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Based on observation and interview, the facility failed to provide a safe and sanitary environment, resulting in the potential for harm and less than optimal outcomes to all 175 patients served by the facility. Findings include:

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A-701 Failure to provide safe environment. Ligature risk

A-724 Failure to ensure furniture promoted safety.
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Based on observation and interview, the facility failed to maintain a safe and sanitary physical environment for all 173 patients at the facility at the time of observation, resulting in the potential for less than optimal outcomes and the potential for harm, including death. Findings include:

On 11/27/2023 at 1120, during the facility tour on (adult co-ed) Unit E, patient room doors were noted to be a possible ligature risk. The Chief Operations Officer (COO), Staff C was queried about the patient room doors being "ligature free". Staff C indicated that the doors were recognized as a risk to patient safety, and that new doors were on order. Staff C described the new doors as having a "piano hinge" (a solid closed hinge) and that the intent was to replace all patient doors. The Assistant Chief Nursing Officer (ACNO), Staff G, then pointed out one of the newer "ligature resistant" doors.

On 11/27/2023 at 1130, room 514 was observed to have one of the new doors. Staff B, C, E, & G confirmed patient room (514), was fitted with a "ligature resistant door". Staff G stated "these doors were vetted by the supplier as well as the state". A 2X6 inch rectangular hole was observed in the doorframe above the new door. At 1131 this writer requested a flat sheet be brought to room 514. Staff G returned to room 514 with a flat sheet in hand. In less than one minute the sheet was used by the writer to secure a ligature point, strong enough to hold an adult off the floor. The excess sheet was then used to wrap securely around one's neck resulting in the potential for asphyxiation. There was enough excess sheet that it could be tied in a loop and used around the neck, to induce suffocation while bending one's knees, doing an alligator roll or hanging.

While performing the above maneuvers, the door was in both the open and closed positions without visibility from the hallway staff or cameras. The lack of visibility was confirmed by facility Staff B, C, E, and G.

All of the above above described activity was witnessed by, and confirmed by the COO, CNO, Director of Regulatory and the ACNO. A request was made for a tally of patient room doors, including hinge types. The tallys were as follows:

Total patient room doors: 97
Piano hinged doors: 21
Multi-hinged doors: 76

An Immediate Jeopardy was called on 11/28/2023 at 1512.

An additional ligature risk evaluation was completed on 11/29/2023, while patients were scheduled to be off the unit for activities.

On 11/29/2023 at 1130, the Director of Plant Operations, Staff O, who is in charge of ordering and installing doors, the Director of Risk Management, Staff D, in charge of evaluating the environment for patient safety risks, and a state employed Engineer Surveyor were present during the evaluation. Both types of doors were evaluated and confirmed to be a potential ligature risk on 11/29/2023 at 1134.

Twenty-one (21) doors with a solid hinge (Piano Hinge) and the concerning 2X6 inch holes were determined to be installed and in use.
One of the piano hinged door frames was newly retrofitted with a metal cover plate, obstructing the 2 x 6 inch hole where the sheet was stuffed and anchored.

Twenty (20) door frames remained with a 2 x 6 inch hole in the top frame.

Seventy-Six (76) remaining patient rooms, still had the multi hinged doors, (previously recognized as a safety risk) by the facility.

On 11/29/2023 at 1230, when queried, the Director of Risk Management, Staff D and Director of Plant Operations, Staff O, described the risk mitigation for multi-hinged doors, was to replace them with the solid hinged doors (piano hinge).


13069

On 11/29/2023 starting around 10:00 AM during a tour of the Unit D of the second floor and all following floors/units (including clean and dirty storage rooms), excessive build-up of lint and grime were observed on the floors specifically behind doors, on shelving units, on the walls, and on the ventilation grilles.

Above findings were also confirmed by accompanying staff members C and D at the time of observation.

Based on observation and interview, the facility failed to provide furniture that promoted safety in the psychiatric setting on 4 (unit A, B, C, D) of 4 patient care units observed, resulting in the potential for harm to all patients on the four units. Findings include:

On 11/29/2023 at around 10:00 AM during the tour of the second floor unit D, the facility completely or partially replaced heavyweight chairs with a lightweight (plastic) chairs in the unit's activity room, quiet room, and dining room. The lightweight plastic chairs could be easily thrown and/or used as a weapon. The same observations were made on units A, B, and C.

At the time of observation, accompanying staff members C and D confirmed the findings and agreed the lightweight chairs were not the best type of chair for the psychiatric setting.