HospitalInspections.org

Based on observation, interview and record review, the facility failed to meet the Condition of Participation requirements for Patient Rights. The facility failed to ensure compliance with patient's rights to receive care in a safe setting and to be free from abuse:

A) Patients on suicide precautions were exposed to a room that contained ligature risks and other patient safety hazards on the facility's A1/A2 unit. The unit, a general adult male unit, had a dysfunctional self-locking door opening to a nutritional galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. There were currently 19 patients with active suicide precautions orders residing on the unit (refer to tag A-144);

B) Facility's A1/A2 unit had a hallway leading to it with a door opening to a group activity room that also contained ligature risks and other patient safety hazards accessible to patients. This room also had a dysfunctional self-locking door which failed to automatically lock. This was also unrecognized by staff (refer to tag A-144);

C) Facility was not adhering to their own Safety/Security Risk Assessment-Hospital Wide procedure for not having any plastic bags on campus; large plastic trash bags were found inside the A1/A2 unit's galley room (refer to tag A-144);

D) Facility had two bulletin board units present in the entrance to the hospital made of materials that were unsafe to be used in a behavioral health hospital. These bulletin boards were identified as an environmental risk (refer to tag A-144);

E) Facility failed to ensure staff maintained patients' food trays at a safe temperature once the trays were delivered to the unit. Staff had not been properly educated on the safe storage of food trays that had been delivered to the unit. A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas (refer to tag A144);

F) Facility failed to ensure that a timely and thorough, objective investigation of allegations of abuse made by a patient was conducted by the Risk Manager as outlined in hospital policy. Additionally, the facility failed to ensure that the three licensed staff members that conducted a skin assessment on this patient reported to the Risk Manager the allegations of abuse made by this patient (refer to tag A-145)

Based on observation, interview and record review, the facility failed to meet the Condition of Participation requirements for Physical Environment. The facility failed to ensure the hospital was maintained to ensure compliance with patient safety:

A) Patients on suicide precautions were exposed to a room that contained ligature risks and other patient hazards on the facility's A1/A2 unit. The unit, a general adult male unit, had a dysfunctional self-locking door opening to a nutritional galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. There were currently 19 patients with active suicide precautions orders residing on the unit (refer to tag A-701);

B) Facility's A1/A2 unit had a hallway leading to it which had a door opening to a group activity room that also contained ligature risks and other patient hazards which was accessible to patients. This room also had a dysfunctional self-locking door which failed to automatically lock. This was also unrecognized by staff (refer to tag A-701);

C) Facility had two bulletin board units present in the entrance to the hospital made of materials that were safe to be used in a behavioral health hospital. These bulletin boards were identified as an environmental risk (refer to tag A-701).

Based on observation, interview and record review, the facility failed to ensure patient's rights to receive care in a safe setting as shown by:

A) Failing to prevent 19 of 29 patients on facility's Unit A1/A2 who were on active suicide precautions (Patient #'s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30), from being exposed to a room containing hazards for self-harm. This unit, housing adult males, had a dysfunctional self-locking door opening into a patient nutrition galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. The room, which connected to the unit's common area dayroom, contained numerous ligature risks and other hazards;

B) Unit A1/A2 had a hallway leading to it which had a door opening to a group activity room that was also a dysfunctional self-locking door that failed to automatically lock, and remained open. This was also unrecognized by staff. There was potential for patients passing through the hallway to enter this room which contained ligature risks and other potential safety hazards to patients;

C) Facility was not adhering to their own Safety/Security Risk Assessment-Hospital Wide procedure for not having any plastic bags on campus; large plastic trash bags were found inside the A1/A2 galley room.

D) The presence of 2 of 2 bulletin board units in the common entrance foyer to the hospital which were made of materials that were unsafe to be used in a behavioral health hospital. The bulletin boards were identified as an environmental risk, and;

E) Staff failing to maintain 6 of 6 food trays at a safe temperature once the trays were delivered to the unit. Staff had not been properly educated on the safe storage of food trays that had been delivered to the unit. A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas.


