HospitalInspections.org

Based on observation, record review, document review and staff interview it was determined the hospital failed to provide a safe setting in the behavioral health unit by utilizing beds with open rails which pose a ligature tie off risk. This failure was observed on six (6) of twenty-three (23) beds in the unit (Room #s 304, 312, 313 and 321). This failure increases the hanging risk for all suicidal patients.

Findings include:

1. A tour of the behavioral health unit was conducted with the Program Director between 1:45 p.m. and 2:20 p.m. on 11/28/16. The unit was observed to have twenty-three (23) beds. Six (6) of these beds were observed to have open bed rails which pose a tie off risk for ligature suicide attempts. These beds were observed in rooms 304, 312, 313 and 321. These beds were also noted to have cranks which raise the head of the bed. The rails were up and the head raised on five (5) of the (6) six beds observed. These beds were located in unlocked rooms and patients were observed to have unsupervised access to these beds.

2. Review of the current census revealed twelve (12) patients were on the unit at the time of the observation. Eight (8) of the twelve (12) patients had Suicidal Ideations listed as a presenting problem. Five (5) of the six (6) observed beds with open rails were assigned to patients. Review of the census revealed three (3) of the five (5) patients assigned to these beds were noted to have Suicidal Ideation as an admitting problem (patients #1, 2 and 3).

3. This observation was discussed with the Program Director and she acknowledged the rails do pose some risk. She was asked how the hospital keeps patients safe from the risk posed by the open bed rails and she stated that nurses assess for the risk at the time of admission. When asked if this was a formal suicide risk assessment, she stated, "No, it was more of a nursing judgement." The Director then stated the hospital would seek a safer replacement for these beds.

4. The Program Director later provided the policy, "Patient Assignments", last reviewed/revised 4/2016. The policy states in part: "The RN assesses the risks associated with the use of a medical bed by a patient at risk for suicide and the patient's medical condition. The RN assigns the patient to a medical bed or to a psychiatric platform bed based on the results of this assessment."

Based on document review, staff interview, observations and NFPA (National Fire Protection Association) 101 Life Safety Code 2012 Edition, it was determined the facility failed to ensure fire drills are held at unexpected times under varying conditions and quarterly on each shift (see Tag K 712); failed to ensure proper testing of line isolation monitors in accordance with NFPA 99, (see Tag K 914); failed to maintain the emergency generator's in accordance with NFPA 110, (see Tag K 918); failed to maintain the sprinkler system free of loading in accordance with NFPA 25, (see Tag K 353); failed to maintain continuous egress free of all obstructions to full instant use in accordance with NFPA 101, (see Tag K 211); failed to maintain delayed egress locks in accordance with NFPA 101, (see Tag K 222); and, failed to maintain electrical wiring in accordance with NFPA 70 & 99, (see Tag K 912).