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Based on observation, staff interview and document review the hospital failed to ensure the safety of their patients from ligature (hanging) hazards from one of one water fountain, one of one padlock, six of seven exit signs, eight of 20 locked doors with exterior hinges in the south and west hallways assessable to patients, two of three entrance/exit doors (front and east exit door in the north hall) and two of two fire doors (one in the north hall and one in the south hall). This deficient practice has the potential to cause harm and even death to any of the patients receiving care at the hospital. At the time of survey, the hospital had two of 13 patients (Patient #10 and #11) on suicide precautions.

Findings include:

Policy titled, "Admission Assessment-Nursing, Multidisciplinary Integrated Assessment (MIA)," effective 09/2016 and revised 12/2016, directed, Initial Screen for Self-Harm Potential: Complete the Screens and select the appropriate nursing diagnosis, then implement the appropriate interventions. Level I (high)-continuous observation, Level II (Moderate)-line of site, Level III (low) every 15-minute observation, or indicate not at risk for self-harm.

Policy titled, "Suicide Precautions," effective 09/2016 and revised 12/2016, directed, the hospital to ensure a safe environment for potentially self-destructive patients and to establish specific guidelines for staff observation of these patients. All patients placed on suicide precautions will be assigned an acuity level based upon the severity of the suicidal thoughts, plan or behavior. The levels are as follows: Every 15-minute observation, Line of sight observation and one-to-one observation at all times.

Policy titled, "Assessment for Suicidal Ideation," effective 09/2016 and revised 12/2016, directed, to ensure safety, prevent injury and maintain a therapeutic relationship with all patients.

Observations from 03/26/18 through 04/04/18, ligature risks identified throughout the facility included the following:

Inside the front door, south hall looking west:

1. The inside door handles of the Entrance/Exit Double Doors, have open push arms not flush with the glass doors leaving a gap between the handles and the door creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
2. The Entrance/Exit Doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
3. The ceiling header (a horizontal structure over an opening) has an exit sign with large round lights on each side of the sign creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
4. Exit sign above the Entrance/Exit door has large round lights on each side creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.

South Hall looking East:

1. The double fire doors have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, at the top backside of both fire doors, there are magnets that protrude out, the handles on the back side of the door are not flush with the door, latch bars that are not flush and runs vertically on each door and has a flat surface that protrudes out at the top of the door, all creating ligature points that can be used to attach a cord, rope or other material for hanging or strangulation.
2. The exit sign above the locked doors to the administration hall has large round lights on each side of the sign creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.

South Hall:

1. Four of nine locked doors in the south hallway have exterior hinges protruding out creating ligature points that can be used to attach a cord, rope or other material for hanging or strangulation. Patients have access to this hallway.

West Hall looking North:

1. The water fountain located between the soiled utility room and oxygen room with a drinking spout creating ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
2. The electrical box has a padlock with a gap creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
3. The exit sign above the north exit door between room 104 and 105 has large round lights on each side of the sign creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
4. Four of eleven locked, non-patient room doors have exterior hinges protruding out creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.

North hall looking east:

1. Exit door at the east end of the hall between patient rooms 111 and 112 has push arm that is not flush with the door creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
2. Two of two exit signs in the north hall have large round lights on each side of the exit sign creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
3. The double fire doors by the nurses' station have elbow hinges at the top of both doors near the walls leaving a gap in the hinge, the doors have push arm handles that are not flush with the door, handles on the back of the doors that are not flush with the door leaving gaps, all creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.
4. On the top casing of the doorway in the center of the fire doors by the nurse's station there is a bar that protrudes out toward the west creating a ligature point that can be used to attach a cord, rope or other material for hanging or strangulation.

Observation on 03/26/18 at 11:50 AM during the tour of the hospital, showed cameras in the halls and a monitor at the nurse's station showing the halls, dining area and administration hall.

Interview on 03/26/18 at 11:50 AM, Staff D, Administrator said that there is always someone watching the monitor at the nurse's station and corporate also has the ability to view the monitors.

Interview on 03/27/18 at 9:15 AM, Staff F, Registered Nurse (RN) said that all precautions for patients are listed on the board behind the nurse's station. Including suicide precaution. She said that they do not have wrist bands or stickers for patients on suicide precautions.

Observation on 03/27/18 at 9:15 AM of a board in the nurse's station showed Patient #10 and Patient #11 were listed as suicide precautions.

Observation on 03/27/18 at 10:36 AM until 10:50 AM showed the nurse's station empty and no staff viewing camera monitors.

Interview on 04/02/18 at 10:00 AM, Staff A, Chief Executive Officer (CEO), was asked if it was hospital policy that staff watch the camera monitors at all times. Staff A responded by saying that watching the camera monitor all the time is not part policy, he said every 15-minute checks and face to face is how we monitor our patients.

Interview on 03/26/18 at 3:49 PM, Staff A stated that if a patient is placed on suicide precautions the nursing staff are to complete a suicide risk assessment and if the patient scores a certain number then the staff calls Staff P, Psychiatrist to confirm the level of precautions. The patient receives a suicide wrist band and suicide risk stickers are placed on the chart.

Observation on 03/28/18 from 8:40 AM until 8:50 AM, showed there was no staff at the nurse's station viewing the camera monitors. Patient #11 had been standing at the nurse's station for an undetermined amount of time waiting for staff to take her outside for her smoke break. Staff were in and around the dining room away from the nurse's station.

Observation on 03/29/18 at 8:30 AM showed Patient #11, standing in the hall at the nurse's station for an undetermined amount of time. There was no staff at the nurse's station or in the hall near the nurse's station.