HospitalInspections.org

Based on record review, observation and interview, the hospital failed to ensure that a patient guardian was called to discuss an incident for one (Pt #2) of five patients.
This failed practice had the potential to result in rendering the guardian unable to take immediate action to protect the safety and well-being of the patient. (See Tag A-0129)

Based on observation and interview, the hospital failed to ensure all patients received care in a safe environment.
This failed practice had the likelihood to result in mold spores and bacteria which could result in illness. (See Tag A-0144)

Based on record review and interview, the hospital failed to ensure a patient was free from abuse for one (Pt #2) of five patients reviewed.
This failed practice had the likelihood to result in injury and trauma to patients. (See Tag A-0145)

Based on record review, observation and interview, the hospital failed to ensure that a patient guardian was called to discuss an incident for one (Pt #2) of five patients. This failed practice had the potential to result in rendering the guardian unable to take immediate action to protect the safety and well-being of the patient.

Findings:

Review of a policy titled, "Investigating/Reporting Serious Incidents" reviewed/revised 03/24 read in part, "Cedar Ridge policy is that unit staff makes 3 attempts to reach the spouse/guardian during the shift that the incident occurs."

Patient #2
An observation of a surveillance video dated 07/27/25 at 7:24:24 pm to 7:24:43 pm showed:
1) Staff K pushed Pt #2,
2) Pt #2 pushed staff in return,
3) Staff K used closed fists to repeatedly strike Pt #2,
4) Pt #2 attempted to defend theirself.

A review of "Progress Note" dated 07/27/25 showed no documentation the patient's guardian was called to provide notification of the altercation.

On 09/04/25 at 11:25 am, Staff H stated to their knowledge the patient's guardian was not notified of the incident.

Based on observation and interview, the hospital failed to ensure all patients received care in a safe environment. This failed practice had the likelihood to result in mold spores and bacteria which could result in illness.

Findings:

On 09/23/25 at 9:30 am, the surveyor toured the facility and observed one ceiling tile stained. One tile appeared to be wet in the hallway above the entrance to room #1155.

On 09/04/25 at 10:25 am, Staff I stated anything wet for a long period of time or in standing water is a breeding ground for bacteria.

On 09/04/25 at 10:54 am, Staff E stated ceiling tiles should be replaced when they are wet or stained.

Based on record review and interview, the hospital failed to ensure a patient was free from abuse for one (Pt #2) of five patients reviewed. This failed practice had the likelihood to result in injury and trauma to patients.

Findings:
Review of policy titled "Statement of Patient's Rights" read in part, "You have the right to be free from all forms of abuse, neglect, and harassment."

Patient #2
A review of a surveillance video dated 07/27/25 at 7:24:24 pm to 7:24:43 pm showed:
1) Staff K pushed Pt #2,
2) Pt #2 pushed staff in return,
3) Staff K used closed fists to repeatedly strike Pt #2,
4) Pt #2 attempted to defend their self.

Review of an internal document dated 07/31/25 read in part, "MHT observed pushing patient on shoulders backward and patient pushing MHT, leading to physical altercation between the two. Altercation lasting 19 seconds before another staff was able to pull MHT and patient apart." .... "Met with MHT regarding incident and investigation and MHT was terminated from employment with Cedar Ridge effective 08/04/25."

On 09/03/25 at 3:00 pm, Staff D stated:
1) There was an altercation between Staff K and a patient,
2) The patient was in active psychosis, so he was a vulnerable adult,
3) A few days later Staff K was terminated.

On 09/04/25 at 8:18 am, Staff G stated Staff K pushed the patient and that is when everything started.