HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on clinical record review, hospital documentation, staff interviews, and policy review, for 1 of 3 sampled patients reviewed for elopement (Patient #3) the hospital failed to ensure safety measures were implemented and included in the plan of care for a patient who was demanding discharge, and failed to ensure that scheduled maintenance on patient windows and plexiglass window covers was completed to ensure they were secure and the patient could not elope through the seventh (7th) floor window.

Please see A144

Based on a review of clinical records, hospital documentation, policies, and staff interviews for 1 of 3 sampled patients reviewed for elopement (Patient #3) the hospital failed to ensure safety measures were implemented and included in the plan of care for a patient who was demanding discharge, and failed to ensure that scheduled maintenance on patient windows and plexiglass window covers was completed to ensure they were secure and the patient could not elope through the seventh (7th) floor window. The findings include:

Patient #3 was admitted to the behavioral health unit on 6/10/20 after two hospital Emergency Department (ED) visits on 6/9/20 for bizarre behaviors and disorganized thought process.

The history and physical dated 6/10/20 at 1:13 AM identified Patient #3 was admitted to inpatient psychiatry for psychotic behaviors. The note identified Patient #3 was actively delusional and was admitted for acute psychotic behaviors, threatening homicidal ideation's prior to admission and was admitted on a Police Emergency Certificate (PEC). The note further identified Patient #3 was placed on every 15-minute checks, to be seen by psychiatry in the morning and to administer Haldol 5mg and Ativan 2mg for acute agitation/psychosis.

a. Review of the initial psychiatric evaluation dated 6/10/20 at 2:17 PM identified Patient #3 had a past psychiatric history with unspecified psychotic disorder. The note identified since admission onto the unit, Patient #3 had continued with aggressive and inappropriate behavior, punched a hole in the wall, required physical restraints, made sexually inappropriate comments to staff, and behaviors and thought processes had been very disorganized. The note further identified during the mental status exam, Patient #3 initially did not respond, and when he/she did respond it was in an irritable tone. Additionally, the note identified to encourage Patient #3 to participate in therapy sessions and start on Zyprexa 5mg twice a day for psychotic symptoms.

A nursing progress note dated 6/10/20 at 5:56 PM identified Patient #3 was angry with behavioral outburst, upset, slamming the phone and accepted Ativan 2 milligrams (mg) with fair effect.

The nurse's note dated 6/10/20 at 10:05 PM identified Patient #3 refused medications.

The nurse's note dated 6/11/20 at 5:58 AM identified Patient #3 was pacing on the unit, asking if he/she could go home today, was medicated with scheduled Zyprexa and as-needed Ativan 2 mg and Vistaril 50 mg, and maintained on every fifteen-minute checks.

Review of the behavioral health adult admission assessment flow sheet assessment for 6/11/20 at 9:00 AM noted Patient #3 exhibited agitation, anger, rapid speech, racing thoughts, resistant to care, paranoid, change in energy level, poor judgment and was refusing to answer most questions.

The daily shift assessments dated 6/11/20 at 9:00 AM documented that Patient #3's risk factors included thoughts/ideas of leaving unit now, and identified the patient was discharge focused. Additionally, the assessment identified danger to self and self-injurious behaviors. Review of the plan of care (nurse's notes) dated 6/11/20 at 12:40 PM identified, affective disturbance, as one of Patient #3's problems. The plan of care identified Patient #3 would remain safe on the unit. The outcome identified the patient was not progressing as evidenced by testing limits, confrontational and a steady demand of discharge.

Review of the observational record dated 6/11/20 identified Patient #3 was in the hallway at 12:45 PM. Further review noted that at 12:55 PM Patient #3 eloped out the 7th floor window.

