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 observations, interviews, and record reviews, the hospital failed to ensure patients received care in a safe setting. This deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for acute care psychiatric patients admitted for being a danger to self or others.


On 9/18/18 from 9:15 a.m. - 9:45 a.m. an observation was made of the patient care units. During the observation the following safety risks were identified in the patient care environment:

a. Elongated water faucets in patient bathrooms with a base wide enough to provide a potential ligature anchor point. These faucets were noted in all patient rooms.

b.Plastic vent grates on the front of the air conditioning units (present in all patient rooms) that could be broken and potentially used for self harm or as a weapon for harm of others. Broken grates were noted in several rooms.

S2UnitMgr, S1DivDirNsg, and S3RegMgt were present during the observations and confirmed the above safety risks in the patient care environment.

On 9/19/18 at 11:45 a.m. an observation was made of the patient care units. During the observation wooden box patient beds were observed. The box beds were noted to be restraint beds equipped with 10 "u" shaped metal handles for fastening limb restraints - 2 handles located on the head of the bed, 2 handles located on the foot of the bed, and 3 handles located in opposing positions on both sides of the bed - 10 potential anchor points for ligature. The beds were also dressed with sheets and blankets. Further observation revealed the restraint beds were located in patient rooms "a", "b", "c", "d", and "e" (a total of 5 beds). S2UnitMgr, S1DivDirNsg, S3RegMgt, and S4SrDirRegulatory were present during the observations and confirmed the above safety risks in the patient care environment.

Review of the current patient census list revealed Patients#R3 and #R4 were assigned to room "a", Patient#R5 was assigned to room "b", Patient #R6 was assigned to room "c", Patient #R7 was assigned to room "d", and Patient#R8 was assigned to room "e". Further review revealed Patients #R3, #R4, #R5, #R6, #R7, and #R8 were all on suicide precautions.

In an interview on 9/19/18 at 12:48 p.m. with S4SrDirRegulatory, she confirmed the above referenced patients assigned to rooms "a", "b", "c", "d", and "e" were all on suicide precautions.

Based on record review and interview, the hospital failed to ensure a patient's discharge plan was re-evaluated for factors that may have affected the patient's continuing care needs or the appropriateness of the discharge plan. This deficient practice was evidenced by failure to re-evaluate a patient's appropriateness for discharge/discharge plan after a change in the patient's condition (patient required restraints and administration of PRN medication for aggressive behavior) on the evening before discharge for 1 (#R1) of 2 (#R1, #R2) sampled patients reviewed for restraint/seclusion.


Review of the hospital policy last revised 10/10/16 titled "Patient Assessment/Reassessment" revealed the purpose is to provide guidelines for an interdisciplinary, collaborative approach in assessing, reassessing, planning, and providing care to meet each patient's individualized needs for treatment. The policy states ongoing reassessment is done throughout the course of the patient's stay with changes to the plan of care as appropriate.

Review of Patient #R1's medical record revealed the patient was a [AGE] year old female admitted on [DATE] with an admission diagnosis of Reactive Depression and secondary discharge diagnosis of Attention Deficit Hyperactivity Disorder and Oppositional Defiant Disorder.

Review of the "Monthly Restraint Logs" for 7/1/18 - 9/17/18 revealed Patient #R1 had required restraints on 8/6/18 after the patient exhibited aggressive behavior against staff . The patient had required placement in a restraint chair and administration of Ativan (anti-anxiety) 1mg IM, Haldol (anti-psychotic) 2.5mg IM, and Cogentin (anti-cholinergic) 2mg IM on the evening before her discharge.

Review of Patient #R1's Discharge Summary, dated 8/6/18 at 1:11 p.m., completed by S6Psych, revealed the following: Patient #R1's discharge condition was documented as stable and described pre-admission aggressive behavior towards the patient's mother. Further review revealed "Documentation on Day of Discharge" ....there are no thoughts of harming self but thoughts of harming others (patient's mother). Discharge Disposition documented as discharge to stepfather who will transport patient to court. The Discharge Summary was written on the day before the patient's discharge.

Review of Patient #R1's nursing notes revealed the following entries:
8/6/18 at 5:00 p.m.: "Upon arrival to the cafeteria patient was acting in an aggressive manner (behavior) screaming at staff, using profanity, continuing to escalate while staff was attempting to escort patient back to unit. Patient was no longer able to be redirected, continued to act aggressively, and therefore was placed in a restraint chair at 5:00 p.m." Patient #R1 was given 3 intramuscular medications for "severe agitation". Physician and family were notified of incident.

8/6/18 at 5:15 p.m.: "patient was taken out of restraint chair due to patient starting to display a more acceptable behavior."

8/7/18 at 7:48 a.m.: Patient #R1 was discharged to court with mother ...

In an interview on 9/18/18 at 4:00 p.m. with S1DivDirNsg, in the presence of S2UnitMgr, she verified there was no documentation in the medical record of a re-evaluation of Patient #R1 following her aggressive behavior on 8/6/18 which had required placing Patient #R1 in a restraint chair and administration of three PRN medications. It was further verified there was no documentation of this event in the patient's discharge summary.

In an interview on 9/19/18 at 9:15 a.m. with S5Psych, in the presence of S4SrDirRegulatory, he stated, after review of Patient #R1's medical record, "Well, she was going to court. Common sense and typical practice would be the patient would not be discharged , unless there was some kind of circumstance, if they were offered a PRN within 24 hours before discharge." S5Psych further stated "That would sound logical" when asked if patients should be re-evaluated following a significant event before discharge.

A request was made to S4SrDirRegulatory on 9/19/18 to schedule an interview with S6Psych on 9/19/18, but S6Psych was unavailable for interview that day. The survey team exited on 9/19/18.