HospitalInspections.org

Based on review of medical records, internal documents, daily census logs, observation, and staff interviews, it was determined the hospital failed to ensure the physical environment on one of their psychiatric inpatient units was safe and free from ligature points, which poses a high potential risk a patient could use the ligature point to harm themselves by asphyxiation.

Findings include:

A review of 12 geriatric unit medical records on 12/12/17, revealed that 6 patients were assigned to the new stryker beds, 4 patients were assigned to the crank beds and 2 patients were utilizing box beds (wooden platform bed with a mattress).

A review of the hospital's Patient Rights revealed: "...The patient has the right to expect reasonable safety insofar as the hospital practices and environment are concerned...."

A review of the Governing Board Quarterly Meeting minutes dated 01/24/17, revealed: "...We have purchased 8 beds that will be delivered at the end of February. They are electric low beds specifically for the Gero [sic] Unit. A total of 14 beds that will be ordered later in the year. This should prevent some falls and provide some additional comfort to the patients...."

A review of the inpatient geriatric unit daily census log for 11/28/17, revealed 17 patients, with 1 patient aged 83 years and the remaining patients aged 66 and younger, with the youngest patient being 26 years old.

A review of the inpatient geriatric unit daily census log for 11/29/17, revealed 20 patients, with 1 patient aged 83 years and the remaining patients aged 66 and younger, with the youngest patient being 26 years old.

A review of the inpatient geriatric unit daily census log for 11/30/17, revealed 18 patients, with patients aged 66 and younger, with the youngest patient being 26 years old.

Observation of the geriatric unit on 11/30/17, with the hospital's CEO and Quality/Risk Manager revealed two separate models of patient hospital beds Stryker Psych beds (crank beds) and Stryber Spirit Behavioral Health Beds (Spirit beds). The unit was described as the "Geriatric" Unit although adult patients with psychiatric diagnoses are admitted as overflow from the "Adult" Unit. No "Adolescent" patients are admitted to this unit. The capacity for the geriatric unit was identified as being 22 patients. During the Entrance Conference on 11/28/17, the patient census on the geriatric unit was reported to be 17 patients, including 1 geriatric patient.

Ligature points were observed on the Stryker Psych Bed (crank bed). A ligature point is any point which is load bearing that can be used to tie or secure a cord, sheet or other tether that can then be used as a means of hanging. Hanging is the main method of suicide for psychiatric inpatients. The observed obvious ligature points on this bed included: a knob attached to the crank bar at the end of the bed; an oblong shaped grey hook/handle on the side of the bed toward the end which could either be a drainage bag hook or holding the mattress in place; a larger oblong bar situated at the foot of the bed between the mattress and footboard. All of these were examples of ligature points easily accessible to most patients and could be used to tie and secure a sheet, for the high potential purpose of self harm by asphyxiation. All of the ligature points were sufficient to hold a head and shoulders above the floor when the bed is in the lowest position.

DON # 4 confirmed during an interview, that the geriatric unit is currently using 2 of the crank beds and 8 of the Spirit beds, with 8 additional Spirit beds on order.

Tour of the geriatric unit with LPN # 3 on 12/12/17, identified 8 new stryker Spirit beds, 6 crank beds and 8 box beds currently in use.

CEO # 1 revealed during interview on 12/12/17, that the facility is in the process of purchasing 14 additional stryker Spirit beds for the geriatric unit. CEO # 1 relayed that the 14 new beds are to replace the 6 crank beds and 8 box beds on the unit, with the intent to remove the 6 crank beds from the facility.