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 observation and interview, the Facility failed to provide a safe care environment for patients in their secured Behavioral Health Unit.

Findings include:

The Surveyors toured 2 South, the secured Behavioral Health Unit, on 8/13/18 at 8:29 A.M. The Surveyors observed the doors entering each patient's room (nine Rooms total) and the door entering the dining room contained three separate hinges with a space of a 1/4" on the inside of the door jam above and between the hinges that presented as a ligature risk.

The Surveyors observed that the door leading from the patient television room onto the outside porch could not be opened. The Interim Director of Behavioral Health unlocked the door but could not push it open. The Interim Director of Behavioral Health said that due to the humidity the door was swollen shut and could not be opened. The Interim Director of Behavioral Health contacted Maintenance and, after two attempts, pushed the door open. The Surveyors entered the outside porch area attached to the television room. The porch was enclosed with plexiglass plastic windows screwed into a frame. The Surveyors observed one of these windows (sixth window from left to right facing outward) that could be pushed open from the top of the window. The Surveyors also noted a pipe that ran along the center of the ceiling which separated from the ceiling toward the front of the porch and presented as a ligature risk.

The Surveyors interviewed the Maintenance Manager on 8/13/18 at 11:30 A.M. The Maintenance Manager said that the doors in the hallway and the bathroom doors were all being replaced and presented two order forms for their replacement dated 4/12/18 and 7/16/18. The Maintenance Manger said that the hinges to the Patient's rooms were not ordered. The Maintenance Manager said that the hinges were not identified as something needing to be replaced. The Maintenance Manager acknowledged that he did not have a plan in place to address the sticking doors and did not identify the hazardous areas on the outside porch.