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Based on surveyor observation and staff interviews, it has been determined that the hospital has failed to ensure the patient's right to receive care in a safe setting, and to provide protection for the patient's physical safety.

Findings are as follows:

Refer to A 701

Based on surveyor observations, staff interviews, and review of Behavioral Health Safety Inspections data, it was determined that the hospital failed to set priorities for physical environment improvement activities on high risk, problem prone areas by using data obtained to improve patient safety.

Findings are a follows:

1) Refer to A701.

2) Following an interview on 1/5/11 at approximately 9:00 AM with the Director of Plant Engineering and Maintenance, he produced evidence of the bi-annual Behavioral Health Safety Inspection of 6/24/10 when safety issues were addressed, corrective actions identified, and expected dates of completion targeted as late as April 30, 2011. Also, a hospital Behavioral Health Safety Assessment was completed on 11/27/10 following a hospital occurrence, and further opportunities for improvement were identified with an immediate action plan. Additionally, some of these safety issues had also been identified during a hospital survey completed on 1/29/09.

Although the hospital has identified a number of potential hazards on the psychiatric care units that include lever door handles, exposed sink plumbing, exposed heating valves, and open door hinges, and is implementing corrective actions on a phase-in basis, surveyor observations of the hospital psychiatric units on 1/5/11 and 1/10/11 revealed that the hospital continues to have safety issues, and failed to set priorites to improve patient safety on a more immediate basis for these high risk, problem prone Behavioral Health Units.

Based on surveyor observation, record review, and staff interview it has been determined that the hospital has failed to ensure that the physical condition of the four psychiatric units are maintained in a manner to assure the safety and well-being of patients.

Findings are as follows:

During tour of the 4 psychiatric units of the hospital on 1/05/11 from 7:55AM to 9:30AM with the Director of Plant Engineering and Maintenance, the Clinical Quality Coordinator, the Acting Risk Manager, and the Clinical Manager for Unit 2 Center, the following physical conditions were observed:

1. Center 2, a 30 bed adult psychiatric unit, has a floor model television in the dining room with an unsecured electrical cord approximately 3 feet in length plugged higher than the TV itself, hospital beds with open rails not used only for psychiatric patients who require them, and crank beds that pose potential hazards for patients at risk of harming themselves.

. 2. The 2 South 12 bed general adult psychiatric unit has lever door handles, cut door hinges, automatic door closure mechanisms, a 6 inch exposed plumbing pipe and a goose neck faucet in the bathroom adjacent to the seclusion room, exposed heating control valve pipes, lever type sink hardware in all patient rooms and common bathrooms, a round faucet control in the shower room, hospital beds with open rails not used only for psychiatric patients who require them, and crank beds that pose potential hazards for patients at risk of harming themselves.

3.The 2nd floor 8 bed Intensive Treatment Unit has lever door handles on the seclusion room and shower room door, and a round handle faucet control in the shower room that pose potential hazards for patients at risk of harming themselves.
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4.The 3rd Floor South 21 bed Geriatric Psychiatric Unit has lever door handles, exposed sink plumbing in the community bathroom, radiators with exposed heating control valves, a television in the dining room on a stand with an unsecured electrical cord approximately 4 feet in length, hospital beds with open rails not used only for psychiatric patients who require them, and crank beds that pose potential hazards for patients at risk of harming themselves.

During interviews with the above staff on 1/05/2011, they indicated that patients may be alone in the dining rooms.

Additionally, staff indicated that on 11/29/2011 due to a hospital occurrence in Room 246, where a patient was able to remove a crank from a hospital bed, break a window with the crank, climb out of the window, and sustained a distal tibia and calcaneal fracture, the hospital conducted a risk assessment on all the above units and developed a plan to address potential risks.
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Although there are new platform beds on order, the 52 crank beds presently remain in use.

The above environmental concerns had been previously noted during a survey in January 2009.

During interview with staff on 1/06/2011 at approximately 10:00 AM, the surveyor was informed that in June 2010 a safety plan was developed to address potentially hazardous faucets, exposed sink plumbing, exposed radiator pipes, and cut door hinges, with expected dates of completion.