Findings included:

A. B. and C.

Review of facility policy #200.08 titled "SAFETY OF PATIENTS, VISITORS AND OTHERS. Section 02: PATIENT CARE PROCEDURES", revised 03/31/2020 showed that to ensure a safe and secure environment of care, staff will conduct safety rounds on the physical environment every shift done by nursing staff. All safety concerns will be reported to the Charge Nurse or House Supervisor.

Review of facility policy #200.29 titled "ROUNDS FOR PATIENT OBSERVATION. SECTION 02: PATIENT CARE PROCEDURES" last revised 03/31/2020 showed that staff who are performing patient rounds are to observe for and report physical plant damage and ensure that doors which are supposed to be locked, are in fact locked.

Review of facility policy # LD 1.02 titled "PATIENT SAFETY PLAN. SECTION 05: LEADERSHIP", last revised 02/11/2025 showed that the Patient Safety Plan included identifying Hazardous Conditions as part of the ongoing risk assessments, and leadership will perform rounds on a daily basis in patient care areas to ensure safe practices are occurring. In addition, the scope of the Patient Safety Plan encompasses patient safety issues with environment of care.

Observation on 4/9/25 at 3:15 pm of the facility's Unit A1/A2, an all male general adult unit showed the following: There was a large common area dayroom filled with several patients watching TV. A door was present in this room labeled "Galley". This door was cracked open and not closed shut. When the door was pushed open and allowed to close and self-lock on its own as it was designed for, it failed to do so and remained ajar. The door was then tested several times by pushing it open and allowing it to shut on its own, but it consistently and repeatedly failed to do so. This allowed free and effortless entry by all patients on the unit.

Observation inside the Galley room during the time of the door failure findings showed it was mainly being used for patient nutrition and storage. The following were found: ligature risks consisting of numerous metal cabinet door 'loop' type handles, a metal 'V'-shaped door closer protruding from top of the door, a metal refrigerator handle, a 4-foot electrical cord from an ice machine, a sink faucet; large plastic trash bags-one lining a trash can and another unused bag hanging from the side of the trash can-representing suffocation/strangulation risks; a large metal-frame cup holder which could be used as a weapon; a return air vent on the ceiling that led to a space in-between ceiling and roof, large enough for a patient to crawl into and accessible by standing on two tables being stored in room.

In an interview at the time of findings with Administrator (CEO) Staff #A, who was present at the time, he stated that the door should have been shut and locked, and there were numerous patient safety risks inside the room, including ligature points. Staff #A also stated that there should be no more plastic bags allowed on the campus.

In an interview at the time of findings with Director of Plant Operations (DPO) Staff #G, who was also present at the time, he stated that the door to the Galley was not shutting and locking like it should have and must never remain open and unlocked due to ligature risks inside room.

In an interview at the time of findings with Assistant Chief Nursing Officer (ACNO) Staff #C, she stated there were ligature risks inside the Galley room and the door must remain closed and locked.

Record review of the patients clinical charts who were present on Unit A1/A2 revealed there were 19 on active suicide precautions: Patient #'s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30.

Review of facility's documents titled "Safety/Security Risk Assessment-Hospital Wide" showed the following identified hazardous items/conditions inside Unit A1/A2's Galley: "Multiple misc. ligature points (door frame, closer, refrigerator, cabinet door pulls, vents, ice machine, faucet)". The staff responsible for monitoring this room were listed as Nursing and Plant Ops.

Further observation on 4/9/25 at 3:35 pm revealed there was a common area hallway leading into Unit A1/A2. This hall was typically used staff and also by groups of patients when being led around the facility campus by staff. There was another self-locking door identified which opened to the hallway used as a patient activity room, "A101 Activity/Group Room". This door was also cracked open like the Galley room door and did not close shut and lock automatically as it was designed to do.

