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Based on observation, interview, and document review, the facility failed to ensure the physical environment of the psychiatric unit of the hospital was constructed and maintained in a manner to ensure the safety of patients. This deficient practice had the potential to affect all seven patients (patients 16, 17, 18, 19, 20, 23, and 24) in the facility.

The effect of this failure resulted in creating an unsafe clinical environment for psychiatric patients on a locked unit of the hospital and deliver statutory-mandated care to patients.

Findings include:

1. The facility failed to arrange and maintain the physical environment of the psychiatric unit of the hospital in a manner to ensure the safety of patients. Observations conducted on the psychiatric unit of the facility revealed the facility failed to provide a safe, ligature "resistant" or "free" environment for 7 patients (patients 16, 17, 18, 19, 20, 23, and 24) admitted to the unit. (Tag C 221).

Based on observation, interview, and document review, the facility failed to arrange and maintain the physical environment of the psychiatric unit of the hospital in a manner to ensure the safety of patients. Observations conducted on the psychiatric unit of the facility revealed the facility failed to provide a safe, ligature "resistant" or "free" environment for seven patients (patients 16, 17, 18, 19, 20, 23, and 24) admitted to the unit.

Findings include:

On 10/30/19 at 9:15 AM, observations of the locked psychiatric unit of the hospital revealed the following ligature risks were present in the unit:

1. Seventeen doors which included: two doors in each patients' rooms (rooms 1, 2, 3, 4 and 5), the activity room door, the dining room door, the three doors in the nurses' station, and the two doors to the entry of the unit, had regular hinges, creating a ligature risk in multiple areas of the unit.

2. Sink piping located under five patient bathroom sinks in rooms 1, 2, 3, 4, and 5 were exposed and not covered. The exposed piping created a ligature risk under every bathroom sink located in all the patient rooms.

3. Five sink faucets in patient bathrooms in rooms 1, 2, 3, 4, and 5 could be used as anchor point for hanging.

4. The ceiling in the patient care areas of the psychiatric unit was not solid and created multiple access points in the metal framing suspended from the interior roof that could be used for hanging.

A review of a facility document titled, "2019 Risk Assessment of the Behavioral Health Environment", dated 01/03/19, revealed the ligature risks identified during the observation of the psychiatric unit were identified as "high risk" concerns and included recommendations for the facility to remove the ligature risks. The Risk Assessment indicated, it was "highly recommended converting (regular hinges) to the piano hinges-continuous hinges; the assessment recommended the facility to "cover fully" the exposed piping under the sinks located in the patient rooms, the assessment further "highly recommended" the sink faucets in patient rooms, "be switched to psych safe faucets" and the assessment also recommended to the facility to install a solid ceiling in the patient care areas of the psychiatric unit of the hospital.

On 10/30/19 at 12:15 PM, an interview with the Psychiatric Nurse Manager (PNM) revealed the "2019 Risk Assessment of the Behavioral Health Environment" was completed by the Mental Health Management contractor in January 2019 and provided to the facility in May 2019. The PNM further stated the psychiatric unit of the facility was opened in January 2014 and no structural changes had been made to the psychiatric unit since it had been opened. The PNM was aware the risk assessment had been completed. However, PNM was not aware of any plans to correct the high-risk environmental problems on the unit.

On 10/30/19 at 12:30 PM, an interview with the Facilities Manager (FM) revealed the FM was never made aware of any recommendations in the "2019 Risk Assessment of the Behavioral Health Environment."

On 10/30/19 at 12:55 PM, an interview with the Chief Financial Officer (CFO) revealed the CFO was not aware of the "2019 Risk Assessment of the Behavioral Health Environment" and there had been no plans in the hospital's budget to correct any of the high-risk environmental problems on the psychiatric unit of the hospital.

A review of the facility's contract with the Behavioral Health Management contractor, dated 10/31/13, revealed the hospital was responsible to, "Make modifications and alterations to the hospital's facilities necessary for the operation of the Program in compliance with all applicable state and federal licensing, certification, and code requirements."

On 10/31/19 at 1:17 PM an interview with the Chief Executive Officer of the hospital revealed he was made aware of ligature risks in the psychiatric unit by the Psychiatric Program Director (PPD) on 05/03/19. However, the CEO stated there were no current plans in place to address the concerns related to the high-risk environmental problems on the psychiatric unit of the hospital.

