HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure patients identified at risk for harm to self or others were provided care in a safe setting as evidenced by failing to ensure the patient environment was free of safety and ligature risks.

Findings:

On 3/6/19 at 9:20 a.m. an observation was conducted of the 5th floor patient care unit. Room "A" (double occupancy) and Room "B" (double occupancy) were noted to open off of a vestibule. Room "A" opened to the left of the vestibule and was not directly visible from the hallway or from the nurses' station (staff must step into the vestibule to completely visualize Room "A"). The door to Room "A" opened to the inside of the room and was noted to have downward facing paddle handles on the outside and inside of the door. The downward facing door handle on the outside of the door could be used as an anchor point for ligature, draping something, such as linens, over the door and the patient could be out of staff sight behind the door, posing a safety risk (potentially used for hanging). S2DON indicated patients were rounded on/visualized every 15 minutes and confirmed patients could go to their rooms unattended by staff. S2DON agreed she could understand the surveyor's concerns with potential safety risks related to the layout of Room "A".

On 3/7/19 at 8:20 a.m. an observation was made of Room "A" with S1Adm. When the potential ligature risks referenced above were pointed out to S1Adm, she indicated she could see the potential safety risk.
During the observation, one of the two patients (Patient #4 and Patient #5) assigned to Room "A" was observed lying in bed, completely covered by a blanket, and not under direct supervision of staff or within staff eyesight, during the observation.