Observation inside this room revealed it to have a 'drop ceiling', also known as a false ceiling, which had removable tiles. Behind these tiles were ligature risks consisting of plumbing pipes for the sprinkler system, electrical conduits, and light fixtures. Tables and chairs inside this room allowed a patient to stand on top of them to access the ceiling. In addition, there was also a "V"-shaped metal door closer protruding from the top of the door, window blinds, and a TV mount. There was also a portable oxygen tank present on a metal stand with an attached nasal cannula air hose. There were also large air vents present in the room.

In an interview at the time of findings with DPO Staff #G, he stated that there were ligature risks inside the room and the door should have been shutting closed and locking automatically like the Galley room door. He also stated that the doors were part of the facility-wide risk assessment and should have been noticed by staff and reported to him.

Further review of the facility's risk assessment document showed the following hazards for the Activity/Group Room: "Door Frame, chairs, closer, blinds, tv and mount, cords, vents"; Under the heading "Mitigation of Risk", it stated that patients are not allowed in this room without a staff member and the door is secured with a "store room function lock and closer". In addition, under the heading "Mitigation of Risk", it stated that patients are not allowed in this room without a staff member, and the door is secured with a "store room function lock and closer". The staff responsible for monitoring this room were listed as Nursing and Plant Ops.





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D. Bulletin Boards.

During a tour of the hospital on 4/11/2025 at 10:30 AM, two enclosed bulletin boards each with two locking sliding glass doors were observed in the vestibule or airlock (the area that acts as an antechamber between the exterior and the interior structure) at the front entrance of the hospital.

In an interview with Staff A (CEO) and Staff G (DPO) during that tour, they both stated that the glass could be easily broken and then used as a means of harming self or others. They also stated the bulletin board units needed to be replaced with units made from shatter-resistant materials.

Record review of the Environmental Risk Assessment showed that the assessment did not include the bulletin board units with sliding glass doors as an environmental risk.


E. Safe Temperature of Food Trays.

Record review of Policy # C015, "Tray Identification / Delivery / Pick-up," revised 1/2025, showed: "All trays / food served from Food and Nutrition Services Department ... [are] marked with the patient's identifying information. Trays are delivered to each nursing unit by Food and Nutrition Services Department." The remainder of the policy is geared more toward medical surgical facilities and not specific to the unique needs of Houston Behavioral Healthcare Hospital's psychiatric population. Timeframes and mechanisms for storage of food on the units are not outlined in the policy.

During a tour of the adult male unit (A1-A2) on 4/10/2025 at 1:30 PM, six 3-compartment foam hinged lid containers were observed on a small table in the galley. Each container had a patient name and "11:20" [AM] written on the lid and contained chicken and sausage jambalaya, fried okra, and a dinner roll. Based on the documentation on the lid, the food had been in the containers for over two hours.

In an interview with Staff J [MHT] during the tour on 4/10/2025 at 1:30 PM, he stated the six trays that were on a small table in the galley were for patients that had missed lunch because they were asleep. When asked how long the trays could be left out at room temperature, he stated, "How long do you think they can be left out." When pressed by the surveyor to answer the question, he stated he thought the trays could be left out at room temperature for two hours. He was prompted to look at the timeframe written on the lid of the containers, noting that over two hours had passed. He discarded the food only after being prompted to do so.

In an interview with Staff F [Dietary Manager] on 4/11/2025 at 10:07 AM, she stated that some patients are not allowed to come to the cafeteria for meals and that meals are taken to the unit for those patients. She also stated:
" Food is placed in Styrofoam containers by kitchen staff.
" Containers with special diets are labeled with the patient's name and the type of diet.
" The time the containers leave the kitchen is also written on the top of each container of food.
" The containers are delivered to the units on a food cart.
" The MHT on the unit passes out the food to patients.
" The containers of food can sit on the counter for one hour.
" After one hour, the containers are placed in the refrigerator by unit staff.
" When snacks are taken to the units between meals, the containers of food that have been placed in the refrigerator are discarded by kitchen staff.
She concluded by saying, "When I got here, this is the way they did it. I'm unsure of the policy."

