HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure a safe setting for 31 of 31 patients (Patients 2-32) on suicide precautions. This failure resulted in patients being placed in bedrooms with bathroom doors that posed a ligature risk.

Findings included:

Observation of patient bedrooms #403, #405, and #608 on 9/11/2019 at 1:00 PM showed the bathroom doors were cut at an angle across the top. Staff A (CEO) tied a knot in one corner of a sheet and attached the sheet to the hinged corner of the bathroom door. The sheet held his weight.

In an interview with Staff A (CEO) on 9/11/2019 at 1:00 PM, he stated:
a) The bathroom doors in the patient bedrooms created a ligature risk.
b) There were 36 patient bedrooms in the hospital: Meadows 12, Willows 6, Cedars 6, and Sunrise 12.
c) The census was 54.
d) A plan of correction had been developed to replace the current bathroom doors with privacy drapes.
e) This plan of correction had been approved.

Record review of the Staff Assignment Sheet for the Meadows Unit dated 9/11/2019 (no time) showed a census of 17 patients with 10 patients on suicide precautions: Patients 2-11.

Record review of the Staff Assignment Sheet for the Willows Unit dated 9/11/2019 (no time) showed a census of 4 patients with 2 patients on suicide precautions: Patients 12 and 13.

Record review of the Staff Assignment Sheet for the Cedars Unit dated 9/11/2019 (no time) showed a census of 11 patients with 7 patients on suicide precautions: Patients 14-20.

Record review of the Staff Assignment Sheet for the Sunrise Unit dated 9/11/2019 (no time) showed a census of 22 patients with 12 patients on suicide precautions: Patients 21-32.

Record review of the Inpatient Risk Assessment, dated June 2019 showed: Patient bathroom door hinges - not compliant. "Doors are not ligature resistant. Staff will monitor doors during safety rounding. "Based on policy, all patients are assessed for suicidal risk upon admission ... [and] reassessed daily by clinical staff. If a patient is high risk for self-harm/suicide, they will be placed on a higher level of observation (line of sight, 1:1). All other patients are monitored every 15 minutes. The Environment of Care Director and Director of Nursing will train all staff members on this risk. The doors and their hardware are a nation-wide standard use item. Continue to train current and new staff on the risk. Continue to monitor the door hinges for tampering, by staff during the patient rounds."