Based on interview and document review, the facility failed to ensure the governing body of the facility and the Chief Executive Officer (CEO) addressed high risk ligature hazards located in the locked, psychiatric unit of the facility. A review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. In addition, interviews with the Chief Nursing Officer (CNO) and the CEO revealed the facility had not implemented any corrective measures to eliminate the high-risk environmental problems on the psychiatric unit of the hospital. This deficient practice had the potential to affect all seven patients (patients 16, 17, 18, 19, 20, 23, and 24) in the facility.

The effect of this failure resulted in creating an unsafe clinical environment for psychiatric patients on a locked unit of the hospital and deliver statutory-mandated care to patients.

Findings include:

1. The facility failed to ensure the governing body of the facility and the Chief Executive Officer (CEO) addressed high risk ligature hazards located in the locked, psychiatric unit of the facility. A review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. In addition, interviews with the Chief Nursing Officer (CNO) and the CEO revealed the facility had not implemented any corrective measures to eliminate the high-risk environmental problems on the psychiatric unit of the hospital. (See tag C0241)

Based on interview, and document review, the facility failed to ensure the governing body of the facility and the Chief Executive Officer (CEO) addressed high risk ligature hazards located in the locked, psychiatric unit of the facility. A review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. In addition, interviews with the Chief Nursing Officer (CNO) and the CEO revealed the facility had not implemented any corrective measures to eliminate the high-risk environmental problems on the psychiatric unit of the hospital. This deficient practice had the potential to affect all seven patients (patients 16, 17, 18, 19, 20, 23, and 24) in the facility

Findings include:

A review of a facility document titled, "2019 Risk Assessment of the Behavioral Health Environment" dated 01/03/19, revealed the ligature risks identified during the observation of the psychiatric unit were identified as "high risk" concerns and included recommendations for the facility to remove the ligature risks. The Risk Assessment" indicated that it was "highly recommended converting (regular hinges) to the piano hinges-continuous hinges." In addition, the "Risk Assessment" recommended the facility to "cover fully" the exposed piping under the sinks located in the patient rooms; "highly recommended" the sink faucets in patient rooms, "be switched to psych safe faucets"; and the facility to install a solid ceiling in the patient care areas of the psychiatric unit of the hospital.

On 10/30/19 at 12:45 PM, an interview with the CNO revealed the CNO was responsible for the quality assurance program of the hospital. The CNO stated she was aware the "2019 Risk Assessment of the Behavioral Health Environment" was completed by the Mental Health Management contractor in January 2019 and provided to the facility in May 2019. In addition, the CNO stated the recommendations in the risk assessment had not been addressed in the facility's "Quality Assurance Performance Improvement (QAPI) Plan."

A review of the facility's contract with the Behavioral Health Management contractor, dated 10/31/13, revealed the hospital was responsible to, "Make modifications and alterations to the hospital's facilities necessary for the operation of the Program in compliance with all applicable state and federal licensing, certification, and code requirements."

A review of the facility's "Quality Assurance Performance Improvement Plan" dated 05/31/19, revealed the QAPI Plan's objectives included, " ...appropriate, quality, safe patient care is delivered." In addition, the QAPI Plan established priorities based on considerations including, "High risk, high volume, and problem prone" areas within the facility ...the ultimate authority and responsibility for the Organization-Wide Performance Improvement Plan rests with the Board of Trustees" of the hospital. However, the QAPI Plan did not include any planning, implementation, or monitoring related to the high-risk environmental problems identified in the "2019 Risk Assessment of the Behavioral Health Environment" for the psychiatric unit of the facility.

On 10/31/19 at 1:17 PM an interview with the CEO of the hospital revealed he was made aware of ligature risks in the psychiatric unit on 05/03/19. However, the CEO stated there were no current plans in place to address the concerns related to the high-risk environmental problems on the psychiatric unit of the hospital.

