stating she sometimes stays up three nights in a row with frequent awakenings...patient denied hearing any voices or seeing things or felt people are following her or trying to hurt her..."

Patient #8's Physician Orders and Directions dated 12/20/16 timed at 0040 reflected, "Give Haldol [antipsychotic medication] 5 mg times one dose IM and Benadryl 25 mg times one dose IM for agitation/hallucination."

The Nursing Progress Notes dated 12/20/16 timed at 2345 reflected, "On taking over the shift, patient on the hallway walking so drowsy...resisting to go back to 0040 patient still up not in bed...trying to pick stuff from floor...Dr. notified...received order for Benadryl 25 mg and Haldol 5 mg which was given at 0245 patient fell at the doorway with bleeding from nose...abrasion to upper bridge of nose...non-emergency ambulance called and patient was taken to [medical hospital]..."

On 01/19/17 at 1105 Personnel #7 was interviewed. Personnel #7 was asked to review Patient #8's medical record. Personnel #7 reviewed the medical record and stated the above documentation by hospital personnel did not warrant emergent medication nor were any vital signs taken prior to administering the medication at 0040.

2) Patient #10's Notification of Emergency Detention dated 11/28/16 reflected, "Ran into the street hoping to get run over by a herself out of handcuffs and wrapped the seat belt around her neck..."

The Nursing Progress Notes dated 12/13/16 timed at 1330 reflected, "Patient stated she fell in the hallway...stated she was walking on the hallway for group therapy...her sock slippery fell backwards hit her right head on the floor...neuro signs check initiated..."

The Physician Orders and Directions dated 12/13/16 timed at 1335 reflected, "fell ...initiate neuro signs..."

The Neurological and/or Detoxification Record dated 12/13/16 reflected, "Every two hours times 24 2400 vital signs and level of consciousness, mental status, speech, pupillary size, pupillary reaction, gait, neuromuscular, gastrointestinal and cardiopulmonary signs and symptoms..." The document was left incomplete.

The Neurological and/or Detoxification Record dated 12/14/16 reflected, "Vital signs every two hours times 24 hours due to fall...0200, 0400 vital signs and level of consciousness, mental status, speech, pupillary size, pupillary reaction, gait, neuromuscular, gastrointestinal and cardiopulmonary signs and symptoms..." The document was left blank."

The 12/14/16 Nursing Progress Notes timed at 1440 reflected, "Ibuprofen 200 mg [milligrams] administered at 1435 for headache level 6/10 will follow-up 1715 patient discharged 30 day supply of medications called into pharmacy..." No further documentation was found which indicated an assessment was completed for Patient #10 upon discharge after receiving Ibuprofen for complaint of headache.

On 01/19/17 at 1107 Personnel #7 was interviewed. Personnel #7 was asked to review Patient #10's medical record. Personnel #7 verified Patient #10's neuro checks for 12/13/16 and 12/14/16 were left blank. Personnel #7 further verified Patient #10 was administered Ibuprofen for a headache and was discharged several hours later without being reassessed.

3) Patient #13's Initial Nursing assessment dated [DATE] at 2230 reflected the patient's weight of 106 pounds; she was 5 feet 4 inches tall.

Patient #13 was surveyor observed on 01/18/17 between 0710 and 0730 in the hospital's dining room. Patient #13 sat down at a table with her head down while other patients received their breakfast meal at the tray line and did not eat anything. After return to the unit at 0745, Patient #13 informed Personnel #12 that she did not feel well and had vomited during the night. Personnel #12 stated she would inform the physician. Personnel #12 did not complete an assessment or took Patient #13's vital signs.

Nursing Shift Assessment Notes dated 01/18/17 at 1634 reflected a late entry stating Patient #13 had vomited during the night and complained of nausea and "vital signs were assessed at 0826."

4) Patient #14 was surveyor observed on 01/17/17 at 1450 with swelling and red discoloration on his forehead. When surveyor asked, the patient stated he had "bumped" his head on the wall.

Nursing Shift Assessment and Progress Note, undated, timed at 0830, reflected Patient #14 "became agitated...started to bang head against the wall..." Notes, undated, timed at 0930, reflected that Patient #14 was "banging [his] head on [the] wall at entrance to unit..." There was no evidence of nursing assessing the patient for a head wound.

Nursing Shift Assessment and Progress Notes dated 01/17/17 did not reflect a pain assessment.

Restraint/Seclusion/Emergency Medication Order dated 01/17/17 at 0930 reflected the patient "began to butt head on [the] wall..."

Personnel #7 was interviewed on 01/17/17 at 1535 regarding nursing assessment of Patient #14's swelling. Personnel #7 reviewed the patient's chart and acknowledged and agreed with the findings.

5) Patient #12 was observed on 01/18/17 at 0630 with a left facial wound approximately sized at one inch length. The patient frequently touched the wound and stated it was self-inflicted. The patient was observed with a cup of coffee in her hands. The patient stated she would rather have hot tea because of stomach issues but it was not available.

