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, document review, and staff interviews, the hospital's administrative staff failed to establish and maintain a safe environment by not implementing staggered start locations and times for patient safety rounds for 32 of 32 patients on the psychiatric units. The psychiatric unit of the hospital identified a census of 20 patients at the beginning of the survey.

"Rounding" is a term used when staff make periodic special observations of patients with a psychiatric diagnosis who reside on a psychiatric unit. Staff periodically make these observations as they "round" (walk) the unit.

Failure to implement a system of 10-minute or 15-minute observations where patient's could not predict the order of the rooms or the exact period of time when observations would be conducted could potentially result in patient's predicting the frequency and knowing the amount of time they would have to engage in inappropriate behavior, harm themselves, or attempt suicide before the next scheduled observation. This could potentially result in inappropriate patient behavior, patient death or other life-threatening conditions.

Findings include:

1. Observation on 7/9/2019 at 2:43 PM to 3:01 PM of psychiatric unit staff performing rounding safety checks on the psychiatric unit revealed a form with the time pre-printed in 15-minute increments for child and open adult unit and 10-minute increments for special care unit. Documentation showed that staff failed to document the actual times they observed patients or where they began and ended their observations.

2. Review of the forms titled "Child/Adolescent Patient Rounds" and "General Adult Patient Rounds," dated 12/18, revealed in part Precautions monitored every 15 minutes with columns of pre-printed times starting with the hour and every 15 minute increments.

Review of the form titled "Special Care Unit Patient Rounds," dated 12/18, revealed in part Precautions monitored every 10 minutes with columns of pre-printed times starting with the hour and every 10 minute increments.

Each preprinted time is followed with a blank space to document the code of the patient's location and a blank space for the staff member completing the rounds to document their initials.

3. Review of policy titled "Intentional Patient Rounds," revised 9/2018, lacked instruction to vary the safety rounds route and timing within the 10 or 15 minute time frame to prevent patients ability to predict the next scheduled observation.

4. During an interview on 7/8/2019 at 4:50 PM, Staff A, Mental Health Technician, verbalized the rounds are staggered to start at different locations so patients were not able to time the rounds being conducted.

During an interview on 7/9/2019 at 9:15 AM, Staff B, Unit Supervisor, revealed the preprinted time on the "Patient Rounds" form was not the actual time the patient was observed. The "Patient Rounds" form does not allow staff to enter the time the actual observation takes place.

During an interview on 7/9/2019 at 2:52 PM, Staff C, Certified Nursing Assistant, verbalized the rounds are completed close to the pre-printed times on the forms and initial the patients location and not the actual time of the observation.

During an interview on 7/9/2019 at 3:01 PM, Staff D, Float Technician, verbalized staff stagger the starting locations of the patient rounds and do not document the actual time the patient observations are made.