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 review of facility documentation and medical record review (MR), as well as employee interview (EMP), it was determined that the facility failed to ensure the patient's right to receive care in a safe setting in the Inpatient Mental Health Unit and the Emergency Department.

Findings include:

Review, at approximately 2:11 PM on January 16, 2019, of Policy A-100, "Patient Rights and Responsibilities," published on October 23, 2018, revealed, "... Care Delivery Patients have the right to: ... Receive care in a safe setting ..."

A tour of the Inpatient Mental Health Unit was conducted on January 16, 2019, from approximately 12:56-2:00 PM.

1. At approximately 1:50 PM, during a tour of the Inpatient Mental Health Unit, a plastic garbage bag was identified within a garbage can in the Nourishment Room. When asked if the plastic garbage bag was a safety concern for the patients on the unit, EMP3 stated, "Given the volume of people and the amount of waste, it's not really feasible for us to use paper bags for this area. ..."

2. Review, at approximately 11:00 AM on January 16, 2019, of a forwarded internal document completed by OTH3 on December 5, 2018, revealed, "It wasn't until after the patient attempted to hang [himself/herself] in the ED ..."

A tour of the Emergency Department was conducted on January 17, 2019, from approximately 9:30 AM-9:50 AM.

3. During a tour of the Emergency Department, when asked if there was a dedicated area that a suspected suicide patient would be placed, EMP8 stated, "We try to use Exam Room 6 or 13 ..." When asked if suspected suicide patients were ever placed in any of the other bays located within the Emergency Department, EMP8 stated, "Yes."

4. During a tour of the Emergency Department, Exam Bays 1-19 were identified as having non-ligature safe hardware which consisted of non-ligature safe cupboard handles, non-ligature safe call bells, non-ligature safe oxygen stations, non-ligature safe coat hooks, non-ligature safe chairs, non-ligature safe exam lights, non-ligature safe exam tables, non-ligature safe privacy curtains, and non-ligature safe sink and sink handles.

5. The patient restroom was identified to have a non-ligature safe door handle and hinges, non-ligature safe sink handles and plumbing, a non-ligature safe towel rack, a non-ligature safe toilet paper dispenser, and a plastic bag in the garbage can.

6. The Handicap Patient Restroom was identified to have non-ligature safe plumbing under the sink, non-ligature safe grab bars, a non-ligature safe toilet paper dispenser, a non-ligature safe metal table, and a cork board with non-tamper resistant screws.

7. When asked if a suicide patient was permitted to use the Patient Restroom unsupervised, EMP8 stated, "Yes."