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 interview and record review, the facility failed to investigate grievances for 4 of 5 patients per facility policy (Patients #9, #16, #22, and #15).


Record review of facility policy titled "Patient Complaint and Grievance Process" dated 03/23/18 stated: A written or verbal complaint by a patient, or the patient representative would be responded to the complainant within 7 days. If the grievance was not resolved, the facility shall send a response stating that the facility continues to work to resolve the complaint ...with another response within seven days.

Patient # 9:

Patient # 9 was released from the facility prematurely in an unstable condition on 2 separate occasions and the facility did nothing to investigate or acknowledge the complaint.

Further review of the complaint revealed, the family had faxed grievance letters to the facility on two separate occasions (10/6/18 & 10/9/18) and had receipt confirmations that the faxes were received.

Record review on 11/27/18 at time of survey, the Complaint/Grievance Log 2018 of the facility failed to reveal any documentation of complaints/grievances regarding Patient #9.

In an interview on 11/27/18, at 9:45 am, Quality Director (QD) Staff #3 stated, she was unaware of any complaints or grievances regarding Patient #9. QD Staff# 3 confirmed the fax number to nurse's station was correct, and was shown confirmation documentation that the faxes were received on 10/6/18 and 10/9/18. QD Staff# 3 then stated she was left "out of the loop" and never received anything.

Record review on 11-27-18 of facility Grievance Log for 2018 showed 4 documented grievances. Detailed review of 3 of the 4 with no investigations was as follows:

Patient # 22:

Record review of a written complaint from Patient #22 (undated) alleged another patient threatened her life, causing her "major anxiety," therapy sessions were not taking place as scheduled, and staff did not act quickly to help calm her.

Patient # 16:

Record review of a patient #16's written grievance dated 11/16/2018 revealed the following:

-She did not feel safe in the facility due to "multiple verbal altercations" in multiple instances and alleged that staff did not handle the altercations appropriately.

-Several Group therapy sessions in the evenings did not take place as scheduled.

-Multiple environmental issues including the temperature in the facility, lack of hot water for showering.

-Delay in receiving pain medication

-Several dietary issues.

Patient # 15:

Grievance dated 10/23/2018 from Patient#15 revealed, she had lost her glasses at admission check-in on 10/16/2018. The patient asked the facility to replace her glasses.

In an interview on 11/27/18/at 10:40 am with QD Staff# 3, she stated that all four grievances and any investigations should all be contained in the Grievance Log book.

Record review of Grievance Log book failed to reveal any investigations were done for all 4 patients (#9, #16, #25, #15). There was no documentation elsewhere that the facility responded to and investigated any of these complaints.
Based on observation, interview, and record review, the facility failed to ensure safety requirements were met for all current patients. The facility failed to ensure:

1. Close Observation rounding sheets (that indicated safety precaution levels) were accurately completed; and

2. Policies & procedures were developed for all precautions levels listed on the rounding sheets.


Accurate completion of Close Observation sheets:

On 11/27/18, at 9:00 am, record review of physician orders for Patient #4, #10, and #12 revealed they were on Suicide Precautions, and Patient # 6 was on Homicidal Precautions.

On 11/27/18, at 9:30 am, record review of patients' "Close Observation" rounding sheets revealed no indication that Patient #4, #10, and #12 were currently on suicide precautions and that patient # 6 was on Homicide precautions.

In an interview on 11/27/18, at 9:45 am, with Behavioral Health Staff (BHS) Staff #10, she stated that the Close Observation rounds sheets should have indicated that these four patients (#4, #6, #10, and #12) were either on Suicide or Homicide Precautions.

Review of facility policy titled "Suicide Precautions" dated 1/2017 stated " ...Every 15 minutes observation: .....involves continuous monitoring every 15 minutes on the Observation Record, with check marks documenting such".

Lack of policy development related to all precaution levels utilized:

Record review of facility "Close Observation" rounding sheets" revealed the following types of precautions listed:

1. Assaultive precautions
2. Fall precautions
3. Q (every) 15 minutes
4. Unit Restrictions (UR)
5. Self Harm (SH)
6. Sexually Acting Out (SAO)
7. Suicide Precautions
8. Elopement Precautions (EP)
9. 1:1
10.Line of Sight
11. Other (written in as "HI": Homicide precautions)

On 11-28-18, facility quality director was asked to provide all the polices related to the observation levels currently utilized by the facility, as were pre-printed on the "close observation" sheets.

On 11-29-18, record review of the documents provided revealed policies that addressed: Q 15 minute observation; Suicide precautions; and Line of sight observations.

There were no policies that addressed: Assaultive precautions, Fall precautions, Unit Restriction (UR), Self Harm (SH), Sexually Acting Out (SAO), Elopement Precautions (EP), and Homicide Ideation precautions.
Based on observation, interview, and record review, the facility failed to investigate, analyze & implement preventative actions related to an incident that involved a combative /assaultive patient (citing Patient # 23).

The facility failed to identify the current furnishings in the day room were hazards for behavioral health patients.

The facility did not have a policy that addressed the investigation and preventative actions related to occurrences/incidents.

