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.

The hospital failed two of two patients. Patient #1 and Patient #2 by failing to provide them the right to be free from all forms of abuse or harrassment. .

Findings include

Through interview Staff #1 informed the Surveyor that Patient #1 was found in the room of Patient #2 hiding behind the bathroom door.

Through interview Staff #3 informed the Surveyor that Patient #1 was in the room for approximately 22 minutes according to film review.

Through interview Staff #1 informed the Surveyor that Patient #1 reported that she performed oral sex on Patient #2.
Through interview Staff #1 informed the Surveyor that Patient # 1 indicated she was not forced, to perform this act. Patient #1 Reported that a desire to perform the act because Patient #1 stated having a desire to be loved, and not wanting Patient #2 to become mad at Patient #1 if the act was not performed.

Through record review Staff #4 reported ""Patient did well overall, but was caught trying to stay in Patient #2's room while pretending to take a shower."

Through record review according to the observation sheets Staff #4 reported completing rounding on time and posted Patient #1 as being in her room. It was previously reported in interview that the patient was out of her room for approximately 22 minutes.


The hospital policy on Abuse dated 07/17/2019 reflected, "Perimeter Healthcare promotes and requires professional, ethical and legal conduct of staff. The advocacy role of health care is maximized when addressing issues of conduct of staff. Perimeter Healthcare assesses the conditions of illegal, unethical and/or unprofessional conduct of staff. All health care services providers will immediately report to the appropriate supervisors, manager, or department head any suspected illegal, unethical and/or unprofessional conduct by another individual. Illegal, unethical and/or unprofessional conduct by any health care services providers are prohibited behaviors and will be grounds for disciplinary action and reporting to local and or state regulatory and/or legal authorities as mandated by statue, hospital policy and/or regulation(s). It is the responsibility of all staff members and health care professionals of Perimeter Healthcare to report concerns regarding illegal, unethical and/or unprofessional conduct to hospital administration."

The hospital Policy on Observation Rounds dated 07/17/2019 reflected, "an accurate record of the whereabouts and behavior of all patients will be maintained during each shift ...Ensures the patient Observation round are occurring as ordered ...Nurse oversight of patient observation rounds is evident per review/signature on Patient Observation rounds Checklist at a minimum of twice per shift ...Review and update patient observation forms ...Reflect changes in individual patient precautions levels, room or bed changes, new admissions and or discharges as they occur ...Perform rounds at staggered intervals and in a varying pattern or sequence throughout the unit to minimize planned acting-out opportunities ...