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Based on observations, interviews and record review, the facility failed to provide care in a safe setting as evidenced by 1) Observation of exposed fluorescent lighting in an elevator used by patients during admission and discharge; 2) Observation of cracked toilet seats with sharp edges in patient's rooms; 3) Observation of soft plastic wrap and plastic wrappings in patient's rooms; 4) Observation of 2" wide plastic tape securing thresholds between the bathroom floor and the shower in patient's rooms; 5) Observation of non-tamper resistant screws used to secure a piece of plywood to the wall; and 6) Observation via video surveillance of an unsupervised cell phone plugged into an electrical socket using a charging wire in a patient hallway. This deficient practice had the potential to affect any of the 34 patients on the unit at the time of the survey.
Findings:

On 06/15/2022 at 9:10 a.m. a tour of the facility was conducted with S3Assistant Director of Nursing (ADON) which revealed the following:

1) Observation of exposed fluorescent lighting in an elevator used by patients during admission and discharge;

An observation on 06/13/2022 at 9:10 a.m. revealed, in the elevator to the right of the corridor, exposed fluorescent light bulbs at the top of the elevator with tears in the backing of the lighting fixtures. The non-covered light fixture presented an ability for patients to use the fluorescent bulbs to inflict harm to themselves or others.

An observation on 06/15/2022 at 9:35 a.m. revealed, in the elevator to the right of the corridor, exposed fluorescent bulbs at the top of the elevator with tears in the backing of the light fixture. The non-covered light fixture presented an ability for patients to use the fluorescent bulbs to inflict harm to themselves or others.

In interview on 06/15/2022 at 9:35 a.m., S3Assistant Director of Nursing (ADON) verified there was exposed fluorescent bulbs and indicated the elevator was used to transport patients upon admit to and discharge from the unit.

2) Observation of cracked toilet seats with sharp edges in patient's rooms presented an ability for patients to inflict harm to themselves or cause injury to other patients or staff;

Review of the policy and procedure titled, "EOC Safety Rounds" effective 02/05/2015 revealed, in part, it is the policy of the facility to have a hospital-wide system to perform hazard surveillance. Procedure: 1) Each department will inspect for safety issues using an inspection checklist each shift by staff and monthly by administration. The checklist shall encompass all hazards that have the potential for harming patients, staff and visitors or impact the integrity of a safe physical environment; 2) All deficiencies, problems, or failures will be reported on this checklist. Nursing staff is to immediately notify administration on-call of any deficiencies found included on the administration checklist is the corrective action taken, results of the corrective action, whether the issue is closed, and if continued follow-up action is needed. Maintenance is notified by the CEO.

A tour of the unit on 06/15/2022 revealed the following rooms with cracked toilet seats and sharp edges posing risks as follows: Rooms a, b, f, i, j, and k.

In interview on 06/15/2022 during the tour of unit, S3ADON verified the toilet seats were cracked exposing sharp edges.

3) Observation of soft plastic wrapping and plastic wrappings in patient's rooms presented a means for patients to inflict self-harm through choking or suffocation;

A tour of the unit revealed in Room "a" a piece of soft, plastic wrapping paper measuring approximately 5X5 inches in the trash bag of Patient R1 who was admitted on 06/10/2022 with a diagnosis of Major Depressive Disorder;

A tour of the unit revealed in Room "b", a plastic wrapper for a toothbrush in the trash bag of Patient R2 who was admitted on 06/10/2022 with a diagnosis of Schizophrenia;

A tour of the unit revealed in Room "c". a plastic wrapper for a toothbrush on the floor in the bathroom of Patient R3 who was admitted on 06/08/2022 with a diagnosis of Schizoaffective Disorder.

In interview on 06/15/2022, S3ADON verified the above information.

4) Observation of 2" wide plastic tape securing thresholds between the bathroom floor and the shower in patient's rooms presented a means for patients to harm themselves through choking or suffocation;

A tour of the unit revealed in Room "f" a rubber threshold between the shower and the bathroom floor with 2" wide plastic tape securing the threshold of Patient R6's bathroom who was admitted on 06/12/2022 a diagnosis of Bipolar Disorder.

A tour of the unit revealed in Room "g" a rubber threshold between the shower and the bathroom floor with 2" wide plastic tape securing the threshold of Patient R7's bathroom who was admitted on 06/14/2022 with a diagnosis of Schizophrenia and Patient R12 who was admitted on 06/12/2022 with a diagnosis of Schizophrenia.

In interview on 06/15/2022, S3ADON verified the above information.

5) Observation of non-tamper resistant screws to hold a piece of plywood to the wall which could be used for self-harm, harm to others, or removing the piece of wood as a means to harm others; and,

A tour of the unit revealed in Room "d" a piece of plywood measuring approximately 16" x 16" screwed to the wall using non-tamper resistant screws. Further observation revealed Patient R4 who was admitted on 06/12/2022 with a diagnosis of Psychosis in his room lying on his bed. Patient R4 indicated "that was there when I got here".

In interview on 06/15/2022, S3ADON verified the above information.

6) Observation via video surveillance of an unsupervised cell phone plugged into an electrical socket in patient hallway with a charging cord which could be used for self-harm or harm to others.

Review of video surveillance revealed on 05/12/2022 from 10:12 p.m. through 10:28 p.m. in hall "m", an unsupervised cell phone using a charging cord plugged into an electrical socket and resting on the railing.

In interview on 06/15/2022 at 1:55 p.m., S2Director of Nursing (DON) indicated cell phones should not be plugged into an electrical socket outside of the nurse's station because it presents a ligature risk.