In an interview with Staff L [Infection Control] on 4/10/2025 at 2:15 PM, he stated food could be left out for an hour if the room temperature was over 90 degrees and for two hours if the food was at room temperature. He also stated he did not know about the training that Staff C [ACNO] had provided on food storage about a year ago. Also of note, Staff L [Infection Control] had been asked if there was a policy that addressed the timeframes of food storage. The only policy that was provided was Policy # 09 IC 3.03 DRAFT, revised 1/31/2024, titled "Transmission Based Precautions." This policy did not address the issues being discussed.

In an interview with Staff C [Assistant CNO] on 4/10/2025 at 2:10 PM, she stated, "Food can be on the unit for 30 minutes, then to the refrigerator to be disposed of within 2 hours from the time it left the kitchen." She also stated she got the material for her training from Staff F [Dietary Manager], adding that the training was conducted in August of 2024 and "about 80% of the staff got the training." She concluded the interview by saying that additional training needed to be done for all staff handling the patient's food.

Based on observation, interview, and record review, the facility failed to ensure that a timely and thorough, objective investigation of allegations of abuse made by Patient #3 was conducted by the Risk Manager as outlined in hospital policy. Additionally, the facility failed to ensure that the three licensed staff members that conducted a skin assessment on Patient #3 reported to the Risk Manager the allegations of abuse made by Patient #3.

Findings were:

Record review of the policy RI.1.16, "Abuse, Neglect, and Exploitation Reporting, Investigation and Response to Internal Events", revised 2/2024, showed:
"As Houston Behavioral Healthcare Hospital respects and protects the rights and dignity of the individuals served, all allegations of abuse, neglect or rights violations within the facility will be investigated ...
D. Investigation
a. All allegations of patient abuse, neglect or exploitation will be promptly and objectively investigated by the Director of Risk Management by interviewing individuals involved or witnessing the event and conducting a thorough review of the case and situation."

Record review of the Daily Nursing Assessment Note for Patient #3 written by Staff Q [RN] on 2/23/2025 at 9:00 AM showed: "Patient reported to nursing staff stating, 'One of the overnight male staff hit me on my shoulder and I want to be transferred to another unit' ... patient [reported to a family member]. Family member reported to police. Police showed up at the facility to take patient's report. Patient made statement to police ... Physician was notified ... ordered a skin assessment of patient's upper extremities to rule out injury. Skin assessment conducted by NP [Nurse Practitioner], supervisor, and nursing staff at 12:45 PM. Assessment showed no injury, no lacerations. Patient denies all pain or injury."

Record review of the Physician Progress Note for Patient #3 written by Staff P [Nurse Practitioner] on 2/23/2025 at 1:31 PM showed: "A bald guy beat me up last night." The patient phoned her sister who then phoned the police. "Skin assessment done by NP and 2 RNs."

Record review of the Grievance Log showed that on 3/11/2025 (not timed) Patient #3's "mother presented to the hospital regarding report of alleged abuse that occurred while the patient was admitted. Mom felt that daughter wouldn't just make up that someone abused her and that no one did anything about it when it took place."

Record review of the investigative note dated 3/11/2025 [not timed] written by Staff D [Patient Advocate] outlining allegations of abuse made by the mother of Patient #3 showed: "Patient mother presented to facility 3/11/25 regarding report of alleged abuse on 2/22/25 while the patient was admitted in our facility. Mom feels patient wouldn't just make up someone abusing her and that no one did anything about it. Patient Advocate met with mother retrieving incident reports associated with patient and nursing notes. Advocate noted prior elopement attempt and false 911 call three days prior of alleged event. Disorganized thought process and skin assessment post notifying staff of alleged assault towards her which noted no findings supporting her allegation."

