HospitalInspections.org

Based on observation, interview, and document review, the facility failed to meet the requirements of the Condition of Participation for Patient Rights. This failure had the potential to affect all patients receiving services in the hospital.

The facility failed to ensure current patients on suicide precautions (SP) received care in a safe setting :

The facility:

A. failed to ensure that 7 patients on SP were not placed in medical beds with ligature tie-off points and unsecured electrical cords that posed an asphyxiation risk [Patient ID # 19, 20, 21, 22, 23, 25, 42]

B. failed to ensure that 2 patients on SP were not placed in wood framed beds that contained a ligature tie-off point [Patient ID # 44, 45}.

C. failed to develop a policy with specific patient safety strategies when the medical beds were identified as posing ligature risks in February 2023.

D. failed to ensure that 4 patients on suicide precautions, were not exposed to a toxic product (wet caulk) on unit 6 (ID#s 31, 37, 39 and 41).

[Refer to Tag A-0144]

Based on observation, interview, and record review, the facility failed to provide care in a safe setting for 13 of 24 patients on suicide precautions (SP) on units 4 and 6 [ Patient ID #s 19, 20, 21, 22, 23, 25, 31, 37, 39, 41, 42, 44, 45].

The facility:

A. failed to ensure that patients on SP were not placed in medical beds with ligature tie-off points and unsecured electrical cords that posed an asphyxiation risk.

B. failed to ensure that patients on SP were not placed in wood framed beds that contained a ligature tie-off point.

C. failed to develop a policy with specific patient safety strategies when the medical beds were identified as posing ligature risks in February 2023.

D. Failed to ensure patients on suicide precautions, were not exposed to a toxic product (wet caulk) on unit 6

Findings:

Review of a facility admission packet showed a form titled" 'Patient Rights for All Patients," that read: "you have the right to a clean and humane environment in which you are protected from harm ..."

Record review of "Nursing Assignment Sheet, "dated 5/16/2023, on the Geri-Psych Unit showed 16 patients were currently on suicide precautions.
During an interview on 5/16/2023 at 1:00 PM time with Staff # I, Charge nurse, he verified the precautions listed on the assignment sheet were current.

A. Medical beds and unsecured electrical cords:

Surveyors toured Unit 4 on 5/16/2023 between 1 and 2 PM, accompanied by Staff-H, Mental Health Tech (MHT). Observations showed:

- Rooms 401, 402, 405, 406, 407 all contained electric medical beds. Four of the rooms contained 2 beds.

- Seven (7) patients currently on suicide precautions were assigned to occupy the electric medical beds [Patient ID #s 19, 20, 21, 22, 23, 25, 42]

The following was demonstrated in an unoccupied patient room by a surveyor, accompanied by Staff-H:

A bedsheet was tied securely to a bar accessible on the metal bed frame of a medical bed. The sheet was then pulled across the bed. There was ample material left to allow tying the sheet around a person's neck. Surveyor put download pressure using full body weight and the sheet held.

Staff #H acknowledged this was a strangulation hazard and ligature risk, stating he had not seen this as a danger before.

Electrical cords:

All five rooms with electronic medical beds had electrical cords attached to the beds. Some were plugged in; some were not. None of the cords were secured. The cords were approximately three feet long. The cord was long enough to tie around a person's neck and cut off circulation.

Staff #H acknowledged the electric cord posed a strangulation risk. He went in to say the cords were supposed to be secured. He demonstrated how the cord could be placed in a key-locked box with a metal door, located at the bottom portion of the base of the bed.

B. Wooden frame bed:

Continued observation on 5/16/2023 in Unit 4 showed:

Room # 409 - contained two separate wooden bed frames attached to the wall. A gap was observed between the bed and the wall creating a tie off point for self-harm. Patient ID # 44 & 45, assigned to these beds, were both identified to be on suicidal precautions.

Upon request, Staff -H, MHT demonstrated the following:

- A knot was tied in one corner of a bed linen sheet, the knot was secured in the gap between the bed frame and the wall. With the knot firmly secured in the gap Staff# H tugged on the bed linen in a downward motion.

Interview on 05/16/2022 at 2:00 PM with staff ID # H confirmed the bed linen held in place creating a ligature risk. The knot remained in the gap and held in place.

C. Lack of policy related to electric medical beds:

During an interview on 5/17/2023 at 9:45 AM with Staff -Q, Safety Officer, he said they conducted a facility-wide ligature risk assessment annually. He was asked to provide a copy of the latest facility ligature risk assessment.

Record review of facility document titled "2023 Environmental/Ligature Risk Assessment" showed: "....Potential Areas of Risk: Location - Bedrooms: If electric beds are used for patients with co-existing medical issues- all electrical cords should be secured and shortened. Policy in place regarding management of medical beds ...."

During an interview on 05/17/2023 at 10:13 AM with staff ID # B, Performance Improvement Director, he reviewed the 2023 ligature Risk Assessment and acknowledged the medical beds were identified as a ligature risk. He stated they did not develop the policy related to the management of the medical beds.


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D. Failed to ensure 4 of 8 patients on suicide precautions, were not exposed to a toxic product (wet caulk) on unit 6. (ID#s 31, 37, 39 and 41).

Observation on 5/17/2023 at 10:15 AM on unit 6, room 604 patient (ID#31) was lying covered up in bed A. Bed B had wet caulk between the head portion of the bed frame and the wall. Surveyor was able to leave finger impressions in the wet caulk. This same finding was present in rooms:
608- which housed patient ID (#37)
609 -which housed patient ID (#39)
610- which housed patient ID (#41)

Observation on 3/17/2023 at 10:25 AM, in room 610 bed B, surveyor was able to remove approximately 1 1/2 teaspoon amount wet caulk (of similar consistency observed in room 604) with writing utensil.

Record review of safety data sheet for caulk used on unit 6 on 5/17/23 showed the following information:

SUREBOND SB-190 Everseal
Section 2 Hazard Identification

Effects of exposure:
Eyes: can cause irritation, redness, tearing and blurred vision
Skin: prolonged or repeated contact can cause moderate irritation, drying of the skin and dermatitis
Inhalation: excessive inhalation of vapors may be fatal and can cause respiratory irritation, headache, drowsiness and fatigue. High concentration of vapors are anesthetic and may cause central nervous system effects such as dizziness
Ingestion: may be fatal and can cause kidney and liver damage, gastrointestinal irritation, nausea, vomiting and diarrhea

Classification of the substance:
GHS02 Flame
Flam.Liq.2 H225 Highly flammable liquid and vapor

GHS08 Health Hazard
Repr 2 H361 suspected of damaging fertility or the unborn child
STOT. RE 2 H373 may cause damage to organs through prolonged or repeated exposure
Asp. Tox.1 H304 maybe fatal if swallowed and enters airways

GHS07 Exclamation Mark

Skin Irrit. 2 H315 skin irritation
STOT SE 3 H336 may cause drowsiness or dizziness

Precautionary Statements:
-Avoid breathing dust/fumes/gas/mist/vapors/spray
-Wash thoroughly after handling
-Use only outdoors or in well-ventilated area
-Wear protective gloves protective clothing, eye protection, face protection

Interview with RN staff (ID T) on 5/17/23 at 10:00 AM confirmed patients (ID#s 31, 37, 39 and 41) were currently on suicide precautions.

Interview with maintenance staff (ID R) on 5/17/23 at 10:30 AM stated that he was in the process of caulking around the beds using the caulk on his cart, product SUREBOND SB-190 Everseal.