Review of the safety/security event documentation dated 6/11/20 at 12:55 PM identified Patient #3 was able to remove the plexiglass that covered the glass window in his/her room and appeared to have used a chair to break the glass window. The report identified a sheet was tied to the radiator vent that Patient #3 used to lower him/herself to the ground. Security was alerted that someone was climbing down the outside wall of the building and ran off. The report identified that a search was initiated, and police were notified. Further review identified that after the incident additional staff were added to the unit, all patients were placed on every 5 minute checks, top sheets were removed from patient beds, and engineering would check all windows on the behavioral units to ensure screws were secure in the plexiglass.

Review of the hospital incident report dated 6/11/20 at 1:02 PM identified security was notified that a patient broke a 7th floor window and a person was sliding down the wall of the building and jumped to the garden. The documentation identified that a bedspread was hanging out the broken window from the 7th floor. Further review identified that when they arrived in Patient #3's room, they identified broken glass, screws on the floor, bed sheets were tied to the heating unit and the pane of plexiglass and the window blinds were observed in the patients shower stall in the bathroom. Review of hospital documentation identified that Patient #2 was located by the Hartford Police and was transported to the emergency department.

Review of Patient #3's emergency department clinical record dated 6/11/20 at 3:51 PM identified that he/she was admitted with complaints of low back and ankle pain following a drop from a 6th floor window (medical record error, was 7th floor). CT scans and X-rays of the head, neck, thoracic, lumbar, knee and ankles were obtained, and all were negative. There was an identified 3-centimeter laceration on the posterior aspect of the distal right leg. Patient #3 was discharged from the emergency department and admitted to another hospital for continued psychiatric care.

Interview with RN #6 on 6/13/20 at 10:45 AM stated Patient #3 had been medicated for behaviors on the night shift and when he cared for Patient #3, he/she was irritable and fidgety. RN #6 stated the patient was discharge focused and would ask when he/she could leave. Review of documentation dated 6/11/20 at 12:40 PM and interview with RN #6 identified that they document in a patient's chart based on patient goals (established in the care plan) and in this case, he documented that Patient #2 wasn't meeting the goals. RN #6 stated that they work as a team with social services and the psychiatrist, but he did not talk to them that day regarding Patient #3 not meeting the plan of care goals. RN #6 further stated that he did not implement any other interventions for Patient #3 related to being discharge focused, beside every fifteen-minute checks he/she was already on, but he was watching Patient #3 on the unit.

Review of the clinical record including Patient #3 treatment plan with the Director of Behavioral Health on 6/16/20 at 10:50AM failed to identify that any new interventions were implemented for Patient #3's plan of care related to the behaviors of demand for discharge, confrontational, refusal of medications and testing limits. The Director stated that nursing staff document the progress of care and if Patient #3 was not meeting his/her goals then there should be documentation of other interventions staff put into place related to Patient #3's issues, in order to help Patient #3 meet his/her goals. Review of the Multi-Disciplinary Problems with the Director of Behavioral Health at that time failed to identify any new interventions were documented regarding Patient #3's behaviors that he/she was exhibiting.

The policy for Multidisciplinary Plan of Care dated July 2018 identified that the RN would document against the plan of care twice daily and that any changes in patient's clinical status will be updated by RN, when change occurs.


b. Review of the unit safety inspection checklist that is completed every shift by nursing staff did not identify that windows were part of the unit safety inspection check list for behavioral health.

Interview with the Director of Behavioral health on 6/16/20 at 10:50 AM stated the investigation is ongoing but part of the Root Case Analysis (RCA) would include adding window checks to be completed as part of the unit's environmental shift rounds.

c. Review of hospital documentation (planned event work order) dated 4/15/19 identified that routine checks of all windows included a check for broken glazing, check all plexiglass for loose or missing security screws and repair any defects. The work order dated 4/15/19 did not identify that any of the windows or plexiglass required repair.

