HospitalInspections.org

30195

Based on document review, observation, and interview, it was determined that the Hospital failed to ensure patients were safe from ligature risks. This potentially places all current and future patients who are suicidal, at risk for serious harm. As a result, the Condition of Participation, 42 CFR 482.13, Patient Rights, was not in compliance.

Findings include:

1. The Hospital failed to ensure patients' rooms and shower rooms were free of ligature risks (A144).

Based on document review, observation, and interview, it was determined that for 1 of 1 Acute Psychiatric Units (Brunk Unit), the Hospital failed to ensure patients' rooms and shower rooms were free from ligature risks. This could potentially affect all 24 patients who are in the unit, or become suicidal during their admission, requiring suicide precautions.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification ) Memo: 18-06- Hospitals, dated December 08,2017, reviewed on 7/25/18 at approximately 2:00 PM included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames..."

2. A tour of the Brunk Unit (acute psychiatric unit), was conducted on 9/4/18 at approximately 3:00 PM. The unit was a 27 bed unit with a census of 24 patients. The unit consisted of 15 patient rooms. There were no patients on suicide precautions at the time of the tour. The room entrance doors were all unlocked, and all patients had access to all the patient rooms. The doorframes were square and the doors reached to the top. Each room entry door had 3 separate hinges, and protruding door knobs, which could potentially be anchors for hanging by the patients on the unit. The bathrooms in the patient rooms did not have doors. Three shower rooms were observed in the Brunk Unit. The shower curtains (made with cloth, and netting on the top one third to view patients head while in the shower) were hung on 13-16 break away plastic clips.

3. The Hospital's ligature risk removal plan (a plan in response to identified ligature risks by the Hospital's Accrediting Organization), dated 8/7/17, as well as the Hospital's risk assessment (conducted in March 2018), included a time line of replacing the door handles and hinges by 5/1/18. The shower curtains, the use of the clips and plastic curtain were not assessed during the ligature risk assessment done in March 2018. However, as of survey date 9/6/18, no door handles, hinges, or shower curtain clips had been replaced.

4. The Quality Manager (E # 9) was interviewed on 9/5/18 at 11:30 AM. E #9 indicated that a yearly risk assessment is conducted, and the last one was conducted in March 2018. E #9 presented the Risk Assessment and stated, "The corridor doors (patients room entry doors), hinges and door knobs were identified as ligature risks, the shower curtains and clips were not identified at the time of the risk assessment." E #9 indicated that when the ligature risks were identified all staff were educated on identification and awareness of the ligature risks. E #8 stated, "There is always a potential for harm with ligature risk for mental health patients, even more so in the acute unit (Brunk)."

5. An interview was conducted with a Safety Officer (E #4) on 9/5/18/at approximately 2:00 PM. E #4 stated, "Most of the curtains are held by 16-20 clips. We tested the clips today (09/05/18) using a rope, and tied drums of water. The majority of the clips came off at about 100 pounds."

6. The Director of Nursing (DON-E #10) was interviewed on 9/5/18 at approximately 4:00 PM. E #10, in regards to the the ligature risks identified stated, "The risk for harm effects all patients."