HospitalInspections.org

Based on observation and interview, the CAH failed to ensure the physical environment was maintained for the safety of the patients. This deficient practice is evidenced by failing to ensure the behavioral health unit did not contain safety risks for the psychiatric patients admitted for being at risk for harm to self or others.

Findings:

During an observation on the BHU on 04/21/2021 beginning at 10:00 a.m., the following patient safety risks were found:

Room 17:
Both mattresses had split covers making them unable to be sanitized and afforded a place where contraband could be hidden.

Room 18:
a. Upper right hand top of the wooden room entry door - the wood was ragged and splintered. S2RNMgr, present during the observation, indicated the wood was splintered due to a metal bar having been removed from the top of the door.
b. The cover was missing of the metal "school-house" type bell, mounted near the head of the bed, on the left side of the wooden box bed, leaving an open "V" shaped piece of metal protruding - potential ligature anchor point
c. Metal bell frame was secured with screws that were not tamper resistant and due to the missing cover the screws were accessible to patients.

Room 22
a. 3 pills under the mattress
b. Mattress cover split making it unable to be sanitized and a place where contraband could be hidden.
c. Toilet away from wall at base allowing it to be a ligature point
d. The metal bar at the top of the door connected to the door frame, when opened, could be used as a ligature point
e. Screws in the door hinges and latch plates were not tamper proof.

Rooms 23, 20 and the group room - The metal bar at the top of the door connected to the door frame, when opened, could be used as a ligature point.

Hallway:
A blood pressure machine was noted on a back hallway with multiple blood pressure cords and power cords. Patients were in the hallway with no staff around for 15 minutes. The hallway was also not being directly visualized by staff from the nursing station at the time of the observation.

Bathrooms:
The bases of the toilets in the patient's bathrooms were away from the wall allowing them to become a ligature point.

Nurses' Station:
In an observation on 04/21/2021 at 2:25 p.m., S3LPN was the only staff member in the nurses' station. She was on the phone and had her back to a half door that separated the hall and the nurse's station. The surveyor was able to reach into the room and obtained access to a medication cart located directly in the unit. The surveyor opened the top drawer of the medication cart, there was a cell phone accessible on top of the cart and a bottle of hand sanitizer was also accessible. S3LPN never noticed the surveyor had accessed the cart.

In an interview on 04/21/2021 at 2:27 p.m. with S5RN, she verified the surveyor could reach the cart and nobody had observed the surveyor. She said it is a small unit and there is limited space to move it.

Outdoor Patio Area:
04/21/2021 at 10:25 a.m. an observation was made of the outdoor patio area where patients have smoke breaks/outdoor time. There were 3 benches with opened metal frames and separated wooden slats which could be used as ligature anchor points.

In an interview on 04/21/21 at 10:30 a.m. with S4Maint, he said the outside courtyard has a lot of ligature risks but staff is with them when the patients are out there and the door is locked otherwise.

In another observation on 04/21/21 beginning at 1:50 p.m. of the BHU, patients were noted to be coming and going from the courtyard with no staff present. The window between the courtyard and the nurses station had a curtain pulled over it. The 3 benches with opened metal frames and separated wooden slats were accessible to the patients, without staff supervision, and the benches could be used as ligature anchor points.

In an interview on 04/21/21 at 2:10 p.m. with S6MHT, she said the door to the courtyard is only locked at night and prior to that the patients can come and go into the courtyard.