HospitalInspections.org

Based on observation, interview, and record review, the facility failed to ensure a safe safe environment for 1 of 12 current patients ( Patient # 1). The facility failed to:

* Ensure Patient #1's bathroom was free of ligature risks.

* Monitor Patient # 1 per physician order ( 1:1; Line of Sight).

Findings include:

Ligature risk:

Observation on 05-17-18 at 10:00 a.m. revealed Patient # 1 in room 320. Interview with RN Director #6 at the time of observation, she stated this patient had been admitted during the night after attempting suicide; she had been placed on suicide precautions.

Further observation revealed Patient # 1 awake, lying in bed; both of her wrists were bandaged. There were no staff or visitors in room. A call light cord was observed in this patient's bathroom. The call light "pull" consisted of a white cord (approximately 15 inches long) with a plastic red portion (approximately 6 inches long) attached to the bottom of the white cord. Interview with RN # 6 at the time of observation, she stated the call light cord should have been rolled up and secured. It was a ligature risk.

Interview on 5/17/18 at 12:30 p.m.. with RN Director # 6 she stated all of the bathroom call lights had been cut short. She further stated the facility maintenance director informed her the call lights were "breakaway cords" at 30 pounds. They had been tested when installed but he was unable to locate documentation of the testing.

Record review of facility policy titled: "Suicide Prevention Plan" dated 8/2017, read: " ...Suicide Precautions ...5. Additional safety interventions are implemented for patients on suicide precautions ...These interventions include ...Nurse call cords will be secured ..."

Patient Monitoring:

Record review of Patient # 1's physician orders, dated 5/17/18 (time 0425) read: Observation: every 15 minutes; Line of sight; 1:1 ."

Observations of Patient # 1 on 05-17-18 at 10:00 a.m.; 10:45 a.m. and 11:15 a.m. revealed her to be lying in bed, alone in room: no staff; no visitors..."

Record review of Patient # 1's "Behavioral Health Patient Monitoring" form, dated -5-17-18, had the following types of Precautions indicated at the top of the form (by check mark):" Standard (q [every] 15); Suicide; and Fall"; "Line of Sight" and "1:1" (monitoring) were not checked.

Record review of facility policy titled: "Suicide Prevention Plan," dated 8/2017, read: " ...Heightened Observations: 1:1 Monitoring: The patient is NEVER to be out of arms reach of the assigned and dedicated staff member (facility bolding & capitalization) ...Line of Sight Observation: monitoring and observation. Continuous observation means that at no time is the patient out of the visual contact of a staff member ..."

Record review of facility "Senior Program Patient Information Handbook", read: "Patient Rights ... (3) The right to an....environment that ensures protection from harm ..."