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Based on observation and interview, it was determined the facility failed to protect each patient's rights in that patients did not receive care in a safe environment for ligature risks in 22 of 22 patient rooms (400-413, 451, 500-502, 505-509) on the 4th and 5th floor Psychiatric Units as follows; exposed bathroom plumbing pipe three feet in height, protruding round door knobs, plastic shower curtains with metal shower curtain rings on a metal track, cabinetry pull handles, toilet paper dispensers extending out from the wall, shower heads with a 1/8 inch screw extending out of the top of the shower head, door hinges protruding out from the walls, exposed door closers, electronic cords dangling from the bottom of the television in the 4th floor Day Room, and exposed screws throughout the Facility were hex screws with sharp edges. The ligature risk had the likelihood to affect 18 patients currently admitted to the facility. See A- 0144 for details.

On 05/17/19 at 2:30 PM the Nurse Executive was informed there was Immediate Jeopardy to patient health and safety in the facility in that ligature risks existed in 22 of 22 patient rooms (400-413, 451, 500-502, 505-509) on the 4th and 5th floor Psychiatric Units as follows: exposed bathroom plumbing pipe three feet in height, protruding round door knobs, plastic shower curtains with metal shower curtain rings on a metal track, cabinetry pull handles, toilet paper dispensers extending out from the wall, shower heads with a 1/8 inch screw extending out of the top of the shower head, door hinges protruding out from the walls, exposed door closers, electronic cords dangling from the bottom of the television in the 4th floor Day Room, and exposed screws throughout the Facility were hex screws with sharp edges. The ligature risk had the likelihood to affect 18 current patients and any patient being admitted to the facility.
The Immediate Jeopardy was lifted at 11:00 AM on 05/20/19 with the following plan of action:
1. Implementation of one-on-one patient monitoring with continuous visual observation beginning 05/17/19 on the PM shift until all environmental ligature risks are resolved.
2. Reduction of the average daily census on the Units to a level that can ensure one-on-one observation of each patient.
3. On the 5th floor, have replaced as many hex head screws as possible on the window covers and HVAC covers, with tamper proof button top, until running out of screws. Toilet paper, paper towel, and soap dispensers have been removed in patient areas. The sink and shower light fixtures have been replaced with vandal resistant fixtures that have Lexan covers. All hooks and closet rods have been removed from closets. A TV cabinet has been built for the dayroom on 5th floor to enclose the TV and all cabling. The shower curtains and track have been removed from all showers. The dayroom and smoking room bathrooms have been sealed so they cannot be used. On 3rd floor, all windows in the ED and nursing unit have been fixed where they cannot be opened.
4. Starting Wednesday May 15th after the exit process on the 14th, I (facility) started to contact vendors for the needed ligature resistant fixtures, screws, and door hardware. To date I have contacted the vendors listed below, I have some of the materials ordered already and as they arrive, we will be making the appropriate upgrades to mitigate the potential harm for our patients.

-On 5/15/19 I contacted (nNamed) with American Building Specialties about our door hardware needs, I am awaiting his quote in order to proceed.

-On 5/15/19 I contacted (Named) with Arkansas Glass about our door hardware needs.

-On 5/16/19, (Named) with Arkansas Glass made a site visit to looks at our needs, I am awaiting a quote in order to proceed.

-On 5/15/19 I contacted (Named) with Cirb Services about our door hardware needs. He was scheduled to make a site visit on 5/17/19 but had to reschedule for Monday 5/20/19. I will be awaiting his quote before we can proceed.

-On 5/15/16 I contacted (Named) with Ross and Associates about our pluming fixture needs. He is scheduled to do a site visit on 5/24/19 to quote new fixtures.

-On 5/15/19 I contacted (Named) with C.A. Riner Company about our plumbing fixture needs. He made a site visit on 5/16/19. He has submitted an estimate sheet to his supplier and as soon as we hear back from them, we will be able to proceed.

-On 5/17/19 I ordered button topped screws from Bolt Depot to replace hex head screws, they are in transit as of that afternoon.

-On 5/17/19 I ordered red medal cover plates, so emergency generator outlets are clearly marked

-On 5/17/19 I contacted (Named) with LPfast about button topped tamper resistant anchor bolts and placed an order for the anchors and tools for installation.

-On 5/17/19 I went to Lowes and picked up all the stainless-steel cover plates they had in stock; I ordered the rest needed for the patient areas.

- On 5/17/19 I contacted (Named) with Wholesale Electric about some stainless-steel cover plates, and after receiving his quote I ordered some of the covers on the same day.

-On 5/6/19 I contacted (Named) at CED/MOR Electric about ordering some vandal light fixtures, after receiving the quote on 5/8/19 I ordered them, and we are awaiting their arrival to install them.

