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.


Base on record review, interview and observation, the hospital failed to provide a safe environment for 5 of 21 patients (Patients #18, #19, #20, #9, #2).

1) Patients #18, #19, and #20 occupied rooms with metal framed beds and electrical cords which could potentially pose a safety hazard and/or ligature risk for those patients who required inpatient psychiatric treatment for their mental illness.

2) Patient # 9 was bit by Hospital Personnel #14 during a restraint incident on 01/14/16. Although Hospital Personnel #14 did not follow hospital policy of emergency behavior management, the employee was allowed to continue his shift for additional four hours on a different unit before administration suspended him.

3) Elderly Patient #2 was ambulatory on admission. Two days into her hospitalization , the patient fell twice within seven hours and required emergency medical evaluations. Although unable to bear weight, unresponsive and shaking for a brief period of time, and noted to be with a dangerously low blood pressure after her second fall, Patient #2 had to wait for approximately 105 minutes to be transported to the medical center.

Findings included:

1) Observations on 03/21/16 between 16:30 and 17:20 reflected patients occupied Rooms #119, #120, and #121 that had metal framed beds and electrical cords. The rooms were assigned to Patients #18, #19 and #20.

Pants with strings and a plastic spoon were observed in Room 121 on 03/21/16 at 16:40. Hospital Personnel #3 stated at that time that those items were "not supposed to be there."

Patient #18's Inpatient Admission Orders dated 03/18/16, untimed, reflected admission diagnosis of Mood Disorder. Intake screening documentation, undated, timed at 19:25 reflected an involuntary admission. Patient #18 was noted to be a danger to herself.

Patient #19's Inpatient Admission Orders dated 03/17/16 at 22:05 noted diagnoses including Bipolar Disorder, manic, with psychotic features. Admission staff was unable to assess Patent #19's suicidality. The patient was too psychotic.

Patient #20's Intake assessment dated [DATE] at 16:02 reflected a patient statement that she was "severely depressed...drinks because of depression..."

Hospital Personnel #3 and/or #15 accompanied the surveyor during the tour and acknowledged the observations. Hospital Employee #3 stated on 03/21/16 at 16:40 that the hospital had eight metal-framed beds.

2) Patient #9's Physician Discharge Summary reflected an admission date of [DATE] and a 01/19/16 discharge date . Admission and discharge diagnoses included Major Depressive Disorder.

Progress Notes dated 01/14/16 at 23:00 noted that Patient #9 "...received a bite mark during the admission process."

Hospital Personnel #8 stated during an interview on 02/10/16 at 16:40 that a patient "bit a tech [mental health technician] and the tech bit the patient."

Hospital Personnel #3 stated on 02/10/16 at 16:40 that Patient #9 was restrained in the Intake Department's lobby on 01/14/16 at 19:40. Patient #9 during the restraint bit Hospital Personnel #14 who "bit back."

Hospital Personnel #7 stated on 02/10/16 at 17:00 that Hospital Personnel #14 did not follow the hospital's emergency behavior management procedures and bit Patient #9 on the right shoulder during a restraint. Pictures showed bruises on Patient #9's right shoulder. After the incident Hospital Personnel #14 "was sent back to his unit and continued his shift." The employee was then suspended and did not return to work.

Record review of Hospital Personnel #14's time card reflected he started his 01/14/16 shift at 16:00 and left at 23:50. There was no time recorded for Hospital Personnel #14 after 01/14/16.

3) Patient #2's Pre-Admission Exam and Certification dated 12/10/15 at 16:43 noted the patient was admitted with a chief complaint of "delusional."

Multidisciplinary Progress Notes dated 12/10/15 at 20:37 reflected Patient #2 "arrived on the unit, ambulatory, with upright gait."

Multidisciplinary Progress Notes dated 12/12/15 at 15:25 reflected Patient #2 wandered the halls "where she bent to pick up items from the floor in front of another patient...[who] came out of his room, hollering, and pushed ...[Patient #2] to the floor...[physician on unit] gave order for...[Patient #2] to be sent to ER [emergency room ] for evaluation ..."

Multidisciplinary Progress Notes dated 12/12/15 at 17:07 reflected that nursing staff gave report to the acute care hospital ED [emergency department] and "...EMS [emergency medical services] left unit with...[Patient #2]" approximately 102 minutes after the incident.

Multidisciplinary Progress Notes dated 12/12/15 at 20:20 noted the patient returned to the unit "from ED due to injury."

Three hours and twenty minutes later, on 12/12/15 at 23:40 nursing staff noted the patient fell , had a blood pressure of 82/57, was "unable to bear weight...there was a period where [Patient #2] did not respond to staff and began to shake for 5 seconds ...EMS called ..." The notes reflected that EMS were "on the unit for transport" on 12/13/15 at 01:25, approximately 105 minutes after the patient fell . Patient #2 returned from the acute care hospital ED about four hours later on 12/13/15 at 05:35.

Multidisciplinary Progress Notes dated 12/13/15 at 09:30 reflected Patient #2 left the hospital per her family's request. The family had informed nursing staff that Patient #2 was "not safe" at the hospital.

During an interview on 03/21/16 at 14:45 Hospital Personnel #3 reviewed Patient #2's chart and acknowledged the findings.