Findings include:

Record review of facility's Occurrence Log for 2018 showed a documented incident, dated 10-16-18 that read :" pt (#23) returned from hospital & became angry. Pt became combative & aggressive. Pt threw a chair & attempted to throw day area table. Pt also attempted to break (unfinished sentence).."

The Occurrence Log had a column with heading "Corrective Action".. Under this column for the incident that involved Patient # 23, it was documented: "pt returned from hosptial, no new orders."

Further review of the Occurrence binder failed to reveal a completed occurrence report and a corresponding investigation.

In an interview on 11/27/18 at 10:40 am with QD Staff #3, she stated that the Occurrence Binder 2018 contained all of the occurrence documentation, including investigations.

The facility failed to investigate the incident with Patient # 23; and failed to identify the furnishings in the day room were hazards for all behavioral health patients.

Observation on 11/27/18, 11/28/18, and 11/29/19, during the survey revealed there were 27 normal weight chairs with metal legs and frames. These chairs were located in the common area day room as well as the Group Therapy room. Further observation revealed a large table for patients in the common area was not bolted down to the floor and was moveable. These furnitures can be used by patients to harm other patients and staff.

In an interview on 11/29/18, at 10:30 am, with Plant Operations Manager Staff # 12, he stated he was unaware that the majority of the patient chairs were light-weight, and acknowledged these chairs were easy for the average person to lift and throw.

Record review of facility policies titled: "Incident Report Protocol," dated 01/2017 and "Occurrence Report Protocol,"dated 01/2017 , failed to address the investigation and implementation of preventative actions related to occurrences/incidents.
Based on interview and record review the facility failed to address an assessed need prior to discharge. The facility failed to follow its established process for contacting adult protective services (APS) for patient ID #8.

Finding Include:

Record review of current facility policy "Suspected Child/Elder Abuse Report" dated 3/2017 stated: "Providers who have actual knowledge of elder abuse...must report the suspected instances to elder/child protective agencies, within 24 hours..".

Record review of patient (ID#8) medical record review of interdisciplinary note dated 05/06/18 (timed 1755- 1855) by the Licensed Professional Counselor ( ID#15) revealed: The patient (ID #8) stated her husband beat her regularly.
Staff (ID #15) stated he would report to Adult Protective Services and notify staff.

Record of interdisciplinary note date 5/10/2018 by the Case Manager (Staff # 20), stated in the note the patient (ID # 8) was discharged to a personal care home and had an open APS (Adult Protective Service) case, and the owner agreed.

Interview with on 11/29/2018 at with Staff (ID #11) she stated: "I do not see a case number and the therapist should have a written note with a case number and an outcome".

Based on observation, interview, and record review, the facility failed to maintain a safe environment for patients in the inpatient hospital and the off-site partial hospitalization program (PHP) location.

1. The facility failed to correct the environmental and safety issues cited during the 09-12-18 survey;

2. Additional environmental and safety issues were identified on 11-27-18 to 11-29-18 survey.


PHP Location:

Observation on 11-28-18, at 9:15 a.m., outside a large conference room, surveyor's shoe caught on a piece of laminate flooring that was "bowed up." Surveyor tripped and almost fell .

Interview at the same time with Plant Operations Director # 12, he stated the flooring was recently put in; he would address the issue immediately.

At the time of this occurrence, approximately 60 patients were present in the PHP, some utilizing assisstive walking devices.

Continued observations at the PHP on 11-28-18 between 9:15 a.m. and 10:15 a.m. revealed :


* Microwave was dirty.
* Missing tiles at counter frontage.

Men's & Women's restrooms:

Multiple large tiles were missing on fronts of counters that held the handwashing sinks. The areas where the tiles were missing were sharp and hazardous. The missing tile areas also made it easy to remove the tiles that were in place. Plant Operations Director # 12 confirmed this situation could be hazardous to the patients.

Hospital Location:

Issues previously cited during the 09-12-18 survey and not corrected:

Observations on 11-29-18, at between 11 a.m. and 12 p.m., in the hosptial revealed the following:

* anti-ligature faucets in male and female restrooms were not installed.

* seclusion ante-room call system did not function properly when first tested on [DATE]; had to be re-set at hosptial front desk; constant beeping sound at the nursing station remained after the testing was completed.

* laboratory area: laminate flooring tapped down: 6 inches by 2 feet.

* nursing station (men's unit): one drawer had laminate covering separating at the top: held together with tape and foam.

New environmental/safety issues identified:

Three (3) patient rooms ( 212, 215, and 221) had wall-mounted "temperature sensor" device covers that were missing. The devices behind the missing covers had exposed screws and sharp metal pieces that were protruding.

Six (6) patient rooms ( 217 , 218, 215, 214, 212, and 219 ) had the plastic door handles missing on the cabinets, exposing the porous particle-board material behind the handle. Some of the missing handle spaces had a gel-type glue substance in them. This substance was removable and could be ingested by a patient.

Interview at the time of observation with Plant Operations Director # 12, he stated the items observed could be utilized by a patient for self-harm.