HospitalInspections.org

Based on review of hospital documents, training records, and staff interviews, it was determined the hospital failed to ensure the
behavioral health technicians were trained with competencies verified for moving or transferring patients and providing peri-care to female patients, for 7 of 7 behavioral health technician (BHT's). This failure could result in patient harm with improper moving or peri-care.

Findings include:

Review of the hospital document titled "Haven Training Matrix--Initial Orientation," included a list of classroom content and the online courses for BHT's. This document did not include training on moving or transferring patients safely from the bed to a wheel chair or from a wheel chair to a bed. The document did not indicate that peri-care was taught to the BHT's for female patients.

The Clinical Educator confirmed on 03/15/17, that they have not had specific training for BHT's in moving patients or education on peri-care for female patients. S/he confirmed that BHT's are responsible for cleaning incontinent female patients and that they would be performing peri-care.

Seven (7) BHT's working at the facility, confirmed during an interviews conducted on 03/15/17, that they have not had training on moving patients, nor have they had training on peri-care.

Based on observations during a tour of the units and interview with staff, it was determined the hospital failed to ensure the safety of patients as evidenced by the following ligature points;

1. The Mesquite Unit had 15 sink faucets that extended approximately 6 inches over the sink, 7 bath tubs with faucets that extended approximately 8-9 inches inches over the tub, each with a water control valve, that could be used as a ligature;

2. two (2) oxygen concentrator units, with approximately 6 foot long electrical cords;

3. patient beds with footboards and siderails, that could be used as ligature points when the beds were not in the low position; and

The failure to remove these ligatures poses the high potential risk of patient harm by hanging.

Findings include:

A tour of the Mesquite Unit on 03/14/17, at 1000 hours, with the Quality/Risk Manager was conducted. Each of the 15 rooms contained a sink that had a faucet that extended over the sink approximately 6 inches, that could be used as a ligature point for hanging. The hospital has 15 sinks with this type of faucets. This unit also contained 7 bathtubs with faucets that extended approximately 8-9 inches over the tub, each with a water control valve that could be used as a ligature.

The Quality/Risk Manager confirmed these items could be used as a ligature point for a patient to hang themselves.

A tour of the Juniper Unit on 03/15/17, at 1100 hours, with the Quality/Risk Manager was conducted. An oxygen concentrator was observed in a room by a bed. The concentrator was plugged in, with an electrical cord that was approximately 6 foot long. The concentrator was left unattended and not in use by a patient when observed during the tour. A second oxygen concentrator with a 6 foot electrical cord was observed in a group room plugged in, without a patient using the unit. Another patient was present in the group room, no staff were present with the equipment or other patient.

The Quality/Risk Manager confirmed the electrical cords could be used by a patient to harm themselves by hanging.

Patient beds in the Mesquite and Juniper Units had footboards and siderails. All beds observed were not in the low position. This allowed the beds to be off the floor greater than 10 inches, thereby creating a ligature point with the footboard and siderails.

The Quality/Risk Manager confirmed that this could be used as a ligature point for a patient to harm themselves by hanging.