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Based on observations 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 located on the 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 potential looping devices that do not meet the required minimum design standard on patient care units. Findings include:

1. On 12/01/10 during the time frame of 9:30 a.m. and 11:30 a.m., a tour of the hospital patient care units was conducted. At this time, the following design requirements of American Institute of Architects (AIA) guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met:

Twenty-six (26) of twenty-six (26) patient care rooms had four (4) or more of the following potential looping devices or tie-off points:

a. Shower service handles/heads;
b. Corridor/toilet room doors had standard type hinges (cut-hinge type is acceptable);
c. Corridor/toilet room doors had ball-type handles;
d. Accessible/exposed toilet and hand sink water service lines and drain lines;
e. Furniture had open-type handle hardware (not recessed type);
f. Shower grab bars open-type (open space between bar and shower wall). Wall mounted towel rack (open space between bar and wall);

Also, the adult unit corridor was observed to have open-type handrails (open space between handrail and wall) and the electrical receptacles in the patient rooms were not tamper-proof or ground fault circuit interrupter (GFCI) protected.

These conditions found in the patient care units are not giving the required special design consideration to prevent potential patient injury or suicide.