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Based on observations, interviews, and document review, the facility failed to ensure a safe patient care environment. Specifically, the facility failed to ensure items, which posed a safety risk to patients or others, were monitored and tracked on the inpatient psychiatric units in two of four patient care units observed (Meadows and Cedars units).

Findings include:

Facility policy:

Review of the policy Linen Management revealed no mention of the amount of linen a patient was allowed to have in the patient room.

Further review of facility policies revealed no tracking system or monitoring in place to ensure a patient had only the amount of linen allowed.

References:

The facility document General Unit Rules revealed a patient was allowed two sheets, one blanket, one comforter, and one pillow.

The Close Observation Sheet revealed no reference to the tracking of linens a patient was allotted access to.

The Unit Safety Check Sheet revealed no reference to the tracking of linens a patient was allotted access to.

1. The facility failed to have a process in place to ensure excess linens were monitored and tracked within patient rooms.

a. On 11/16/22 at 1:52 p.m., observations revealed four rooms on the Cedars Unit (Detox Unit) and one room on Meadows Unit (First Responder and Active Military Duty Unit) had two sets of linens in each room and only one patient occupied the room:
On 11/16/22 at 1:52 p.m., Room P17 on Cedars Unit had two sets of linens in the room and only one patient occupied the room.
On 11/16/22 at 1:52 p.m., Room P20 on Cedars Unit had two sets of linens in the room and only one patient occupied the room.
On 11/16/22 at 1:52 p.m., Room P21 on Cedars Unit had two sets of linens in the room and only one patient occupied the room.
On 11/16/22 at 1:52 p.m., Room P22 on Cedars Unit had two sets of linens in the room and only one patient occupied the room.
On 11/16/22 at 2:02 p.m., Room P24 on Meadows Unit had two sets of linens in the room and only one patient occupied the room.

b. An interview on 11/17/22 at 11:55 a.m. with registered nurse (RN) #1 revealed housekeeping staff changed bedding in rooms after a patient discharged and as needed or requested by the patient. RN #1 stated no check out list existed for patient linens on the unit. RN #1 stated each patient was allowed to have one fitted sheet, one top sheet, one blanket, and one pillowcase in their possession. RN #1 further stated a patient was not supposed to have extra blankets, but was not sure how extra linens were tracked when asked for by the patient.

RN #1 stated during unit safety checks (a checklist of the patient care environment on the unit), the extra linens were monitored by patient care assistants (PCAs); however, RN #1 stated she did not recall a specific monitoring process in place of patients who had access to multiple pieces of linens. RN #1 stated there was no specific mention of monitoring for extra linens on the close observation sheet (15 minute checks of patient location and behavior). RN #1 stated the second bed had linens placed on the bed after a patient discharged in preparation for an admission even if there was one patient assigned to the room. RN #1 further stated a patient with access to multiple sets of linens was at risk to self-harm behavior or strangulation.

c. An interview on 11/17/22 at 12:12 p.m. with licensed practical nurse (LPN) #2 revealed housekeeping staff were expected to change all bedding when a patient was discharged or when requested by unit staff. LPN #2 stated patients were allowed to have one flat sheet, one top sheet, one blanket, and one pillowcase. LPN #2 stated patients were allowed two blankets if requested. LPN #2 stated there was not a process in place for tracking the number of linens in each patient room. LPN #2 stated the second bed in a patient's room was made upon discharge of a patient, leaving one patient in the room with two full sets of linens. LPN #2 further stated observations during 15 minute checks included tracking the extra linens; however, LPN #2 stated there was no specific reference which addressed linen count on the 15 minute check sheets. LPN #2 stated a patient was at risk of self-harm or hanging themselves with access to excess linens.

d. An interview on 11/17/22 at 12:35 p.m. with PCA #3 revealed patients were allowed two blankets if requested. PCA #3 stated the monitoring of linens was observed during unit safety checks. PCA #3 further reported the facility had no formal checklist to account for the linens a patient had access to or when a patient received extra linens. PCA #3 stated beds were made when a patient discharged, even when only one patient occupied the room. PCA #3 further reported housekeeping staff made beds and supplied each room with linens upon patient discharge in preparation for the next patient. PCA #3 reported it was important to monitor patients for access to linens due to strangulation risk and possibly flooding bathrooms. PCA #3 further stated patients were at risk to harm themselves with access to more than one set of linens.

e. An interview on 11/17/22 at 1:05 p.m. with housekeeping supervisor (Supervisor) #4 revealed housekeeping received a phone call or was notified when patients wanted new linens or a discharge occurred to provide fresh linens to the room. Supervisor #4 stated no specific tracking system existed related to what linens were given to patients or the amount of linens in each room. Supervisor #4 further stated patients were at risk for self-harm with access to excess linens.