HospitalInspections.org

Based on observation during a complaint investigation conducted on 09/22/10 to 09/23/10, it was determined the hospital failed to provide/maintain the required special design consideration for a safe environment and to prevent potential patient injury or suicide (due to the observation of a large number of looping devices) on the 4 East /NorthEast and 6 South Behavior Health Units. Therefore, this Condition is not met. Refer to physical environment deficiency identified as tag A0722.

Based on observation it was determined the hospital failed to maintain the required special design consideration for a safe environment by failing to remove all potential looping devices in the Behavior Health Units located on 4 East/Notheast and 6 South. Findings include:

1. On 09/22/09 during the time frame of 10:30 a.m. and 1:30 p.m., a tour of the hospital behavior health units was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met:

a. Sixteen (16) of seventeen (17) patient rooms located on 4 East/Northeast had wall mounted toilet service lines and exposed hand sink plumbing (water service and drain lines) creating tie-off points. Seventeen (17) of seventeen (17) patient rooms had the following identified looping devices (locker handles and pad locks, lever/knob type toilet room handles, and shower water service handles. Also patient room 4009 was observed to have open grab bars (space not filled between wall and bar) in the shower and toilet wall area.

b. Pendant type sprinkler heads were observed in the 4 East/Northeast corridors and are not the required type for behavior units (must be recessed or tamper-resistant type). Also, activity/dining room had wall mounted sprinkler heads that were not tamper-resistant type.

c. Group therapy room (4029) was observed to have open type handles (tie-off point) on the television cabinet doors. Also, corridor door to this room had a round type door knob (tie-off point and doesn't meet minimum design standard).

d. Handrails are installed in 4 East/Northeast and 6 South corridors and are not designed to prevent them from being a looping device (open space between handrail and wall).

e. Ten (10) of ten (10) patient rooms located on 6 South had exposed hand sink plumbing (water service and drain lines), water service shower handles, and toilet room lever type door handles that are creating tie-off points and are not meeting the minimum design standard. Also, group therapy room was observed to have wall mounted bracket for the television and the corridor door handle is a lever type handle (both tie-off points). The lay-in ceiling tiles in the corridor for this unit do not meet the minimum design standard, due to the fact that they are not clipped down to secure them.

These conditions found in these two (2) Behavior Units are not giving the required special design consideration to prevent potential patient injury or suicide.