HospitalInspections.org

Based on observation and interview it was determined the Facility failed to assure equipment and furnishings were of a type (i.e. anti-ligature) to prevent injury to psychotic patients in one of one (Geropsychiatric) Unit. Failure to provide anti-ligature furnishings and equipment for psychotic patients did not assure they were free from self injury by strangulation or hanging. The failed practice was likely to affect all patients admitted to the Geropsychiatric Unit. Findings follow:

A. During tour of the Geropsychiatriac Unit with the Nurse Manager for the Unit on 11/18/15 at 1240, observation revealed patient rooms were not equipped with anti-ligature furnishings. In the bathrooms, assistive hand rails did not have blocks between the rail and the wall to prevent wrapping material around them. Basin and commode plumbing was exposed which did not prevent wrapping material around them. Shower curtains were not capable of being easily freed (i.e. Velcro, releasing hooks). All bed side rails had openings (handles) which did not prevent wrapping material around them. Door handles to all rooms were horizontal bars which did not prevent wrapping material around them.

B. Findings listed as A were verified with the Nurse Manager for Geropsychiatric Unit at the time of the tour.