In an interview with Staff D [Patient Advocate] on 4/9/2025 at 12:45 PM, he stated: Patient #3 described the male staff member that allegedly assaulted her as "tall" and "wearing a beanie-style hat." He further stated that he reviewed the surveillance video for 2/23/2025 for the following timeframes: 10:00AM - 5:00PM and 11:00PM - 2:00AM, adding "The surveillance video for 11:00PM-2:00AM showed Staff J [MHT] making rounds. He was wearing a beanie-style hat. He was seen interacting with Patient #3. At times Staff J [MHT] would be off camera in patient's rooms as he rounded." Staff D [Patient Advocate] concluded the interview by saying he did NOT talk with Staff J about the allegations.

In an interview with Staff J [MHT] on 4/9/2025 at 4:55 PM, he was observed as being a tall - approximately 6'6" - black male. He was wearing a beanie hat. He was shown a picture of Patient #3. He stated he remembered her. He also stated he knew nothing of any allegations of abuse made by Patient #3 toward him or anyone else. He also stated he had not been questioned by Staff D [Patient Advocate] or Staff B [Risk Manager] about any allegations of abuse made by Patient #3. It was during this interview that he "first heard of the allegations." He denied hitting Patient #3.

In interviews with Staff D [Patient Advocate] and Staff B [Risk Manager] on 4/9/2025 at 4:55 PM and 5:10 PM respectively, they stated that Staff Q, the RN on duty when Patient #3 alleged abuse; the RN Supervisor; and Staff P, the Nurse Practitioner, did NOT report to them any allegations made by Patient #3 of abuse by a male staff member. Staff B [Risk Manager] went on to say that he had not been involved in the investigation of alleged abuse made by Patient #3, adding that he had read the letter composed by Staff D [Patient Advocate]. Staff B [Risk Manager] concluded by saying that allegations of patient abuse are to be investigated by him as the Risk Manager.

Based an observation, interview, and record review, the facility failed to ensure that the Director of Dietary Services was qualified in safety practices for food handling. This resulted in the facility's failure to ensure that:
1) Staff maintained 6 of 6 food trays at a safe temperature once the trays were delivered to the unit.
2) Staff had been properly educated on the safe storage of food trays that had been delivered to the unit.
3) A policy clearly outlined the timeframes and mechanisms of safe food storage in the patient care areas.

Findings were:

Record review of Policy # C015, "Tray Identification / Delivery / Pick-up," revised 1/2025, showed: "All trays / food served from Food and Nutrition Services Department ... [are] marked with the patient's identifying information. Trays are delivered to each nursing unit by Food and Nutrition Services Department." The remainder of the policy is geared more toward medical surgical facilities and not specific to the unique needs of Houston Behavioral Healthcare Hospital's psychiatric population. Timeframes and mechanisms for storage of food on the units are not outlined in the policy.

During a tour of the adult male unit (A1-A2) on 4/10/2025 at 1:30 PM, six 3-compartment foam hinged lid containers were observed on a small table in the galley. Each container had a patient name and "11:20" [AM] written on the lid and contained chicken and sausage jambalaya, fried okra, and a dinner roll. Based on the documentation on the lid, the food had been in the containers for over two hours.

In an interview with Staff J [MHT] during the tour on 4/10/2025 at 1:30 PM, he stated the six trays that were on a small table in the galley were for patients that had missed lunch because they were asleep. When asked how long the trays could be left out at room temperature, he stated, "How long do you think they can be left out." When pressed by the surveyor to answer the question, he stated he thought the trays could be left out at room temperature for two hours. He was prompted to look at the timeframe written on the lid of the containers, noting that over two hours had passed. He discarded the food only after being prompted to do so.

