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 review of hospital policies and procedures, staffing schedules and personnel files, and interviews with hospital staff, the hospital failed to ensure staff, working on the mental health/psychiatric (psych) unit, were trained and kept current in the safe implementation in CPI (Crisis Prevention Intervention by Crisis Prevention Institute), the facility's approved method to hold/restrain patients, identify behaviors/circumstances that might trigger the use restraints, and deter the necessity to utilize restraints and seclusion, before patient care was assigned. This occurred for six of eleven (Staff # F, H, J, K, L, and N of Staff #D, E, F, G, H, I, J, K, L, M, and N) personnel files reviewed for CPI competency.


1. On the morning of 03/15/2012, Staff B told the surveyors that the hospital used CPI as the hospital's approved method for identifying and managing potential aggressive situations, including methods to physically hold/restrain patients. This was confirmed by policy review and personnel file review.

2. State Licensure Chapter 667 Hospital Standards, Subchapter 33, 310:667-33-2(b)(2), stipulates, "All staff providing active treatment or monitoring patients shall be trained in facility methods approved to physically hold or restrain patients before patient care responsibilities are assigned. These staff members shall be reoriented regarding these policies annually or when policies are revised."

3. Six of the eleven personnel file reviewed did not have CPI training. All six staff who did not have CPI training had worked on the psych unit within the last month. This was verified with Staff B at the time of review on the afternoon of 03/15/2012.
Based on surveyors observation and review of hospital documents and policies, the hospital failed to maintain the environment on the New Directions Unit (the hospital's geriatric psychiatric unit) to ensure the safety and well-being of the patients are assured.


1. The hospital has a 14-bed geriatric psychiatric unit. Patient rooms are private and semi-private rooms.

2. During the tour on the morning of 03/15/2012, Staff D told the surveyors that patient population on the unit was generally 70 years and older adults, but that in special cases they accepted younger patients with physician review. The admission criteria provided to the surveyors for review recorded admission age of 65 years or older unless physician approval occurred.

3. During the tour, the surveyors noted one individual using a walker. The patient had a slow, hesitant gait and staff accompanied the patient with a hand partially outstretched.

4. All patient room doors swung inward and had frame mounts that prevented the doors from swinging out into the hall.

5. Patient room doors for rooms 304, 306 and 307 did not have access panels in the door or any other mechanism to access a patient/individual should they fall against the door and be unable to move to allow access to others.

6. The doors that had access panels to patient room had been painted. For one of two of these doors, that staff and surveyors tried to unlock, the access panel would not open to allow entrance should the need arise.

7. The hospital did not have a plan/procedure on what would be done if a patient/individual fell against the door or barricaded themselves in the room and the door/room did not have a functioning access panel opening outward to allow entrance. With the age and fragility of the patient population on the unit, if staff tried to force the door open upon a fallen patient, it could cause injury/further harm to the patient.