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Based on observation and interview, the psychiatric hospital failed to ensure the patients' right to to receive care in a safe setting as evidenced by failing to ensure that patient bathroom toilets were free of ligature risks.

Findings:

On 02/13/23 at 10:15 a.m., observation revealed patient rooms a, b, c and d had ligature risks around the toilets which included exposed plumbing pipes and openings around the toilet base and toilet seat.

An interview with S1DON at this time confirmed the toilets posed a ligature risk to suicidal patients. He further confirmed that the toilets in all patient rooms were of the same construction.

Based on record review and interview, the hospital failed to ensure that drug administration errors were immediately reported to the attending physician and documented in the medical record for 2 of 2 patient medication errors reviewed (Patient #11 and #12).
Findings:

In an interview on 02/13/2023 at 2 p.m., S1DON stated there were two medication errors recorded for the past year.

Review of Patient #11's medical record revealed an admit medication on 03/07/2022 for Amlodipine which was not transferred to the MAR and therefore not administered as ordered. The physician was notified. Further review of Patient #11's medical record failed to reveal the medication error was documented in the patient's medical record.

Review of Patient #12's medical record revealed Zyprexa 2.5 mg IM PRN was administered 10/19/2022 prior to a first dose review by the pharmacist. Pharmacist first dose review revealed an allergy to Zyprexa. The physician was notified and there was no adverse reaction. Further review of Patient #12's medical record failed to reveal the medication error was documented in the patient's medical record.

In an interview on 02/14/2023 at 12:00 p.m. after review of the medical record for Patient #11 and Patient #12, S1DON acknowledged the medication error was not documented in the patient's medical records for Patient #11 and Patient #12.

Based on observations and staff interview, the hospital failed to ensure the condition of the physical plant and overall environment was maintained to ensure the safety and well-being of the patients.
Findings:

Observations of rooms a, b, c and d with S1DON on 02/13/2023 beginning at 10:00 a.m. revealed the following:

Room a - had a brown substance on bathroom wall below toilet paper holder and grime and debris on the shower wall.

Room b - had debris, hair and dead insects on window sill and the plastic safety cover over air conditioner's electrical plug was not secured, allowing access to the receptacle/outlet.

Room c - had chair-rail molding along the wall coated with grime, debris and black hairs; small insects crawling on the wall and from under the call bell panel; the window frame had spider webs and the window sill was covered with debris and hairs; a water stain from leak in the ceiling; and a tear in the patient's mattress cover.

Room d - had its window ajar approximately 1/4 inches which was unable to be closed; bugs observed crawling on window sill; baseboards and floor coated in a build-up of grime and debris; and grime and debris on the chair-rail molding.

In an interview following the observations, S1DON acknowledged the above findings and confirmed rooms a, b, c and d were vacant and designated as clean.



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