Interview with Engineer #1 on 6/16/20 at 11:30 AM stated that the planned event work order is completed yearly and the last time it was completed was April 2019. Engineer #1 stated that the window checks should have been completed in April 2020 but were not completed until after the 6/11/20 elopement because one of the engineers had been on furlough. Engineer #1 stated there are three engineers and their job are to check windows in all patient care areas to ensure safety.

d. Review of the Risk Assessment Matrix dated 6/1/20 failed to identify that room 738 was part of the biannual risk assessment. Interview with the Quality staff and Engineer #1 on 6/16/20 identified although room 738 was not identified on the risk assessment matrix, review of the hospital blueprint plans identified that the room that is on the matrix as room 735 is actually room 738.

Interview with Engineer #1 on 6/16/20 at 11:30 AM stated that the Risk Assessment Matrix is completed twice a year and involves an interdisciplinary team who walk through patient areas to see if any repairs are needed. Engineer #1 stated that they only go into unoccupied rooms and depend on staff to report any issues that arise in any of the rooms. Engineer #1 stated he was not aware of a policy for completing the Risk Assessment Matrix, but the process for checking patient areas has always been twice a year and once a year for non-patient areas.

The hospital lacked a mechanism to ensure that unit rooms and windows that were not inspected by the interdisciplinary team during the twice a year risk assessments were inspected within a reasonable timeframe to ensure that all rooms and windows were safe.

The Condition of Participation for Nursing Services has not been met.

Based on a review of clinical records, hospital documentation, interviews and policies, for 1 of 3 sampled patients reviewed for elopement (Patient #3), the hospital failed to ensure the patient's plan of care was reviewed and updated to include safety interventions when the patient exhibited behaviors of wanting to leave the hospital, and for 1 of 3 sampled patients reviewed for alcohol withdrawal (Patient #2), the hospital failed to follow physician orders related patient assessment and monitoring for alcohol withdrawal.

Please see A396

Based on a review of clinical records, hospital documentation, staff interviews, and policies, for 1 of 3 sampled patients reviewed for elopement (Patient #3), the hospital failed to ensure the patient's plan of care was reviewed and updated to include safety interventions when the patient exhibited behaviors of wanting to leave the hospital, and for 1 of 3 sampled patients reviewed for alcohol withdrawal (Patient #2), the hospital failed to follow physician orders related patient assessment and monitoring for alcohol withdrawal. The findings include:


a. Patient #3 was admitted to the behavioral health unit on 6/10/20 after two hospital Emergency Department (ED) visits on 6/9/20 for bizarre behaviors and disorganized thought process.

The history and physical dated 6/10/20 at 1:13 AM identified Patient #3 was admitted to inpatient psychiatry for psychotic behaviors. The note identified Patient #3 was actively delusional and was admitted for acute psychotic behaviors, threatening homicidal ideation's prior to admission and was admitted on a Physician's Emergency Certificate (PEC). The note further identified Patient #3 was placed on every 15-minute checks, was to be seen by psychiatry in the morning, and to administer Haldol 5 milligrams (mg) and Ativan 2mg for acute agitation/psychosis.

Review of the multi-disciplinary problems dated 6/10/20 identified a plan of care was developed on admission (6/10/20) for affective disturbance. Goals and interventions included that the patient would remain safe on the unit, mood would not interfere with adaptive functioning, monitor the patients whereabouts every fifteen minutes, meet with patient every shift to assess level of dysphoria, participate in prescribed treatment plan, meet with staff twice a shift to identify two alternate coping skills and medication compliance.

Review of the admission therapist interview and case formulation note (behavioral health progress note) dated 6/10/20 at 1:15 PM identified Patient #3 refused to answer any questions during the interview. Review of the behavioral health progress note dated 6/10/20 at 1:30 PM identified Patient #3 refused the suicide/safety assessment. Further review of the clinical record failed to identify that the suicide/safety assessment was completed during the patient's admission.