Based on observation and interview, it was determined the facility failed to ensure patients received care in a safe environment in that a ligature risk existed in 22 of 22 patient rooms (400-413, 451, 500-502, 505-509) on the 4th and 5th floor Psychiatric Units as follows; exposed bathroom plumbing pipe three feet in height, protruding round door knobs, plastic shower curtains with metal shower curtain rings on a metal track, cabinetry pull handles, toilet paper dispensers extending out from the wall, shower heads with a 1/8 inch screw extending out of the top of the shower head, door hinges protruding out from the walls, exposed door closers, electronic cords dangling from the bottom of the television in the 4th floor Day Room, and exposed screws throughout the Facility were hex screws with sharp edges. The ligature risk had the likelihood to affect 18 patients currently admitted to the facility. Findings follow:

A. Observations of the 4th and 5th floor Psychiatric Units on 05/13/18 from 1:00 PM to 2:30 PM showed patient rooms (400-413, 451, 500-502, 505-509) ,with exposed plumbing 3 feet in height, door knobs, pull handles, sharp screws in the windows, shower heads with protruding screws, plastic shower curtains with metal clips, protruding door hinges, accessible door closers, protruding toilet paper dispensers, and dangling electronic wires from the 4th floor day room television.

B. The above findings in A were verified 05/14/19 at 2:30 PM with the Nurse Executive

C. During an interview with the Chief Executive Officer (CEO) on 05/14/19 at 1:00 PM he stated that he presented a power point to the Board identifying ligature risk challenges of the facility due to the regulatory changes on 12/27/17. The CEO stated that $75,000 was allotted to begin construction changes to the 4th floor ceiling which was identified as a high risk area and the left over monies were to be used to begin implementing other areas of ligature risk. The CEO produced an invoice dated 02/27/19 for 200 smooth head screws which have not been installed. As of the time of this survey no other actions have been taken to ensure patient safety from the above mentioned ligature risk.

D. The above findings in C were verified on 05/14/19 at 1:00 PM with the Chief Executive Officer.

Based on observation, review of policy and interview, the facility failed to maintain records in a manner that ensured the integrity of the authentication and protected the security of all records in that eight of eight medical records were observed in a locked room at the nurses station on 3rd floor, waiting for them to be completed after the patients were released, and not in the HIM (Health Information Management) Department. By storing discharged records outside of the control of HIM, the facility could not ensure integrity of the authentication and the security of all records as the nurses had access to the room. The failed practice had the potential to affect all records of patients that had been discharged from the facility. Findings follow:

A. Review of the policy titled, "Location of Patient Records," revised May 2018, showed records that were in the completion process were to be maintained by the HIM (Health Information Management) Coordinator Clerk in the HIM Department until they were ready for permanent closed record filing.
B. During a tour on 05/15/19 from 12:00 PM until 1:15 PM, observation showed eight discharged patient charts in a locked room behind the nurse's station on 3rd floor.
C. During an interview on 05/15/19 at 12:20 PM, the Director of Health Information Management confirmed the records were stored in the room behind the nurses station on the 3rd floor, to allow nursing staff to complete their charting and correct their charting deficiencies instead of the Health Information Management, where the Health Information Management staff could have been able to ensure the integrity of the authentication and protect the security of all records that went through this process.

Based on policy and procedure review and observation it was determine the facility failed to ensure the confidentiality of patient records in that two boxes containing hundreds of patient's information, including name, date of birth, diagnosis, admission and discharge dates, insurance information, allergies and a list of the patients discharge medications were found in unlocked closets on the 4th and 5th floor. The failed practice affected all patients admitted to the hospital. Findings follow:

A. Review of Policy and Procedure on 05/13/18 at 2:30 PM titled "Confidentiality" showed all communication, verbal or written records pertaining to a patient or his/her care, including the source of payment or any treatment issues are confidential. Review of Policy and Procedure on 05/13/19 at 2:40 PM titled "Patient Rights" showed the patient has the right to the confidentiality of records about his/her care unless a disclosure is allowed or mandated by law.
B. Observation of the 4th floor Patient Unit on 05/13/19 at 1:30 PM showed two large cardboard boxes found in an unlocked closet containing confidential patient information.
C. Observation of the 5th floor Patient Unit on 05/13/19 at 2:00 PM showed two large cardboard boxes found in an unlocked closet containing confidential patient information.
D. The above findings in A and B were verified with the Nurse Executive on 05/13/19 at 2:05 PM.

Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being of patients in that ligature risks existed in 22 of 22 patient rooms (400-413, 451, 500-502, 505-509) on the 4th and 5th floor Psychiatric Units as follows: exposed bathroom plumbing pipe three feet in height, protruding round door knobs, plastic shower curtains with metal shower curtain rings on a metal track, cabinetry pull handles, toilet paper dispensers extending out from the wall, shower heads with a 1/8 inch screw extending out of the top of the shower head, door hinges protruding out from the walls, exposed door closers, electronic cords dangling from the bottom of the television in the 4th floor Day Room, and exposed screws throughout the Facility were hex screws with sharp edges. The ligature risk had the likelihood to affect 18 current patients and any patient being admitted to the facility. See A-0724 for details.

