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.


A. Based on document review and interview, it was determined that for 1 of 3 clinical records reviewed for suicide precautions, the Hospital failed to ensure that the Registered Nurse supervised the patient's care by failing to ensure a physician's order was obtained.

Findings include:

1. On 08/19/2021 at approximately 2:00 PM, the Hospital's policy titled, "Suicide Precaution/High-Risk Suicide Precautions/Self-Wounding/Harm (without Suicidal intent) Precautions (undated)" was reviewed and included, " ...F.) An order for "Suicide Precautions" must be obtained from an attending Psychiatrist...H.) Patients requiring additional, individualized levels of assessment, observation or precautionary interventions may have specific orders at the discretion of the psychiatrist ...The need for additional precautions must be clearly documented in the medical record and reviewed daily by the psychiatrist through a patient visit."

2. The clinical record of Pt. #7 was reviewed 08/19/2021. Pt. #7 was admitted on [DATE] with a diagnosis of psychosis. The clinical record indicated that Pt. #7 was placed on suicide precautions from 8/14/2021 until 8/17/2021 however, a physician's order was not placed until 8/17/2021.

3. On 8/20/2021 at approximately 9:30 AM, an interview was conducted with the Manager of Behavioral Health Unit (E #3) to discuss the findings. E #3 stated, "the doctor should have been paged to obtain orders or to let the doctor know that suicide precautions has been initiated, because we still have to get the order from the doctor."

B. Based on document review and interview, it was determined that for 1 of 3 patient's records reviewed, the Hospital failed to complete a patient safety event, to ensure a Registered Nurse supervised and evaluate the patients care.

Findings include:

1. On 8/20/2021 at approximately 2:00 PM, the Hospital's Job description for registered nurses (effective 1/20.21) included, "Responsible for providing and coordinating comprehensive accordance with established standard and policies and procedures...G. Promotes culture of safety through identifying threats to patient safety and intervening to prevent patient harm. Reports patient safety events and near misses in a timely manner..."

2. On 8/20/2021 at 9:00 AM, the Hospital's policy titled, "Confidential Patient Safety Event Form (Template date: 05/15/2014)" was reviewed and included, "All confidential Patient Safety Event forms must be completed immediately upon the first observation of a patient safety event and routed to the Risk Management Department ...Definition A. Patient safety event ...1. An unexpected or unusual event involving a patient that has resulted in or has the potential to result in emotional harm, physical injury, complaint of abuse or property loss. 2. An unexpected or unusual event that is not consistent with the routine care of the patient. 3. An event that did not reach the patient (near miss) but would have had the potential for harm or outcome to the patient ..."

2. The clinical record of Pt. #4 was reviewed 08/19/2021. Pt. #4 was admitted on [DATE] with diagnosis of Psychosis and discharged on [DATE]. The clinical record included the following:

-Nurses note dated 6/11/2021 10:43 AM included, "(Pt. #4) remains disorganized and paranoid with his thoughts. (Pt. #4) offered a shower after breakfast and (Pt. #4) says ["Get me in the shower now"]. MC (Mental Health Counselor went in to try to get vitals but that is when the patient pulled the sprinkler out which caused flooding in his room. (Pt. #4) had to be pulled out from the washroom as Pt. (Pt. #4) refused to get out. RR (Rapid Response Team) was called just to make sure patient is ok medically. RR came and assessed the patient which everything came up negative for injuries ...(Pt. #4) is maintained on 1:1 (direct observation) observation for safety ...Psychiatrist and Father notified ..."

-Nurses note/Plan of care note dated 6/11/2021 at 8:35 PM included, " ...(Pt. #4) has been in room sleeping on and off with one to one sitter. Thoughts remain disorganized ...his answer to questions are nonsensical ...Met with (Name of Psychiatrist) and when asked if he remembers safety event this morning where he pulled the water sprinkler in his bathroom patient stated "cannibalism" ...Will continue to monitor behavior."

3. On 8/20/2021 at approximately 11:00 AM, the adverse occurrence logs from 2/01/2021 through 8/16/2021 were reviewed. There was no adverse event listed for Pt. #4 related to setting off the bathroom fire sprinkler and flooding the bathroom of assigned patient room.

4. On 8/20/2021 at approximately 9:25 AM an interview was conducted with Manager of Behavioral Health E #3. E #3 stated that a safety event was not created when Pt. #4 hit the sprinkler causing the flood because there was no procedural breech. E #3 stated, "Pt. #4 was very tall about 6 foot 5 inches and all he did was punch up hit the sprinkler causing the flood."