HospitalInspections.org

Based on observation, interview, and document review, the facility failed to provide care in a safe setting for 9 (#5, #6, #7, #8, #9, #10, #11, #12, #13) of 16 patients resulting in the potential for unsatisfactory outcomes up to and including death for all patients. Findings include:

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A-144 Failure to provide a ligature-free setting

Based on observation, interview, and document review, the facility failed to ensure a ligature-free environment for 9 (#5, 6, 7, 8, 9, 10, 11, 12, 13) of 16 patients who were found to be suicidal or a risk to harm themselves resulting in the potential for self-harm up to and including death. Findings include:

During the initial tour on 4/12/2022 at 1130, a discussion ensued with Director of Nursing (DON) Staff B in which she stated "medical beds" were used on the geriatric unit for patients who had medical issues in which they could not lay flat such as patients with respiratory issues or those who used a CPAP (Continuous Positive Airway Pressure-a device used for patients with sleep apnea).

Upon entering the geriatric unit on 4/12/2022 at 1207, it was immediately observed that Room 300 and Room 302, which both had their doors opened, had four regular medical beds present, two beds to each room. The medical beds included open, moveable side rails. Multiple areas on the side rails and the bed frame itself were present that presented a ligature risk with the use of clothing or bedding.

On 4/12/2022 at 1208, DON Staff B was queried as to how many medical beds were on the unit to which she stated all of the beds on the unit were regular medical beds, 16 in all. All of the beds were currently occupied.

On 4/12/2022 between 1210-1300, all 16 medical records were reviewed and 9 (#5, 6, 7, 8, 9, 10, 11, 12, and 13) were found to have suicidal ideation or were considered a harm to themselves and others. The medical record findings were as follows:

On 4/12/2022 at 1255, review of the medical record for Patient #5 revealed she was a 57-year-old female who had been admitted to the facility with depression and a suicide attempt. Her plan of care was to be placed on suicide precautions.

On 4/12/2022 at 1247, review of the medical record for Patient #6 revealed he was a 63-year-old male who had been admitted with schizoaffective disorder bipolar type. In the Psychiatric Evaluation, in the section titled "Justification for Hospitalization" the physician wrote "Danger to self, danger to others..."

On 4/12/2022 at 1210, review of the medical record for Patient #7 revealed he was a 63-year-old male who had been admitted with bipolar disorder. In the Psychiatric Evaluation, in the section titled "Justification for Hospitalization" the physician wrote "Danger to self, danger to others..."


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On 4/12/2022 at 1220 document review occurred of the medical record of patient #10. During the review of the patient #10 's medical record it was revealed that the patient was a 63-year-old female who was admitted to the facility on 03/09/2022 for "worsening AH (auditory hallucinations) to harm herself." Further review of documentation stated that the auditory hallucinations told the patient to "cut her throat." A diagnosis of suicidal ideation was included as part of the patient's intake information. The patient was identified to be in placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.

On 4/12/2022 at 1239 document review occurred of the medical record of patient # 13. During the review of the patient #13 's medical record it was revealed that the patient was a 61-year-old male who was admitted to the facility on 03/15/2022 with depression, difficulty sleeping, auditory hallucinations, substance abuse, and SI (suicidal ideation). The patient was identified to be placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.

On 4/12/2022 at 1244 document review occurred of the medical record of patient #12. During the review of the patient #12's medical record it was revealed that the patient was a 41-year-old male with was admitted to the facility on 03/24/2022 for a suicide attempt by ingesting 12 gabapentin capsules. Further review of the intake information sheet stated, "current suicidal ideation: yes - active, past ideation: yes, previous suicide attempts: yes, current plan: overdose." The patient was identified to be in placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.

On 4/12/2022 at 1249 document review occurred of the medical record of patient #11. During the review of the patient #11's medical record it was revealed that the patient was a 64-year-old male with was admitted to the facility on 04/05/2022 for a suicidal ideation for the past 3 days with a plan to kill himself with a gun. Further review of the intake information sheet stated, "current suicidal ideation: yes - active, past ideation: yes, previous suicide attempts: yes, current plan: shoot himself with a gun." The patient was identified to be in placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.

On 4/12/2022 at 12 document review occurred of the medical record of patient #9. During the review of the patient #9's medical record it was revealed that the patient was a 57-year-old female with was admitted to the facility on 04/08/2022 for a suicidal ideation with racing thoughts to hurt herself. The patient had access to a gun and stated that she had laid the gun beside of her. Further review of the intake information sheet stated, "current suicidal ideation: yes - passive." The patient was identified to be in placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.

On 4/12/2022 at 1301 document review occurred of the medical record of patient #8. During the review of the patient #8's medical record it was revealed that the patient was a 65-year-old male with was admitted to the facility on 04/07/2022 for psychotic behavior including hearing voices of God and not sleeping at night. The patient was documented as being a danger to himself and others. The patient was stated to need suicidal precautions, observation, and treatment per the patient's psychiatric evaluation. The patient was identified to be in placed on the generations unit and assigned to one of sixteen beds with ligature risks leaving the patient vulnerable to self-harm.