Interview on 6/12/20 with Licensed Professional Counselor (LPC) #1 stated that on the day of admission (6/10/20) Patient #3 refused to complete the suicide/safety assessment and the next day when she went to see Patient #3, he/she was sleeping so she did not complete the assessment and reported this to the RN (RN #11). The LPC stated that the assessment is completed to assess for safety, patient's mood and used to develop a plan of care. Review of the clinical record indicated that the suicide/safety assessment was not completed. Several attempts to interview RN #11 were not successful. Interview with Psychiatrist #3 on 6/12/20 at 11:05 AM stated that she assessed Patient #3 and felt he/she was calm and cooperative and felt every 15-minute checks were appropriate at that time.


b. Review of the initial psychiatric evaluation dated 6/10/20 at 2:17 PM identified Patient #3 had a past psychiatric history with unspecified psychotic disorder. The note identified since admission onto the unit, Patient #3 had continued with aggressive and inappropriate behavior, punched a hole in the wall, required physical restraints, made sexually inappropriate comments to staff, and behaviors and thought processes had been very disorganized. The note further identified during the mental status exam, Patient #3 initially did not respond, and when he/she did respond it was in an irritable tone. Additionally, the note identified to encourage Patient #3 to participate in therapy sessions and start on Zyprexa 5mg twice a day for psychotic symptoms.

Interview with Psychiatrist #3 on 6/12/20 at 11:05 AM stated that she assessed Patient #3 on 6/10/20 after Patient #2 punched a hole in the wall, and at the time of the assessment, the patient was calm and resting. Psychiatrist #3 stated that when she evaluated Patient #3 on 6/11/20 at 11:30 AM he/she was asking to be discharged but was talking in a calm manner.

A nursing progress note dated 6/10/20 at 5:56 PM identified Patient #3 was angry with behavioral outburst, upset, slamming the phone and accepted Ativan 2mg with fair effect.

The nurse's note dated 6/10/20 at 10:05 PM identified Patient #3 refused medications.

The nurse's note dated 6/11/20 at 5:58 AM identified Patient #3 was pacing on the unit, asking if he/she could go home today, was medicated with scheduled Zyprexa and as-needed Ativan 2mg and Vistaril 50mg, and maintained on every fifteen-minute checks.

Review of the behavioral health adult admission assessment flow sheet assessment for 6/11/20 at 9:00 AM noted Patient #3 exhibited agitation, anger, rapid speech, racing thoughts, resistant to care, paranoid, change in energy level, poor judgment and was refusing to answer most questions.

The daily shift assessments dated 6/11/20 at 9:00 AM documented that Patient #3's risk factors included thoughts/ideas of leaving unit now, and identified the patient was discharge focused.

Review of the plan of care (nurse's notes) dated 6/11/20 at 12:40 PM identified affective disturbance as one of Patient #3's problems. The documentation identified the outcome of the goal was not met as evidenced by patient being angry, confrontational, with steady agitation, non-disclosing and refusing medications. The plan of care identified the patient would remain safe on the unit. The outcome identified the patient was not progressing as evidenced by testing limits, confrontational and a steady demand for discharge. Further review of the plan of care noted that the patient would participate in the prescribed treatment plan and the outcome was that the patient was not progressing as evidenced by refusing treatment and resistant to care.

Interview with RN #6 on 6/13/20 at 10:45 AM stated Patient #3 had been medicated for behaviors on the night shift and when he cared for Patient #3, he/she was irritable and fidgety. RN #6 stated the patient was discharge focused and would ask when he/she could leave. Review of documentation dated 6/11/20 at 12:40 PM and interview with RN #6 identified that they document in a patient's chart based on patient goals (established in the care plan) and in this case, he documented that Patient #2 wasn't meeting the goals. RN #6 stated that they work as a team with social services and the psychiatrist, but he did not talk to them that day regarding Patient #3 not meeting the plan of care goals. RN #6 further stated that he did not implement any other interventions for Patient #3 related to not meeting his/her goals but he was watching Patient #3 on the unit.

