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Based on medical record review, observation, interview and document review, the facility failed to provide care in a safe setting by failing to identify physical environmental safety risks for patients. This resulted in Patient #1 self-exiting a 3rd story window, causing physical harm.

See findings under Tag # 0144.

Based on medical record review, observation, interview and document review, the facility failed to provide care in a safe setting by failing to identify physical environmental safety risks for patients. This resulted in Patient #1 self-exiting a 3rd story window, causing physical harm.

Findings include:

Medical record review on 06/29/20 revealed a progress note dated 06/19/20 at 06:25 PM that indicates Patient #1 was able to get out of the window (Chemical Dependency or CD counselor office) and fell straight down, landing on his feet.

Observation on 06/29/20 at 10:15 AM in the CD counseling office revealed a large window located across from the door.There are two bolts on the handle and two bolts on the closure mechanism of the window. The bolts appear to have been removed previously as there are markings around them.

Interview on 06/29/20 at 10:03 AM with Staff (DD), Director of Physical Plant revealed all patient room windows are screwed shut including the CD counseling office, just before Thanksgiving (2019), however, there is no documentation. Immediately after the incident (on 06/19/20), facilities staff went to the CD unit counseling office, saw that the "screws" from the window had been removed, and were sitting on the windowsill. The window was re-screwed shut. Physical rounds are done a few times a week but we don't always document what was done. Physical environment rounds of units are done monthly using the check off sheet, except during COVID.

Review on 06/29/20 of the Facility Environmental Rounding binder revealed a Reflections CD unit inspection dated 03/05/19 from the Newfane site. No facility rounding documentation for the CD unit was found since the program relocated to the Lockport site on 11/26/19.

Review on 06/29/20 of the Reflection CD Unit Daily Rounding sheets from 06/18/20 to 06/21/20 revealed a "window-sill check" for 09:00 AM, 03:00 PM and 09:00 PM. Interview at 10:24 AM with Staff (F), RN CD Manager revealed the window-sill check was for patient rooms, not the counseling offices.

Interview on 06/30/20 at 01:20 PM with Staff (D), Assistant Administrator for Quality, and Staff (HH), Infection Preventionist, revealed there is no facility environmental rounding policy. An interdisciplinary team rounds on one unit monthly. Findings are written up and given to the unit manager for correction.

Based on medical record review, observation, and interview, the facility failed to maintain a safe patient care environment in the Chemical Dependency (CD) Unit by failing to ensure all windows were secure. This resulted in Patient #1 self-exiting a 3rd story window, causing physical harm.

See findings under Tag # 0724.

Based on observation and interview, the facility does not ensure all components of the electrical system are maintained.

Findings include:

Observation on 07/02/2020 at 09:30 AM, outside of the Center building, a PVC electrical conduit, used for electrical receptacles, was not secure. It was sagging in two spots and there were missing fasteners. At 09:50 AM, in the Laboratory/EKG room (blood draw) there was a red electrical receptacle not secure, that was loose, and had plugs in it. At 10:08 AM, in the CT room, there was an electrical panel that was missing 3 of the 4 mounting bolts, and had an unused space without a filler plate. At 02:36 PM, the 3rd floor electrical room had an electrical panel labeled 2LNL-1 that had two unused spaces without filler plates.

Interview on 07/02/2020 at 02:45 PM with Staff (DD), Director of Physical Plant and Staff (FF), Assistant Administrator for Planning, verified these findings.

Based on observation and interview, the facility does not ensure that all doors were able to fully close and that all corridor walls have a minimum ½-hour fire resistance rating.

Findings include:

Observation on 07/02/2020 during a facility tour revealed the following:
- At 10:24 AM, the door separating operating room recovery area from the corridor was held open with a metal wedge.
- At 11:08 AM, the door separating the South building from the Center building did not fully close. The door stopped three inches before the frame leaving an opening. The door was a 90-minute rated fire door. The closing device appeared to be damaged.
-From 11:40 AM to 02:35 PM corridor wall penetrations were found without a fire rated system above the drop ceiling in the following locations: over the pharmacy door in the basement; over the double fire doors on the 1st floor near radiology, next to the double fire doors on the 1st floor near the emergency department waiting room; over the fire door on the 2nd floor next to the 2 North service elevator; over the fire door on the 3rd floor next to the 3 North elevator; over the double fire doors on the 3rd floor connecting the corridor of 3 Center; and over the rear door of the cardiac unit.

Interview on 07/02/2020 with Staff (DD), Director of Physical Plant, verified these findings as they were identified.

Based on medical record review, observation, and interview, the facility failed to maintain a safe patient care environment in the Chemical Dependency (CD) Unit by failing to ensure all windows were secure. This resulted in Patient #1 self-exiting a 3rd story window, causing physical harm.

Finding include:

Medical record review on 06/29/20 revealed a progress note dated 06/19/20 at 06:25 PM that indicates Patient #1 was able to get out of the window (CD counselor office) and fall straight down, landing on his feet.

Interview on 06/29/20 at 10:03 AM with Staff (DD), Director of Physical Plant revealed all patient room windows are screwed shut including the CD counseling office, just before Thanksgiving (2019). Immediately after the incident (on 06/19/20), facilities staff went to the CD unit counseling office, saw that the "screws" from the window had been removed, and were sitting on the windowsill. The window was re-screwed shut.

Interview on 06/29/20 at 11:15 AM with Staff (D), Assistant Administrator for Quality, revealed 4 window bolts were removed by Staff (GG), former CD Counselor and Intake Coordinator (last day of employment was 01/02/20). The date the screws were removed is unknown.

Interview on 06/29/20 at 12:00 PM with Staff (E), CD Counselor revealed Patient #1 had gotten outside of her office window, was holding onto the ledge, and fell out of the window. The window was not open on that day. There were no bolts in the window since she came back to work full time in March/April 2020. The window did open and had no screen.