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.

WINDMOOR HEALTHCARE OF CLEARWATER 11300 US 19 N CLEARWATER, FL 33764 June 10, 2021
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on review of the facility policy, staff interview, and facility documents it was determined the facility failed to ensure patients were free from all forms of abuse or harassment for one (#5) of six patients sampled.

Findings included:

Review of facility documents revealed on 7/15/2020 the facility conducted an investigation for a patient allegation of physical abuse against a staff member. Documentation stated the alleged staff member was removed from the unit but it did not indicate where the staff member was moved to or if the staff member was escorted.

Review of the facility policy, "Patient Abuse and Neglect," #RI. 121, last revised 7/2018, stated ...depending on the circumstances the employee may be reassigned temporarily or may be suspended pending the results of the investigation.

The policy does not address where the employee will be reassigned or if the employee will be escorted to another location in the building or out of the building to ensure patient safety pending the results of the investigation.

An interview was conducted on 6/10/2021 at 3:25 p.m., with the Director of Risk Management (RM). He confirmed the documentation failed to identify where the staff member went and if the staff member was escorted.
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on staff interview and observation the facility failed to ensure that patient's rights were readily available and provided in a language that the patient could understand.

Findings included:

On 06/10/2021 at 9:47 a.m., a tour conducted on unit 12 revealed a poster of the Patient's rights which was posted in English only, located in a common area of the unit. There was no evidence the Patient's rights were available to review in another language. An interview with staff member (B), Chief Nursing Officer (CNO), confirmed some of the patients served at the facility can only speak and read Spanish.

On 06/10/2021 at 10:13 a.m., a tour conducted on unit 14 revealed a poster of the Patient's rights which was posted in English only, located in a common area of the unit.
An interview conducted with the CNO confirmed the above findings.

On 06/10/2021 at 3:34 p.m., an interview was conducted with staff member (D), Nurse Manager. The nurse manager stated the patient's rights were available in Spanish at the nursing station. The Nurse Manager was asked to provide a copy but was unable to locate them.

On 06/10/2021 at 3:47 p.m., an interview was conducted with staff member (E), Registered Nurse (RN), on unit 11. The RN was asked to provide a copy of the Patient's rights in Spanish. The RN stated they did not have a copy on the unit and were located in the intake unit.

On 06/10/2021 at 3:53 p.m., an interview was conducted with staff member (F), intake therapist. The intake therapist stated she had never seen a copy and did not know where to locate one.

On 06/10/2021 at 3:55 p.m., an interview was conducted with staff member (H), Intake Director of Admissions. The Intake Director confirmed they had a copy of the Patient's rights available in Spanish. He was asked to provide a copy but was unable to locate them at the time of the interview.

On 06/10/2021 at 4:20 p.m., the CNO provided a copy of the Patient's rights in Spanish.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, staff interviews and facility documents it was determined the facility failed to ensure patients received care in a safe setting for the population of patients served at the facility.

Findings included:

On 06/10/2021 at 9:54 a.m., a tour of unit 12 was conducted. The facility/unit was noted to serve a population of patients in need of acute mental health services. Observation was made of the bathroom door latch in room #504. The type of latch present on the door creates a positive latch when closed and would require a twisting or turning motion to open. This type of latch presents a potential ligature risk.

Review of facility documentation revealed on October 5, 2016, the facility submitted upgraded features to be done in the facility of the bathroom doors to the Agency for Health Care Administration Office of Plans and Construction. Documentation revealed the latches of the doors were to be a roller latch. The roller latch allows the door to be closed for privacy but does not pose a ligature risk.

An interview was conducted with staff member (B), Chief Executive Officer (CEO), at which time he confirmed the above findings.