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 medical record review, staff interview and document review it was determined the Quality Assurance/Performance Improvement Director failed to monitor one (1) episode of a potential to cause self-harm in one (1) of one (1) record reviewed involving self-harm (patient #1). This failure has the potential for all patients to have the ability to cause self-harm.

Findings include:

1. Review of the medical record for patient #1 revealed during an individual therapy session on 04/17/17 at 9:16 a.m., the patient told her therapist (therapist #1) that she had unscrewed two (2) screws from the toilet and had given them to one of the workers on the unit. When patient #1 was asked if she used them she told the therapist no. Therapist #1 documented three (3) scratches with scab noted on patient's left forearm.

2. An interview was conducted on 6/12/17 at 11:37 p.m. with therapist #1. When asked to explain any self-harm behavior patient #1 exhibited during her hospitalization , she stated, in part: "She would take her fingernails and dig them in her skin and there was an incident where she got some screws from the toilet and turned them in but she didn't harm herself with them."

3. An interview was conducted with Behavior Health Technician #1 (BHT) on 6/14/17 at 7:57 a.m. When asked if she remembered patient #1, she stated, "Yes." When asked if she remembered an incident involving the patient with screws and if so to please explain, she stated, "Yes, I was working when that happened and she gave the screws to the other BHT and then we went to the bathroom and checked to make sure that was all of the screws missing; we checked her body and she only had her scabbed areas on her arm from scratching herself." When asked if she reported it to any one, she stated, "Yes, I filed a work order to have the screws replaced and the other BHT told the charge nurse and they filled out the paper work."

4. An interview was conducted on 6/14/17 at 8:41 a.m. with BHT #2. When asked if he remembered an incident involving the patient with screws and if so to please explain, he stated, "Yes, the patient brought me two (2) screws and said she got them out of the bathroom in the hallway and when asked if she harmed herself the patient stated no." When asked if he checked her for any harm to herself, he stated, "The other BHT and nurse did." When asked if the supervisor was contacted, he stated, "Yes, I know she was because I had to sign the form to say what happened."

5. Review of a policy with a section noted under "Risk Management", last reviewed 01/23/16, revealed it states, in part: "A report should be completed by any staff member who witnesses, discovers or has direct knowledge of an incident...The Director of Quality will complete an investigation and follow-up."

6. A joint interview was conducted on 6/14/17 at 10:30 a.m. with the Director of Quality and the Director of Nursing. When asked if they could find the event record on the patient, the Director of Quality stated, "No, we have looked everywhere and can't find it." They both concurred with the above findings.