HospitalInspections.org

This is a repeat Condition Level deficiency.

Based on medical record review, review of facility policies and procedures, a tour of one patient care unit, and interviews with administrative staff, it was determined that the facility failed to protect and promote the rights of each patient.

Findings include:

The facility failed to ensure that patients have the right to receive care in a safe setting (Refer to Tag A 144).

This is a repeat deficiency.

Based on a review of hospital policy and procedure, a tour of one patient care unit, interviews with administrative staff, and a review of related documentation, it was determined that ligature risks existed in patient care areas and contraband was available on a patient care unit.

Findings include:

Reference #1: Policy and procedure titled, "Patient Safety Search" states:
"I. STANDARD
Prohibited items are not brought onto hospital grounds or are removed when they are found.
.....
III. POLICY
A. The hospital has a responsibility to provide a safe environment for patients and staff. Patients may not possess prohibited items. Any items identified as contraband will be removed, if brought onto hospital grounds. All hospital staff shall be familiar with this policy and must prevent patient access to contraband.
.....
Ancora Psychiatric Hospital Patient Contraband List
.....
Contraband items are as follows:
.....
* Electrical appliances
.....
Movies rated R for restricted audience, unless approved by Administration
....."

Reference #2: Document titled, "Movie List" did not include the R (Restricted) rated movie: "Speed" as an approved movie for patient viewing.

1. A tour of Unit F-2 (geriatric unit) on September 23, 2020, beginning at 2:21pm, accompanied by Administrators #1, #2, and #5, revealed:

a. Female Wing:

(i) Room B, occupied by Patient #11, contained a portable air filtration unit with an approximately 4 foot electrical cord attached to it.

(ii) Room C, occupied by Patient #12, contained a portable air filtration unit with an approximately 4 foot electrical cord attached to it.

(iii) Room D, occupied by Patient #13, contained a portable air filtration unit with an approximately 4 foot electrical cord attached to it.

(iv) Room H, occupied by Patient #14, contained a portable air filtration unit with an approximately 4 foot electrical cord attached to it.

(v) At approximately 4:30pm on September 23, 2020, Administrator #1 stated that there were 30 portable air filtration units dispersed within the facility, some in patient care areas.

On 9/23/20, Staff #1 was notified that the above findings resulted in an Immediate Jeopardy (IJ). A copy of the completed IJ template was provided to Staff #1 at 5:15pm. An acceptable IJ removal plan was received from the facility on 10/6/20 at 4:45pm.

On 10/7/20, an onsite visit was conducted to assess facility compliance with the IJ removal plan. During the onsite visit, the following was conducted: A tour of PPE (Personal Protective Equipment Shed 4; Review of a revised policy and procedure; Review of evidence of staff training; Interviews with administrative and physical plant staff; Review of an attestation by administrative staff of the location of portable air purifiers in non-patient care areas.
All air purifiers were determined to have been relocated to non-patient care areas.

The facility was in compliance with its IJ removal plan and the IJ was removed.

b. Activities Supply Room (Room F-243): A drawer containing VHS (Video Home System) tapes included an R rated tape titled: "Speed."