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Based on document review, observation and interview, it was determieded that for 1 of 1 Behavioral Health Unit, the Hospital failed to protect and promote each patient's rights by not removing ligature risks as required. As a result, the Condition of Patient Rights 42 CFR 482.13 was not in compliance.

Findings include:

1. The Hospital failed to ensure that ligature risks were removed as required. See deficiency at A -144.

Based on document review, observation, and interview, it was determined that for 1 of 1 Adult Behavioral Health Unit (BHU), the Hospital failed to ensure that patients received care in a safe setting by not removing the ligature risks as required. This has the potential to affect the safety of the current 20 psychiatric patients on census as of 08/14/19 and any future psychiatric patients who become suicidal.

Findings include:

1. The CMS (Centers for Medicare and Medicaid Services) S & C (survey and certification) Memo: 18-06 - Hospitals (dated 12/8/17), was reviewed on 08/13/19, and included, "Memorandum Summary...Definition of a Ligature Risk: A ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include...door frames...hinges..."

2. The Hospital's policy titled, "Suicide Precautions" (approved 07/05/19) was reviewed on 08/14/19. The policy required, "...Provide a ligature resistant safe environment by removing hazardous items from the environment..."

3. The Hospital's document titled, "Ligature Risk Assessment Form" dated 05/06/19 was reviewed on 08/14/19. The document included, "Items/Concerns: Bathroom door with hinges and door touching the metal frame; door hinges to corridor room doors of patient bed rooms; Beds - medical beds have looping potential, beds have protruding edges and exposed corners. Patients can remove parts from these beds and use as weapons." The document failed to include medical beds with siderails on both sides of the medical beds as ligature risks.

4. On 08/13/19 between 9:30 AM - 12:30 PM, an observational tour of the Adult Behavioral Health Unit (BHU) was conducted. The following were observed during the tour.

- There were a total of 20 patient rooms (Room #201 to Room #239) in the BH Unit. There were six (6) patient rooms closed for construction (Room # 201 to Room #206). There were five (5) unoccupied patient rooms that were kept locked that were utilized for office space and out of service for patients. There were 14 semi private, unlocked patient rooms occupied by patients (Rooms 209, 211, 212, 213, 214, 215, 216, 229, 230, 231, 233, 234, 235 and 236). There were 11 semi private, unlocked patient rooms had attached, unlocked bathrooms with wooden bathroom doors up to the ceiling and three door hinges (Rooms 209, 211, 212, 213, 214, 215, 216, 229, 230, 234 and 236). The entrance to each patient room had three door hinges to the door entrance which could be used for hanging. There were eleven medical beds in eleven (11) unlocked patient rooms (Rooms 209, 211, 212, 213, 214, 215, 216, 229, 230, 234 and 236) including one (1) quiet room, with bed side rails on both sides of bed which could be used for hanging. In summary, the BH unit had bathroom doors, entrance doors and beds that were ligature risks that could be used as attachments for hanging.

5. On 08/13/19 at approximately 10:30 AM, the Director of Nursing (E #1) was interviewed. E #1 stated, "We have been working on our ligature risks. We are in the process of changing the bathroom doors and hinges for the whole Behavioral Health Unit."

6. On 08/13/19 at approximately 10:45 AM, the Nursing Manager (E #4) was interviewed. E #4 stated, "We have identified the ligature risks on this Unit. We are working it out step-by-step. If we have any patient identified as high risk, we place them on one-to-one monitoring."

7. On 08/13/19 at approximately 11:00 AM, the Vice-President for Operations/ Patient Safety Officer (E #3) was interviewed. E #3 stated, "We have blocked six (6) rooms as of now. There is construction in progress and we are fixing all the ligature risks."

8. On 08/14/19 at approximately 9:50 AM, the Director of Nursing (E #1) was interviewed. E #1 stated, "We did not identify side rails for medical beds as ligature risk. We plan on moving out all the medical beds and replace them with platform beds."

9. On 08/14/19 at approximately 11:00 AM, the Charge Nurse (E #5) was interviewed. E #5 stated, "Currently we do not have any patients on suicidal risk precautions. We follow standard suicide precautions on all patients by following every 15-minute rounds."