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Based on interview and document review, the hospital failed to ensure patient rights were protected when handles on patient doors were observed to create a ligature risk.

See A 0144. The facility failed to ensure patient safety when the patient room doors on the mental health units had handles and locks were placed on the doors with the opening facing up, creating a potential ligature risk. This had the potential to impact all 85 patients on the mental health units.

An Immediate Jeopardy (IJ) was identified on 2/2/21, at 2:15 p.m. related to patients receiving care in a safe setting. The IJ was removed 2/3/21, at 12:45 p.m., but the hospital remained out of compliance at the Condition of Patient Rights.

Based on observation, and interview, the facility failed to ensure patient safety when the patient room doors on the mental health units had handles and locks that were placed on the doors with the opening facing up, creating a potential ligature risk. This had the potential to impact all 85 patients on the mental health units. An immediate jeopardy to patient health and safety was identified.

The IJ was identified under the Condition of Patient Rights. The IJ was identified on 2/1/21, at 12:45 p.m. when handles to patient doors were observed to create a ligature hazard. The hospital Vice President of Patient Care Services, Mental Health Director of Nursing, Chief Financial Officer, Sr. Director of Facilities, Program Manager Accreditation and Regulatory Compliance, VP of Quality, Director of Quality, Patient Safety and Accreditation were notified of the IJ finding on 2/2/21, at 2:15 p.m.

Findings include:

During the hospital tour on 2/1/21, at 12:35 p.m. it was observed that all patient room doors on the mental health unit NE4, had handles on them which created a V shape with the bottom, narrow part of the V toward the floor. The door locks were positioned in the same way. This created an opening at the top that could be used to place a ligature. The other non-patient room doors on the unit had the handles affixed in the opposite direction, with the bottom of the V facing the ceiling. The NE4 nurse manager (NM)-D stated that all (100) of the mental health patient rooms on all the mental units were set up the same way, with the bottom of the V of the handle toward the floor. NM-D stated that the handles and locks were put on that way to keep patients from putting a ligature under the handle and throwing it over the door inside the patient room. NM-D stated all the hallways have cameras with viewing screens behind the nursing desk for security. NM-D stated that although the health unit coordinator (HUC) is at the desk by the screens most of the time, s/he is not always there observing the cameras. NM-D stated the census on the five Mental Health units today was 85.

A risk assessment for the rationale related to placing the patient door locks and handles in the above manner was requested, but was not provided.

The IJ was removed on 2/3/21, at 12:45 p.m. after observation and interview verification of an acceptable removal plan. Staff members were interviewed and all mental health units were observed for implementation of the removal plan, which included continual monitoring of the patient areas to ensure patient safety.