HospitalInspections.org

Based on document review and interview, it was determined that for 6 of 30 days in September 2022 daily environmental safety rounds reviewed, the Hospital failed to ensure that the care was provided in a safe setting, by completing the environmental rounds each shift as required on the Adult Behavioral Health Unit.

Findings include:

1. On 10/17/2022 the Hospital's policy titled, "Environmental Risk Assessment for Ligature Risk Safety" dated 01/2022 was reviewed and included, " ...close monitoring of the environment for overall safety ...environmental rounding occurs once on the day shift and one on the evening shift daily ...staff members will continuously maintain awareness and observe for safety issues, including potential ligature safety risks ...patient's safety ...continuously monitored ..."

2. On 10/17/2022 the "Daily Environmental Safety Rounds Checklist" for the Adult Behavioral Health Unit (4th Floor) from 8/1/2022 to 10/16/2022 were reviewed. On the following days the environmental checklists did not indicate that the were completed: 09/01/2022, 09/03/2022, 09/13/2022, 09/17/2022, 09/27/2022, and 09/30/2022.

3. On 10/17/2022 at 10:30 AM, the findings were discussed with the Director of Behavioral Health Unit (E #4). E #4 stated that it is required for the mental health technicians to do the environmental safety rounds on a daily basis to provide patient safety.