Review of the clinical record including Patient #3 treatment plan with the Director of Behavioral Health on 6/16/20 at 10:50AM failed to identify that any new interventions were implemented for Patient #3's plan of care related to the behaviors, demanding of discharge, confrontational, refusal of medications and testing limits. The Director stated that nursing staff document the progress of care and if Patient #3 was not meeting his/her goals then there should be documentation of other interventions staff put into place related to Patient #3's issues, in order to help Patient #3 meet his/her goals. Review of the Multi-Disciplinary Problems with the Director of Behavioral Health at that time failed to identify any new interventions were documented regarding Patient #3's behaviors that he/she was exhibiting.

Review of the hospital incident report dated 6/11/20 at 1:02 PM identified security was notified that a patient (Patient #3) broke a 7th floor window and that a person (Patient #3) was sliding down the wall of the building and jumped to the garden. The documentation identified that a bedspread was hanging out of the broken window. Further review identified that when staff arrived in Patient #3's room, they identified broken glass, screws on the floor, bed sheets were tied to the heating unit and that a pane of plexiglass (window cover) and the window blinds were found in Patient #3's bathroom shower stall.

The hospital failed to ensure that Patient #3's plan of care was reviewed and updated to include safety interventions when the patient exhibited behaviors of wanting to leave the hospital.

The policy for Multidisciplinary Plan of Care dated July 2018 identified that the RN would document against the plan of care twice daily and that any changes in patient's clinical status will be updated by RN, when change occurs.


2. Patient #2 was admitted to the inpatient behavioral unit on 5/6/20 for evaluation and treatment related to an attempted hanging and having suicidal thoughts. Patient #2's diagnoses included depression, alcohol/marijuana use and a history of Post-Traumatic Stress Disorder (PTSD). Review of the psychiatry intake evaluation dated 5/6/20 identified Patient #2 with passive suicidal ideation, racing thoughts and a history of mood swings. The intake further identified Patient #2 reported drinking a good amount of alcohol daily for the last several weeks and as of yesterday (5/5/20) had consumed 75 nips of whiskey. The note identified Patient #2 would be admitted for inpatient care and identified the treatment plan would include Clinical Institute Withdrawal Assessment (CIWA) protocol. Review of physician orders dated 5/6/20 at 5:31 PM identified to administer Lorazepam 1 mg every three (3) hours as needed for a CIWA scale of 7-12. Administer Lorazepam 2 mg every three (3) hours as needed for a CIWA score of 13-18, administer Lorazepam 3 mg every three (3) hours for a CIWA score of 19-22 and administer Lorazepam 4 mg every three (3) hours for a score greater than 22.

Psychiatry notes dated 5/8/20 at 3:18 PM identified Patient #2 did utilize 2 mg of Lorazepam yesterday and 1mg today but no CIWA scoring was noted in Patient #2's chart. The note further identified that the psychiatrist spoke to the nurse and requested CIWA score on Patient #2 as the patient appeared very anxious AND may need additional Lorazepam.

Review of the CIWA flowsheets for Patient #2 from 5/6/20 at 7:49 PM through 2:00 PM on 5/8/20 identified CIWA scoring was not completed every 3 hours as per physician order and hospital policy. The flow sheets identified on 5/7/20 although vital signs were taken regularly the CIWA scale for withdrawal symptoms was not completed every three hours as ordered.

Interview with Psychiatrist #2 on 6/2/20 at 10:00 AM stated that she assessed Patient #2 who appeared very anxious and she thought Patient #2 needed more Lorazepam. When she reviewed Patient #2's chart, she identified that the CIWA scoring was not completed on 5/7/20 and that Patient #2 did receive Lorazepam. Psychiatrist #2 stated that the CIWA score is to be completed every three hours to be able to evaluate Patient #2's withdrawal symptoms and the effectiveness of treatment.

