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Based on medical record review, review of hospital policy and procedure, interviews, and a tour of the Psychiatric Unit, it was determined that the hospital failed to provide care according to acceptable standards of practice to ensure a safe patient environment.

Findings:

The alleged incident in this complaint occurred on 04/02/2013. At the time of the incident, the psychiatric unit contained multiple windows that were not made of break resistant material. The unit started caring for psychiatric patients late in the 1990's according to the Nurse Executive during an interview on 05/08/2014 at 1230. Prior to becoming a physiatric unit, he/she stated that it had been a nephrology unit.

During the investigation, on 04/22/2014, it was determined that the hospital did not have a policy and procedure in place to evaluate this unit for safety. It was stated in an interview on 04/22/2014 with the Interim Psychiatric Nurse Manager that the RCA (a method of problem solving that tries to identify the root causes of faults or problems) determined that a ECRI evaluation (a checklist of safety-design features to prevent violence in behavioral health facilities) would be completed every other year opposite of the state survey. When asked when the ECRI evaluation was due next, the team ( The Accreditation and Clinical Compliance Specialist, Interim Psychiatric Nurse Manager and the Nurse Executive) was unable to provide a date or a range of dates.

An ECRI evaluation was completed by the Psychiatric Nurse Manager after the alleged incident, on 05/06/2013. The findings of this evaluation were: The blinds in the kitchen were found to have cords attached which posed a potential risk of patient use for suicide attempts and the baseboards were not permanently fixed in order to prevent the concealment of potentially harmful items. The ECRI evaluation was completed 05/06/2013, the blinds were replaced on 01/21/2014. From 05/06/2013 to 01/21/2014 the cords on the blinds continued to be a potential hazard to the patients. As of this investigation (04/23/2014) the rubber baseboards continue to be a hazard to the patients on the unit.

On 04/23/2014 during the exit interview it was determined that the hospital did not have a policy or procedure in place to address the findings of the ECRI evaluation or any actions to be taken by staff as a result of the findings.

In addition to the ECRI evaluation the RCA also determinined that: 1. There was a delayed response to the event due to the operator not designating which garden the patient had fallen into. 2. The psychiatric patients wear blue hospital scrubs which are the same color/style as the staff scrubs. The Nurse Executive stated "they mistook the patient for a colleague at first." During a tour of 4SE, patients were observed wearing blue scrubs. The interim Psychiatric Nurse Manager stated that they have been unable to find a different color/style of scrubs at this time but that they are still working on it. It is unclear when the facility will implement a change to the type/color of scrubs so that there is a distinction between the psychiatric patients and hospital staff. From 05/06/2013 to 04/23/2014 there remains a potential for patients to be identified as a staff member.

The hospital failed to design, implement, monitor and evaluate a mechanism to ensure the safety of the patients on 4SE.

Based on Medical record review, review of hospital policy and procedure, interviews, and tour of the Psychiatric Unit it was determined that the hospital failed to maintain an overall environment that was developed and maintained in a manner that safety and well being of patients was assured.


Findings:

The alleged incident in this complaint occurred on 04/02/2013. At the time of the incident, the psychiatric unit contained multiple windows that were not made of break resistant material. The unit started caring for psychiatric patients late in the 1990's according to the Nurse Executive during an interview on 05/08/2014 at 1230. Prior to becoming a physiatric unit, he/she stated that it had been a nephrology unit.

The facility did not ensure that the unit was maintained in accordance with State OAR 333-535-0061(6)(g) which stipulates "Windows, including interior and exterior glazing, shall be non-operable and shall be of break resistant material (i.e., will not shatter). Window sills, curtains and blinds shall be constructed to prevent attachment of other articles.

On 04/23/2014 at 0700 this surveyor requested a list of all windows in the unit (4SE), how they treated (interior, exterior, both) and what substance/process was utilized to ensure the windows would not shatter.

During review of the RCA it was discussed that some of the windows on the unit were treated with "Lexan" [a protective film used to prevent the glass from shattering] on either the interior or the exterior to prevent shattering if broken.

The hospital failed to design, implement, monitor and evaluate a mechanism to ensure the overall hospital environment was appropriate for patients.