HospitalInspections.org

Based on observation, interview, and review of records, the facility failed to maintain an environment that provides for the safety of psychiatric patients in 9 out of 9 patient rooms on Unit 4 West (Room #403, 404, 405, 406, 407, 408, 409, 410, and 411).


Refer to Tag A0144

Based on observation, interview, and review of records, the facility failed to maintain an environment that provides for the safety of psychiatric patients in 9 out of 9 patient rooms on Unit 4 West (Room #403, 404, 405, 406, 407, 408, 409, 410, and 411). The patient rooms contained multiple ligature risks and items that could be utilized for self harm that placed patients at risk of harm.


This deficient practices were determined to pose Immediate Jeopardy to patient health and safety, and placed all psychiatric patients on Unit 4 West at risk for the likelihood of harm, serious injury, and possibly subsequent death.


A tour of the Geriatric Psychiatric Unit, 4 West, was conducted on 4-18-2017 with Staff #2, #3, #6, #7, and #9 present. Interview with Staff #3 revealed the unit was licensed for 10 Medicare patients that were cared for in 9 patient rooms. A tour of room 406 was made.


The following conditions that represented safety hazards to psychiatric patients were observed:


1. The patient bedrooms and bathrooms had drop down ceilings. The ceiling was not hard. The drop down ceilings were easily accessible by standing on a bed or chair. The acoustical tiles can be lifted allowing medications or contraband to be stored. The metal railings can be removed from the ceiling and used as a weapon to harm themselves or others. The railing could also be used by the patient to hang themselves.


2. A standard medical bed was in the room. This bed was found to have multiple ligature points for a psychiatric patient to hang self built in to the hand holds at the head boards, foot boards, and four side rails that raise and lower.


3. A bedside table that allows patients to eat in bed was found in the room. This table was found to provide ligature points for a psychiatric patient to be able to hang self.


4. The light switch plate was found to have a flat head screw in it. This type of screw had the potential to be removed from the switch plate by a psychiatric patient and the sharp point used to harm self.


5. Fluorescent light fixture covers were not of the locking type or screwed shut with tamper proof screws. The light bulbs could be accessed by psychiatric patients and used to harm self or others.


6. A white board for writing on was found to be attached to the wall with cross tip screws. This type of screw had the potential to be removed from the white board by a psychiatric patient and the sharp point used to harm self.


7. The electric outlets on the wall were not tamper proof or covered to prevent a psychiatric patient from accessing the outlet to harm self.


An interview was conducted with Staff #7. Staff #7 stated that patients are assessed for suicidal or homicidal ideation on admission and routinely throughout their stay. Unless the patient is determined to be a suicidal or homicidal risk, the staff is only required to observe the patients in their room once every 15 (Q 15) minutes. Staff #7 stated that because the patients are geriatric patients, they needed medical beds. Staff #7 confirmed that patients were not identified to be at increased risk due to the environment in their rooms. Patients did not receive special monitoring while in their rooms unless it had been determined they were suicidal or homicidal.


An interview with Staff #17 was conducted. Staff #17 stated that they did not believe the solid ceilings were necessary since the patients were geriatric patients. Staff #3 confirmed that the minimum age for admission to the geriatric psychiatric unit was 55 years old.


Review of Behavioral Health Policy titled, Level of Supervision, defined four levels of staff supervision.


"1. In order to provide protection to patients, four levels of staff supervision are provided.

A. 1:1 Supervision - Patient is extremely dangerous to themselves or to others and requires 1:1 constant supervision to remain safe.

i. NOTE: This level of supervision is considered a restraint when the patient's method of egress is limited (they are not allowed to move freely from room to room)

ii. Patient is accompanied by staff at all times including bathing, showering, shaving, and toileting.

iii. Orders must be reviewed and changed or renewed by MD every 24 hours.

B. Close Observation - patient must remain in constant eyesight of staff and within reaction distance to allow a reasonable effort to intervene to reduce risk of target behavior. Orders must be reviewed and changed or renewed by MD every 24 hours.

C. Close Observation during waking hours and Q 15 minutes while asleep - Patient needs close observation within eyesight and reaction distance during waking hours and Q 15 minutes while sleeping. Orders must be reviewed and changed or renewed by MD every 24 hours.

D. Routine monitoring - The patient will be directly viewed by staff every 15 minutes, visual observation of patient no less than every 15 minutes."


The policy did not include increased level of supervision for unsafe environmental conditions.