Based on observation, interview, and policy review, the facility failed to implement infection control measures for one of two patients observed to have laboratory (labs) drawn and fluids infused through their central venous catheter port (Patient (P) 21.) Specifically, the nurse failed to change gloves and sanitize her hands when moving from a dirty task to a clean task while accessing the central venous catheter port, and when collecting blood samples through the port. This deficient practice had the potential to increase the risk for infection for any patient whose port may be accessed to administer treatments or collect laboratory samples.

Findings include:

Review of the P21's primary care physician orders dated 09/18/19, and provided by the Chief Nursing Officer (CNO), on 10/31/19 at 5:00 PM showed, "CBC [complete blood count] auto differential to be done: Every week, Details: ADD-On; to be done at [hospital]," and, "10/02/19 IV [intravenous] hydration order for the following dates in October ... Wednesday ... 10/30 ... D5W [dextrose in water] 2000 ml IV over 4 hours to run at 500 CC [cubic centime] /hr [hour]. "

During an observation on 10/30/19 at 10:00 AM, Registered Nurse (RN)1, after dawning sterile gloves and placing the sterile drape over P21's chest and clothing, used her left hand, touching P21's skin, to pull the drape and P21's shirt down and away from the central venous catheter port site. The RN proceeded to clean the port site. The RN then picked up the intravenous cannula and extension set with both hands and removed the protective cover from the cannula. The RN did not remove her gloves or sanitize her hands. RN1 palpated the port site with the index finger on her left hand and placed the cannula. RN1 placed a vacutainer to collect blood samples. RN1 attempted to obtain a sample several times without success as the sample tube was not functioning properly. The RN flushed the IV line several times using 10 milliliter (ml) saline syringes in between attempts to collect the sample. RN1 left P21's side and went to the door of the room to get the attention of another nurse. The RN did not remove her gloves or sanitize her hands. While waiting for the second nurse to return with additional supplies, RN1 picked up several used saline syringes and disposed of them in a sharps container across the room. The RN used both of her hands to open the container and dispose of the used syringes. RN1 did not change her gloves or sanitize her hands. After collecting the ordered blood samples and hanging the fluid order, RN1 cleaned the area, removed her gloves, and washed her hands.

In an interview on 10/30/19 at 11:30 AM, RN1 said she would try to touch the skin as little as possible. The RN had been trained to sanitize her hands and change her gloves after handling items that could be dirty. RN1 said she should have changed her gloves and sanitized after disposing of the saline syringes. RN1 said she palpated the port to be sure where the center of the port was. The RN said she should have cleaned the port site again after palpating the port.

In an interview on 10/31/19 at 10:00 AM, the Chief Nursing Officer said after a nurse has touched a patient's clothes or skin, they need to change their gloves. If the nurse had used the gloves while disposing the syringes, she should have changed gloves before moving on to draw more labs. If the gloves were dirty and the port had already been cleaned, the nurse should not have palpated the port with their gloved hand before accessing the site.

In an interview on 10/31/19 at 4:05 PM, the Infection Control Registered Nurse (ICRN) said when a port site had already been cleaned, the site should not be palpated, if the nurse had touched the patient's skin with her gloved hand. The gloves should have been changed. When the nurse took the syringes to the sharps container, she should have changed her gloves. The facility expectation would have been for the gloves to be changed.

Review of the facility's policy titled, " Indwelling Port and PICC Draws for Outpatient Labs", dated 11/20/2012, provided by the CNO on 10/31/19 at 1:34 PM, showed, " ... Apply sterile gloves and palpate the port system with the non-dominant hand and stabilize the port edge with 3 or 3 fingers ... "

Review of the facility's policy titled, "Hand Hygiene Program", dated 10/26/10, provided by the CNO on 10/31/19 at 1:34 PM, showed, " ...Alcohol Based Hand Sanitizer Policy: ...Decontaminate hands if moving from a contaminated body site to clean body site during patient care. Decontaminate hands after contact with inanimate objects, including medical equipment, in the immediate vicinity of the patient ... "
Review of the facility's policy titled, "Central Venous Access Device", dated 4/14/2007, provided by the CNO on 10/30/19 at 1:24 PM, showed "Complications, Use strict asepsis in handling the catheter exit site, opening hub of catheter, and catheter caps.