In an interview with Staff F [Dietary Manager] on 4/11/2025 at 10:07 AM, she stated that some patients are not allowed to come to the cafeteria for meals and that meals are taken to the unit for those patients. She also stated:
" Food is placed in Styrofoam containers by kitchen staff.
" Containers with special diets are labeled with the patient's name and the type of diet.
" The time the containers leave the kitchen is also written on the top of each container of food.
" The containers are delivered to the units on a food cart.
" The MHT on the unit passes out the food to patients.
" The containers of food can sit on the counter for one hour.
" After one hour, the containers are placed in the refrigerator by unit staff.
" When snacks are taken to the units between meals, the containers of food that have been placed in the refrigerator are discarded by kitchen staff.
She concluded by saying, "When I got here, this is the way they did it. I'm unsure of the policy."

In an interview with Staff L [Infection Control] on 4/10/2025 at 2:15 PM, he stated food could be left out for an hour if the room temperature was over 90 degrees and for two hours if the food was at room temperature. He also stated he did not know about the training that Staff C [ACNO] had provided on food storage about a year ago. Also of note, Staff L [Infection Control] had been asked if there was a policy that addressed the timeframes of food storage. The only policy that was provided was Policy # 09 IC 3.03 DRAFT, revised 1/31/2024, titled "Transmission Based Precautions." This policy did not address the issues being discussed.

In an interview with Staff C [Assistant CNO] on 4/10/2025 at 2:10 PM, she stated, "Food can be on the unit for 30 minutes, then to the refrigerator to be disposed of within 2 hours from the time it left the kitchen." She also stated she got the material for her training from Staff F [Dietary Manager], adding that the training was conducted in August of 2024 and "about 80% of the staff got the training." She concluded the interview by saying that additional training needed to be done for all staff handling the patient's food.

Based on observation, interview and record review, the facility failed to ensure the condition of the physical plant was maintained to ensure the safety and well-being of patients as shown by:

A) 19 of 29 patients on facility's Unit A1/A2 who were on active suicide precautions (Patient #'s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30, were exposed to a room containing hazards for self-harm. This unit, housing adult males, had a dysfunctional self-locking door opening into a patient nutrition galley room which failed to automatically lock, remaining open for easy patient accessibility. This was not recognized by any staff. The room, which connected the unit's common area dayroom, exposed patients to ligature risks and other dangers;

B) The same unit, A1/A2, had a hallway leading to it which had a door opening to a group activity room that was also a dysfunctional self-locking door which failed to automatically lock and remained open. This was also unrecognized by staff. There was potential for patients passing through the hallway to enter this room which also contained ligature risks and other potential hazards to patients;

C) The presence of 2 of 2 bulletin board units in the entrance to the hospital which were made of materials that were safe to be used in a behavioral health hospital. The bulletin boards were identified as an environmental risk.


Findings included:


Review of facility policy #200.08 titled "SAFETY OF PATIENTS, VISITORS AND OTHERS. Section 02: PATIENT CARE PROCEDURES", revised 03/31/2020 showed that to ensure a safe and secure environment of care, staff will conduct safety rounds on the physical environment every shift by nursing staff. All safety concerns will be reported to the Charge Nurse or House Supervisor.

Review of facility policy #200.29 titled "ROUNDS FOR PATIENT OBSERVATION. SECTION 02: PATIENT CARE PROCEDURES" last revised 03/31/2020 showed that staff who are performing patient rounds are to observe for and report physical plant damage and ensure that door which are supposed to be locked, are in fact locked.

Review of facility policy # LD 1.02 titled "PATIENT SAFETY PLAN. SECTION 05: LEADERSHIP", last revised 02/11/2025 showed that the Patient Safety Plan included identifying Hazardous Conditions as part of the ongoing risk assessments, and leadership will perform rounds on a daily basis in patient care areas to ensure safe practices are occurring. In addition, the scope of the Patient Safety Plan encompasses patient safety issues with environment of care.