Patient #12's Physician History and Physical Exam dated 01/15/17, time not legible, reflected the patient had a medical condition, Superior [DIAGNOSES REDACTED].

Psychiatric Evaluation dated 01/13/17, untimed, reflected the patient had Superior [DIAGNOSES REDACTED] and used alcohol and marijuana to "improve her appetite because of her mesenteric problems."

Patient #12's Care Documentation and Nursing Shift assessment dated [DATE] did not reflect the patient's meal intake or amount of fluids consumed. There was no evidence of nursing assessing the wound. Nursing assessed the patient's skin and gastrointestinal systems to be "within normal limits."

Personnel #15 acknowledged the above findings during an interview on 01/19/17 at 0930.

6) Patient #11's Physician's Memorandum of Transfer Orders dated 01/10/17 at 1410 reflected the diagnosis of [DIAGNOSES REDACTED]

There was no evidenced blood glucose documentation in the patient's nursing shift assessments.

Personnel #15 reviewed the chart on 01/10/17 at approximately 1100 and stated the patient refused and "did not get a blood glucose [reading]."

7) Patient #3's Initial Nursing Admission assessment dated [DATE] at 215 did not reflect any patient bruising.

Nursing Shift Assessment Notes dated 12/20/15 did not reflect any vital signs. The notes timed at 0900 reflected the patient "...bent over to pick something up and fell forward hitting head on floor, order to transfer to...[acute care hospital]...911...transfer 1030..." There was no evidence of a nursing assessment of injuries, vital signs, or an assessment of potential neurological deficits.

Nursing Shift assessment dated [DATE] at 1400 reflected the patient returned from emergency medical evaluation and was "resting in bed." Nine hours after the patient fell , nursing documented Patient #3 with a blood pressure of 145/74 mmHg according to nursing notes dated 12/20/15 at 1800. Although considered hypertensive at that time according to the American Heart Association (, Patient #3's vital signs were not rechecked until fifteen hours later on 12/21/15 at 0900.

Notes dated 12/21/15 timed at 0900 reflected the patient had a hematoma on her head. There was no further documentation regarding the patient's head injury.

Hospital Policy entitled, "Assessment and Reassessments of Patients" dated 09/26/16 reflected the procedure that an RN "will reassess the patient based on the patient's least once every shift...when there is a change in the patient's condition, physical complaint..."
Based on record observation and interview, the hospital failed to ensure patients received care in a safe and sanitary environment.

1) Staff failed to ensure that plastic eating utensils potentially breakable and for use in self-harm were not available on the hospital's female adolescent unit
2) The hospital's most critically ill patients had access to an electric outlet without wall plate cover on their unit's dayroom At least one patient was observed in the dayroom without staff presence.
3) Three rooms on the hospital's pediatric male unit and the pediatric female unit day room were in need of paint, cleaning, and/or repair, and
4) Fourteen out of 16 chairs in the open seating area accessible to patients had broken armrests that left them unable to be sanitized.

Findings included:

1) Observations on the hospital's dining area on 01/18/17 at 0710 reflected eight adolescent female patients walked up to the serving line to receive their breakfast meal which included French toast, eggs, and bacon. All patients received a plastic fork with their meal. On 01/18/17 at 0730 all patients had disposed of the refuse on their trays into the trash container.

Personnel #18 was asked by the surveyor how staff ensured that no breakable plastic ware was taken back to the patient unit. Personnel #18 stated that staff members checked the patients' pockets upon return to the unit in case of suspected plastic ware. The patients returned to the unit on 01/18/17 at 0730. None of the nine patients was checked for retained plastic ware by 0745.

2) Observations on the hospital Psychiatric Intensive Care Unit (PICU) on 01/18/17 between approximately 0535 and 0610 reflected the unlocked day room had a cover pulled off one of the electric outlets. Personnel #8 witnessed the findings at that time. On 01/18/17 at 0545 Patient #11 was observed without staff in the day room.

3) Observations on the preadolescent and adolescent boys' unit on 01/17/17 between 1445 and 1530 reflected a baseball-size area of paint was peeled off the wall next to Bed A in Patient Room #314. The wood closet had two laminate boards pulled apart exposing six sharp screws. The wall in Patient Room #301 was soiled. Patient Room # 312's bathroom ceiling had multiple white particles as observed on 01/17/17 at 1448. Personnel #1 stated they were "spit balls."

Observations on the hospital's pediatric girls units on 01/18/17 between 0410 and 0435 reflected the paint underneath the TV console and the white protective molding on the wall were stained. The window sill had areas of peeled off paint. The material of one chair was ripped. The wall encasing the nurses' station had a hole the size of a fist. Personnel #9 acknowledged the findings at that time.

4) Observations of the open seating area in front of the dining room/Intake Department on 01/18/17 at 0535 reflected four tables with chairs identified by Personnel #8 as accessible to patients. The armrests of 14 out of 16 chairs had leather-like fabric peeled off, exposing underlying foam. Personnel # 8 acknowledged the findings at that time.