Based on observation, interview, and document review, the facility failed to ensure patient care services affecting patient safety in the psychiatric unit of the hospital were evaluated. Observations conducted on the psychiatric unit of the facility revealed the facility failed to provide a safe, ligature "resistant" or "free" environment for seven patients (patients 16, 17, 18, 19, 20, 23, and 24) admitted to the unit. A review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. In addition, interviews with the Chief Nursing Officer (CNO), Psychiatric Nurse Manager (PNM), and the Chief Executive Officer (CEO) revealed the facility did not implement any quality assurance measures to ensure corrective measures were taken to eliminate the high-risk environmental problems on the psychiatric unit of the hospital.

The effect of this failure resulted in creating an unsafe clinical environment for psychiatric patients on a locked unit of the hospital and deliver statutory-mandated care to patients.

Findings include:

1. The facility failed to ensure patient care services affecting patient safety in the psychiatric unit of the hospital were evaluated. Review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. The facility did not implement any quality assurance measures to ensure corrective measures were taken to eliminate the high-risk environmental problems on the psychiatric unit of the hospital. (See tag C337)

Based on observation, interview, and document review, the facility failed to ensure patient care services affecting patient safety in the psychiatric unit of the hospital were evaluated. Observations conducted on the psychiatric unit of the facility revealed the facility failed to provide a safe, ligature "resistant" or "free" environment for seven patients (patient 16, 17, 18, 19, 20, 23, and 24) admitted to the unit. A review of an environmental risk assessment revealed high-risk environmental problems were identified in the psychiatric unit related to ligature risks. In addition, interviews with the Chief Nursing Officer (CNO), Psychiatric Nurse Manager (PNM), and the Chief Executive Officer (CEO) revealed the facility did not implement any quality assurance measures to ensure corrective measures were taken to eliminate the high-risk environmental problems on the psychiatric unit of the hospital.

Findings include:

On 10/30/19 at 9:15 AM, observations of the locked psychiatric unit of the hospital revealed ligature risks were present in the unit. (See tag C221)

Review of a facility's document titled, "2019 Risk Assessment of the Behavioral Health Environment" dated 01/03/19, revealed the ligature risks identified during the observation of the psychiatric unit were identified as "high risk" concerns and included recommendations for the facility to remove the ligature risks. In addition, the assessment recommended the facility to "cover fully" the exposed piping under the sinks located in the patient rooms. The assessment also recommended to the facility to install a solid ceiling in the patient care areas of the psychiatric unit of the hospital.

On 10/30/19 at 12:15 PM, an interview with the Psychiatric Nurse Manager (PNM) revealed the "2019 Risk Assessment of the Behavioral Health Environment" was completed by the mental health management contractor in January 2019 and provided to the facility in May 2019. The PNM was aware the risk assessment had been completed. However, PNM was not aware of any plans to correct the high-risk environmental problems on the unit and stated she had not addressed any of the recommendations found in the risk assessment in quality assurance projects within the psychiatric unit.

On 10/30/19 at 12:45 PM, an interview with the Chief Nursing Officer (CNO) revealed the CNO was responsible for the quality assurance program of the hospital. The CNO stated she was aware the "2019 Risk Assessment of the Behavioral Health Environment" was completed by the Mental Health Management contractor in January 2019 and provided to the facility in May 2019. In addition, the CNO stated the recommendations in the risk assessment had not been addressed in the facility's Quality Assurance Performance Improvement (QAPI) Plan.

A review of the facility's contract with the behavioral health management contractor, dated 10/31/13, revealed the hospital was responsible to, "Make modifications and alterations to the hospital's facilities necessary for the operation of the Program in compliance with all applicable state and federal licensing, certification, and code requirements."

A review of the facility's "Quality Assurance Performance Improvement Plan", dated 05/31/19, revealed the QAPI Plan's did not include any planning, implementation, or monitoring related to the high-risk environmental problems identified in the "2019 Risk Assessment of the Behavioral Health Environment" for the psychiatric unit of the facility.

On 10/31/19 at 1:17 PM an interview with the Chief Executive Officer of the hospital revealed he was made aware of ligature risks in the psychiatric unit by the Psychiatric Program Director (PPD) on 05/03/19. However, the CEO stated there were no current plans in place to address the concerns related to the high-risk environmental problems on the psychiatric unit of the hospital.