HospitalInspections.org

Based on medical record review, staff interview and review of facility documents, it was determined the facility failed to provide care in a safe setting by ensuring items identified on the Environmental Safety Risk Assessment, as a possible ligature opportunity, are not available to at risk patients

Findings include:

On 7/10/24 review of the Environmental Safety Risk Identification and Prioritization Worksheet for 5 West, dated 5/22/24, states, " ...Category Furniture ...Description of Environmental Risk Hospital Bed presents looping ligature opportunity ...Risk Location ...Unsupervised Patient Areas ...Supervised Patient Areas ...Proposed Remediation Replaced bed with platform bed unless hospital bed is absolutely necessary ...".

On 7/9/24 at 10:47 AM a tour was conducted on the 5 West Behavioral Health unit, a 28-bed inpatient unit with involuntary and voluntary adult patients. S6 (Nursing Director of 5 West) indicated the patients on 5 West have a psychiatric primary diagnosis but can have medical comorbidities that can be managed as well. S6 stated that Patient (P) 1, in room 583, has a bed which is a "medical psychiatric bed [Sizewise Behavioral Health Bed]." S6 indicated P1 was transferred from a medical floor to 5 West with a Foley catheter. S6 stated the patient came with a regular medical bed to hang the Foley catheter bag to, and 1:1 observation was ordered. S6 indicated once the Foley catheter was discontinued, the "medical psychiatric bed [Sizewise Behavioral Health Bed]" was put back in the room and the 1:1 observation was discontinued. Upon observation of the Sizewise Behavioral Health Bed in room 583, it was identified that the side rails could pose as a possible ligature risk. At 11:15 AM, an interview was conducted with S8 (Registered Nurse [RN]), S8 indicated patients are put into room 583 based on a judgment call.

On 7/9/24 at 12:47 PM, medical record review was conducted. P1 presented to the facility on 7/1/24 for a same day procedure for a Cystoscopy with a Transurethral Resection of the Prostate (TURP). P1 had a medical history of Benign Prostatic Hyperplasia, Schizoaffective Disorder, Schizophrenia, and Transsexualism. P1 was admitted on 7/1/24 to the oncology floor. The History and Physical from 7/4/24 at 7:00 AM states, " ...Medical Clearance [P1] is [age] adult who is admitted to five west for schizoaffective disorder. Pt [patient] was evaluated by psych pre-TURP as [he/she] had made suicidal statements to staff. ...3. S/P (status post) TURP ...foley in place with collection bag ...". P1 was transferred to room 583 on 5 West on 7/4/24 at 1:04 AM with an order for 1:1 observation and denied suicidal ideation. The Nurse Practitioner (NP) Progress Note from 7/5/24 at 12:44 PM, stated, " ...patient reported [he/she] is feeling better after [he/she] was started back on [his/her] medication. [He/she] reported depression and anxiety 3/10. [He/she] denied SI/HI thought or plan. ... Safety Continue q15 min [every 15 minutes] patient monitoring. Discontinue 1:1 patient no longer with foley, switch medical bed to regular inpatient bed. ...Medical patient is medically stable ..." P1 was discharged on 7/9/24 at 12:29 PM.

On 7/9/24 at 2:00 PM, S6 confirmed P1 was not moved to a room with a platform psychiatric bed because P1 was transgender, and room 583 is the only room with a single bed. S6 stated, "there is no order needed for the [Sizewise Behavioral Health Bed] or patient criteria for that bed."

On 7/10/24 at 12:48 PM, a tour was conducted on unit 5 West. At 12:57 PM, S20 (RN) confirmed room 583 has been used for patients without medical necessity. S20 stated, "patients with just a psychiatric diagnosis have been in that room, it all depends on the bed availability and census." S20 indicated if a patient is medically cleared while in that room, they will most likely stay there because it does not make sense to move them.

On 7/10/24 at 2:24 PM, the above findings were confirmed with S1 (Director of Quality and Regulatory) and S3 (Vice President and Chief Nursing Officer).