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Based on observations and interviews, the hospital failed to ensure each patient received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for patients admitted for acute inpatient psychiatric services. The deficient practice was evidenced by failure to ensure the patients' environment was free of ligature risks and safety hazards. Findings:


An observation was conducted on 11/07/16 at 10:30 a.m. The following safety and ligature risks were identified and confirmed by S1Adm and S2DON.

The patient mattresses had zippers on the side of the mattresses. An interview was conducted with S2DON on 11/07/16 at 1:30 p.m. She reported all of the mattresses in the hospital had zippers located on the side of the mattresses.

The patients' bathrooms had toilets with exposed plumbing which presented a ligature risk. The faucets in the sinks and showers in the patients' bathrooms were gooseneck in design and also presented a ligature risk. In the majority of the patient bathrooms there were rectangle metal inserts in the wall, which once housed paper towels. The metal inserts had sharp edges and corners and presented a safety risk for the psychiatric patient. The shower heads in the patients' bathrooms were a single pipe protruding from the wall and also presented a ligature risk.

Located in Room "a" there was a electrical outlet in the bathroom which was missing part of the cover to the outlet.

Located in Room "b" the air conditioner had a cracked covering to the unit.

Located in Room "c" the grab rails in the shower had rusted and the metal plate under the grab rail (to enclose the rail) had sharp edges.

Located in a wall, mid way down in Room "d", was a light bulb with wires encased in a metal insert in the wall, with a metal grate over the metal insert.

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Based on record review and interview, the hospital failed to ensure the registered nurse supervised and evaluated the care of each patient as evidenced by failing to ensure recreational therapy was provided to the patients by a qualified individual at all times. Findings:

Review of the patients' schedule revealed the following: On Monday, Tuesday, Thursday, Friday, Saturday and Sunday a recreational therapy group is held at 9:15 a.m. On Monday through Friday a recreational therapy group is held at 12:15 p.m. On Saturday and Sunday the second recreational therapy group of the day is held at 3:15 p.m.

An interview was conducted with S4Recreational Therapist on 11/09/16 at 10:00 a.m. She reported she was the recreational therapist for the hospital. She reported her typical work week was she worked from 7:15 a.m. to 4:00 p.m. Monday through Friday, with Saturday and Sunday off. She went on to report she did a recreational group in the morning and again in the afternoon. She reported on the weekends a few MHTs did the recreational groups, S5MHT and S6MHT.

Review of the personnel records for S5MHT and S6MHT revealed they were not licensed or certified to provide recreational therapeutic activities.

An interview was conducted with S2DON on 11/9/16 at 10:30 a.m. She confirmed on Saturday and Sunday S5MHT and S6MHT do the recreational groups since S4Recreational Therapist only works during the week.

Based on record review and interview, the hospital failed to ensure the registered nurse assigned qualified individuals to provide recreational therapy to the patients as evidenced by the MHTs providing recreational therapy on the weekends were not qualified as recreational therapists. Findings:

Review of the Hospital's Policy and Procedure, titled Scope of Services, revealed in part, Recreational Therapy is provided by recreational therapist (1).

Review of the Job Description/Performance Evaluation for Recreational Therapy Coordinator revealed in part, Qualifications: Education: Bachelor of Science Degree in Therapeutic Recreation or Related Program Certification.

Review of the patients' schedule revealed the following: On Monday, Tuesday, Thursday, Friday, Saturday and Sunday a recreational therapy group is held at 9:15 a.m. On Monday through Friday a recreational therapy group is held at 12:15 p.m. On Saturday and Sunday the second recreational therapy group of the day is held at 3:15 p.m.

An interview was conducted with S4Recreational Therapist on 11/09/16 at 10:00 a.m. She reported she was the recreational therapist for the hospital. She reported her typical work week was she worked from 7:15 a.m. to 4:00 p.m. Monday through Friday, with Saturday and Sunday off. She went on to report she did a recreational group in the morning and again in the afternoon. She reported on the weekends a few MHTs did the recreational groups, S5MHT and S6MHT.

Review of the personnel records for S5MHT and S6MHT revealed they were not licensed or certified to provide recreational therapeutic activities.

An interview was conducted with S3CNO on 11/09/16 at 1:30 p.m. She confirmed the hospital did not have a qualified recreational therapist on the weekends for the patients.