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 observation, document review and interview, it was determined that the Hospital failed to ensure metal paint scrapers were not accessible to patients in the 5 South Behavioral Unit. This presented a potential safety hazard for 15 patients on census on the unit.

Findings include:

1. During an observational tour of the 5 South unit on 9/7/17 at approximately 11:15 AM, 4 metal scrapers used for applying and scraping dry wall spackling/caulking were observed on the floor, near a wall next to large garbage bin. The hallway was monitored by 2 stationary staff, standing at the end of the hallway approximately 30 feet away from the painters' equipment and supplies, while a 3rd staff was performing the every 15 minute patient monitoring. Three painters/contractors were spackling the walls using 3 other metal scrapers. One painter on the opposite wall had his back on the supplies and 4 metal scrapers on the floor, and the other two painters were in another hallway. The supplies and the 4 scrapers on the floor were not in full view of the painters. The 3 unsecured metal scrapers on the floor were accessible to patients walking in the hallway towards the dayroom.

2. The Facility policy titled, "Patients' Bill of Rights and Responsibilities" (Rev 7/17) required, "Patient's Rights-Exercise of Patient Rights...F the right to receive care in a safe setting."

3. The Contractor/Vendor/Intern/Volunteer/Student Orientation Acknowledgement Form" indicated, " ...In order to provide optimal quality of care to our patients, we required all contractors, vendors, review and acknowledge receipt of this important information....Safety: All health care providers are expected to provide a safe environment for patients..."

4. The Director of Behavioral Medicine (E #8) was interviewed while observing 5 South on 9/7/17 at approximately 11:15 AM. E #8 stated that there should be someone watching the equipment (scrapers) while not in use.

5. The Assistant Administrator (E #9) was interviewed on 9/8/17 at approximately 10:45 AM. E #9 presented four signed contractor (painter) orientation acknowledgement forms, stating the contractors (painters, workers) were made aware that they would be working in a behavioral unit needing additional precautions. E #9 stated that she expected the scrapers, supplies and equipment not being used to be locked and secured and not left unattended.

6. One of the three painters/contractors (Z #1) was interviewed on 9/8/17 at approximately 12:45 PM. Z #1 stated that they lock the metal scrapers in the rooms with them when painting a room. Z #1 indicated that while working in the hallway, they usually only have the scarpers that they use in their hands. Z #4 stated they are supposed to keep the scrappers with them or sucure/lock them if not in use. Z #1 stated they were told to watch their equipment and to lock them, especially in this unit (5 South-Behavioral unit).