Interview with RN #3 on 6/3/20 at 1:55 PM stated that the CIWA score is to be completed every three hours and if a patient isn't exhibiting any symptoms, she either leaves it blank or puts zeros in the column. RN #3 stated that although Patient #2 was exhibiting anxiety and was administered Lorazepam after group on 5/7/20 she did not complete the assessment and could not recall why she did not complete it.

Interview with the Director of Behavioral Health on 6/2/20 at 1:40 PM stated nursing staff are to complete the CIWA assessment as ordered. The Director stated that with Patient #2, the order was for (CIWA assessments) every three hours. Review of the clinical record with the Director at that time identified that although Patient #2 received Lorazepam on 5/7/20 at 8:15 PM, the clinical record lacked documentation that the CIWA score was completed.

Review of the hospital policy for detoxification guidelines identified, the guidelines are to provide a consistent approach to detoxifying patients from alcohol, sedatives/hypnotics and opioids. The policy for alcohol detoxification protocol with the use of Lorazepam identified, the protocol would be initiated for a minimum of 24 hours and the registered nurse will obtain a CIWA every hour or when clinically indicated and administer medications based upon CIWA score, observe for symptoms of ataxia, fever, dilated pupils, tremors, confusion, lethargy, nystagmus, disorientation, insomnia, paranoia, hallucinations, change in respiratory rate, or autonomic hyperactivity.

The Condition of Participation for Physical Environment has not been met.

Based on observation during tour of the hospital, review of hospital documentation, and interviews with staff, several possible points of ligature hazards i.e. plexiglass window covers that had holes drilled on them to close or open the blinds between the plexiglass window covers and plate glass windows also the plate glass windows in patient rooms are protected by plexiglass window covers that are secured with institutional fasteners and the fasteners were removed by patient#3 on the day of elopement, enabling patient#3 to use the window blinds between the plexiglass window covers and plate glass windows and/or a chair to break the plate glass window to the exterior and it was also observed that the corridors contained tempered glass windows without security film.

Please see A701

Based upon a tour of the hospital, review of facility documentation, and staff interviews, the facility failed to ensure that the 8th floor Suisman Building Adult dual diagnosis unit, the 7th floor Suisman Building Adult Behavioral Health Unit and the 7th floor Auerbach Building Child & Adolescent Behavioral Health Units Behavioral Health Nursing Units were designed and maintained in such a manner as to promote the safety and well-being of patients. The findings include:

1. On 06/11/2020 - 06/23/2020 at 5:00 PM and times throughout the survey, the surveyor, while accompanied by the Director of Safety and Security, Security Captain, the Director, Quality, Patient Safety, Regulatory Affairs, the Facilities Maintenance Manager, the Engineering Group Leader and the Director of Nursing for Behavioral Health Services, the following were observed:
a. On 6/11/2020, Patient #3 eloped from Room 738 in the Suisman Building by removing the security screws from the plexiglass window covers for the rooms exterior window and removed the window blinds in between the plexiglass window covers and exterior window to break the window out and may have used a chair also. Interview with the Security Captain and the Director of Nursing for Behavioral Health Services on 6/11/20, at approximately 5:30 PM identified that the patient tied four (4) sheets to the wall mounted heating unit attached to the wall and lowered him/herself over the side of the building and then dropped approximately 25-30 feet into a tree with branches breaking his/her fall and then went to the ground. As this incident was happening Security had received calls of someone hanging from the side of the building. Upon Securities arrival, Patient #3 saw the approaching security officer, got up, ran down the road and security weren't able to return the patient to the facility. The Hartford Police were subsequently notified. During tour of the unit, the surveyor was able to remove additional security screws from the heating unit that were loose and could be removed without tools by hand on the day of this incident in room 738 (Patient #3's room). Prior to the onsite visit, the facility had secured the window and room and was in the process of checking all security screws on windows and rooms for the rest of the units.
b. Record review identified that the facility conducted routine window checks for loose security screws, broken glazing or any defects with the units windows. The last check prior to this incident were conducted between 01/14/2019 - 06/26/19 and the last risk assessment conducted was on 06/01/2020. On the 2019 window checks the facility documentation lacked any qualitive and/or quantitative results of these checks i.e. single space checklist with no findings and only hours spent. The risk assessment dated 06/01/2020 identified room 738 as 735 and all areas were identified as having no concerns. The risk assessment dated 06/17/2020 (subsequent to the incident) identified loose, stripped, and missing screws in patient rooms 721,723, 725, 727, 729, 731, Group Room 730, 734, and 736. Subsequent interview of the Engineering Group Leader and Facilities Maintenance Leader identified that they are in the process of re-securing the window plexiglass window covers with another method to eliminate the security screws but couldn't explain the loose security hardware.