Observation on 4/9/25 at 3:15 pm of the facility's A1/A2 unit, a general adult all male unit showed the following: There was a large common area dayroom filled with several patients watching TV. A door was present in this room labeled "Galley". This door was cracked open and not closed shut. When the door was pushed open and allowed to close and self-lock on its own as it was designed for, it failed to do so and remained ajar. The door was then tested by pushing it open and allowing it to shut on its own, but it repeatedly failed to do so. This failure could allow free and effortless entry by all patients on the unit.

Observation inside the Galley room during the time of the door failure findings showed it was mainly being used for patient nutrition and storage. The following were found: ligature risks consisting of numerous metal cabinet door handles, a metal 'V'-shaped door closer protruding from top of the door, a metal refrigerator handle, a 4-foot electrical cord from an ice machine, a sink faucet; large plastic trash bags-one lining a trash can and another unused bag hanging from the side of the trash can representing suffocation/strangulation risks; a large metal-frame cup holder which could be used as a weapon; a return air vent on the ceiling that led to a space in-between ceiling and roof, which was large enough for a patient to crawl into and accessible by standing on two tables being stored in room.

In an interview at the time of findings with Administrator (CEO) Staff #A, who was present at the time, he stated that the door should have been shut and locked, and there were numerous patient safety risks inside the room, including ligature points. Staff #A also stated that there should be no more plastic bags allowed on the campus.

In an interview at the time of findings with Director of Plant Operations (DPO) Staff #G, who was also present at the time, he stated that the door to the Galley was not shutting and locking like it should have and must never remain open and unlocked due to ligature risks in room.

In an interview at the time of findings with Assistant Chief Nursing Officer (ACNO) Staff #C, she stated there were ligature risks inside the Galley room and the door must remain closed and locked.

Record review of the patients clinical charts present on Unit A1/A2 revealed there were 19 on active suicide precautions: Patient #'s 10, 11, 12, 13, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 26, 27, 28, 29, & #30.

Review of facility's documents titled "Safety/Security Risk Assessment-Hospital Wide" showed the following identified hazardous items/conditions inside Unit A1/A2's Galley (a room connected to the common area dayroom, separated by a self-locking door): "Multiple misc. ligature points (door frame, closer, refrigerator, cabinet door pulls, vents, ice machine, faucet)". The staff responsible for monitoring this room were listed as Nursing and Plant Ops.

Further observation on 4/9/25 at 3:35 pm revealed there was a common area hallway leading into Unit A1/A2. This hall was typically used staff and also by groups of patients when being led around the facility campus by staff. There was another self-locking door identified which opened to the hallway used as a patient activity room the A101; Activity/Group Room. This door was also cracked open like the Galley room door and did not close shut and lock automatically as it was designed to do.

Observation inside this room revealed it to have a 'drop ceiling', also known as a false ceiling, which had removable tiles. Behind these tiles were ligature risks consisting of plumbing pipes for the sprinkler system, electrical conduits, and light fixtures. Tables and chairs inside this room allowed a patient to stand on top of them to access the ceiling. In addition, there was also a "V"-shaped metal door closer protruding from the top of the door, window blinds, and a TV mount. The was also a portable oxygen tank on a metal stand with an attached nasal cannula air hose. In addition, there were also large air vents present in the room.

In an interview at the time of finding with DPO Staff #G he stated that there were ligature risks inside the room and the door should have been locking automatically like the Galley room door. He also stated that the doors were part of the facility-wide risk assessment and should have been noticed by staff and reported to him.

Further review of the facility's risk assessment document showed the following hazards for the units Activity/Group Room: "Door Frame, chairs, closer, blinds, tv and mount, cords, vents". In addition, under the heading "Mitigation of Risk", it stated that patients are not allowed in this room without a staff member and door is secured with a "store room function lock and closer". In addition, under the heading "Mitigation of Risk", it stated that patients are not allowed in this room without a staff member and the door is secured with a "store room function lock and closer". The staff responsible for monitoring this room were listed as Nursing and Plant Ops.