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 and interviews it was determined the facility failed to provide care in a safe setting. The facility failed to ensure patients on the Children's Unit ate in a clean environment. This places all patients on the Children's Unit at risk for harm.

Findings include:

A. On 2/10/20 at 1:42 p.m. the surveyor, the Director of Quality and Risk Management and the Clinical Auditor reviewed video tape. The tape showed the Children's Unit and was date and time stamped 1/31/20 4:30 p.m. to 4:50 p.m. The video showed patient #26 eating off a tray sitting on the floor in front of the nurse's station. The patient was surrounded by blocks on the floor and frequently left the tray and went up and down the hall before touching the tray. The video showed a female patient picking up the tray and carrying it down the hall. During this time period behavioral health technician #1 and Registered Nurse #1 observed patient #3 while he was eating from the tray on the floor. Neither of them intervened.

B. An interview was conducted on 2/11/20 at 9:42 a.m. with the Children's Unit psychiatrist. She stated children sometimes eat their meals away from the day room. She revealed her expectation is for small children who eat away from the day room to either eat in the time out room, on a chair or on the bed. The psychiatrist stated small children as young as eight (8) years old should not be eating on trays sitting on the floor. (It was noted patient #26 is five (5) years old.)

C. An interview was conducted with the Nurse Manager of the Tween and Children's Units on 2/11/20 at 10:50 a.m. She stated if she had witnessed the situation shown on the video as described she would have intervened. She concurred a child eating off a tray placed on the floor in front of the nurses' station was a situation that should not occur.
Based on document review, medical record review and interviews it was revealed the hospital failed to include a discharge planning evaluation for one (1) of thirty (30) patients (patient #1) in the medical record. This failure has the potential to adversely affect all patients who require an evaluation for discharge planning.

Findings include:

1. A review of the hospital policy entitled 'Treatment Team,' effective date 8/2/18, revealed in part: "Treatment team will address discharge planning ...A secure discharge plan will be discussed, finalized, and ultimately approved by the attending physician prior to discharge, which includes, but is not limited to: safe, appropriate housing/living situation/placement, appropriate referrals and appointments scheduled in reference to step-down programs/outpatient aftercare services, safe/scheduled transportation to discharge placement, consent obtained by guardian involved (if applicable), and thorough documentation of these services provided ..."

2. A review of patient #1's medical record revealed no documentation of a discharge evaluation present in the record.

3. An interview conducted with the case manager on 2/11/20 at approximately 8:35 a.m. revealed he had worked with the physician and the patient on placement options and was not aware the documentation was not in the patient's record.

4. An interview was conducted with the Director of Quality/Risk Management on 2/10/20 at approximately 3:00 p.m. and she concurred the discharge planning documentation was not in the medical record.