2. On 06/18/2020 - 06/23/2020 at 3:00 PM and times throughout the survey, the surveyor, while accompanied by the Facilities Maintenance Manager, the Director, Quality, Patient Safety, Regulatory Affairs, the Engineering Group Leader and the Director of Nursing for Behavioral Health Services the following being observed:

a. The 8th floor Suisman Building Adult dual diagnosis unit, the 7th floor Suisman Building Adult Behavioral Health Unit, and the 7th floor Auerbach Building Child & Adolescent Behavioral Health Units had patient sleeping rooms that had Plate Glass windows in Patient Rooms protected by Plexiglass window covers. The plate glass windows were breakable if the plexiglass window covers were removed due to them not being protected by security film and/or lockable security screen that posed a potential injury hazard and were not designed or maintained to psychiatric institutional standards or Behavioral Health Design Guide Edition 9.0 November, 2019 or the 2017 edition 7.2; i.e. all windows units shall be properly safeguarded from patients-permanent measures are required to be applied. Subsequent to this observation and staff interviews on 06/18/2020 at approximately 3:00PM with the Facilities Maintenance Manager, the Director, Quality, Patient Safety, Regulatory Affairs, the Engineering Group Leader and the Director of Nursing for Behavioral Health Services identified that the facility was in the process of getting quotes and was in the process of having all window protection upgraded.

b. The 8th floor Suisman Building Adult dual diagnosis unit, the 7th floor Suisman Building Adult Behavioral Health Unit and the 7th floor Auerbach Building Child & Adolescent Behavioral Health Units had windows to common areas, the nurse station and group rooms that were tempered glass that breaks into small shards when broken that posed a potential injury hazard and or elopement hazard and were not designed or maintained to psychiatric institutional standards or the Behavioral Health Design Guide Edition 9.0 November, 2019 or the 2017 edition 7.2; i.e. no protective glazing or security film. Subsequent to this observation and staff interviews on 06/18/ & 06/23/2020 at 9:00 AM and times throughout the survey with the Facilities Maintenance Manager, the Director, Quality, Patient Safety, Regulatory Affairs, the Engineering Group Leader and the Director of Nursing for Behavioral Health Services identified that the facility was in the process of getting quotes and was in the process of having all window protection upgraded.

c. The 8th floor Suisman Building Adult dual diagnosis unit, the 7th floor Suisman Building Adult Behavioral Health Unit and the 7th floor Auerbach Building Child and Adolescent Behavioral Health Units had plexiglass window covers protective cover for exterior windows that had holes to close or open the blinds between the plexiglass window covers and plate glass windows creating several potential ligature attachment points and were not designed to psychiatric institutional standards and/or the Behavioral Health Design Guide Edition 9.0 November, 2019. Subsequent to this observation and staff interviews on 06/18/ & 06/23/2020 at 9:00 AM and times throughout the survey with the Facilities Maintenance Manager, the Director, Quality, Patient Safety, Regulatory Affairs, the Engineering Group Leader and the Director of Nursing for Behavioral Health Services identified that the facility has put an immediate action plan in place and was actively covering the holes.