Based on observation and interview, it was determined the facility failed to ensure the condition of the hospital environment was maintained in a manner that provided a level of safety and well-being of patients in that ligature risks existed in 22 of 22 patient rooms (400-413, 451, 500-502, 505-509) on the 4th and 5th floor Psychiatric Units as follows: exposed bathroom plumbing pipe three feet in height, protruding round door knobs, plastic shower curtains with metal shower curtain rings on a metal track, cabinetry pull handles, toilet paper dispensers extending out from the wall, shower heads with a 1/8 inch screw extending out of the top of the shower head, door hinges protruding out from the walls, exposed door closers, electronic cords dangling from the bottom of the television in the 4th floor Day Room, and exposed screws throughout the Facility were hex screws with sharp edges. The ligature risk had the likelihood to affect 18 current patients and any patient being admitted to the facility. Findings follow:

A. Observations of the 4th and 5th floor Psychiatric Units on 05/13/18 from 1:00 PM to 2:30 PM showed patient rooms (400-413, 451, 500-502, 505-509), had exposed plumbing three feet in height, door knobs, pull handles, sharp screws in the windows, shower heads with protruding screws, plastic shower curtains with metal clips, protruding door hinges, accessible door closers, protruding toilet paper dispensers, and dangling electronic wires from the 4th floor day room television.

B. The above findings in A were verified 05/14/19 at 2:30 PM with the Nurse Executive.

C. During an interview with the Chief Executive Officer (CEO) on 05/14/19 at 1:00 PM he stated that he presented a power point to the Board identifying ligature risk challenges of the facility due to the regulatory changes on 12/27/17. The CEO stated that $75,000 was allotted to begin construction changes to the 4th floor ceiling which was identified as a high risk area and the left over monies were to be used to begin implementing other areas of ligature risk. The CEO produced an invoice dated 02/27/19 for 200 smooth head screws which have not been installed. As of the time of this survey no other actions had been taken to ensure patient safety from the above mentioned ligature risk.

D. The above findings in C were verified on 05/14/19 at 1:00 PM with the Chief Executive Officer.

Based on observation and interview it was determined the Facility failed to ensure the hospital environment was developed and maintained in a manner that provided a level of safety and well-being of patients and visitors in that all patient room windows on the 3rd floor were not able to be locked to prevent patients and visitors from opening them or climbing out. The failed practice had the potential to affect all patients admitted to the 3rd floor. Findings follow:

A. Observations of the 3rd floor patient rooms (304, 305, 307, 308, 309 and 310) on 05/13/19 at 1:55 PM showed all windows were able to be opened completely which could allow someone to climb out of the window causing injury or death.

B. During an interview with the Nurse Executive on 05/13/19 at 2:00 PM he said the windows on the 3rd floor have never been locked or screwed shut.

C. The above findings in A and B were verified with the Nurse Executive on 05/13/19 at 2:00 PM.

This is a continued deficiency.

Based on interview the Infection Control Nurse failed to prevent infection in that there was not a respiratory protection program to include fit testing of personnel. Failure to perform fit testing did not allow protection of employees in the event of likely respiratory exposure. The failed practice had the potential to affect all employees and patients of the facility. Findings as follows:

On 05/14/19 at 1:30 PM, during interview the Nurse Executive stated there had been no fit testing for employees since 2017.


Based on observation it was determined the Infection Control Nurse failed to identify and control infections in that nine of nine laryngoscope blades were unwrapped in the crash carts of the Emergency Room/Medical Surgical Unit (3rd floor), and 4th and 5th floor patient care areas. The failed practice did not assure that the equipment had been cleaned or sterilized and stored in a manner to ensure protection from damage or contamination. The failed practice had the potential to affect all patients in the Emergency Room/Medical Surgical Unit and 4th and 5th floor patient care areas who needed the use of a laryngoscope for intubation. Findings follow:

A. Observation in the Emergency Room/Medical Surgical Unit (3rd floor), and the 4th and 5th floor patient care areas on 05/13/19 at 1:30 PM showed three unwrapped laryngoscope blades in each unit's crash cart for a total of nine laryngoscope blades.

B. Findings in A were verified by the Nurse Executive on 05/13/10 at 2:00 PM.

Based on policy review and interview, it was determined the facility failed to provide training of respiratory procedures to nursing personnel. Failure to ensure proper training of respiratory procedures did not allow nursing personnel to be knowledgeable in order to safely perform the procedures in the facility. The failed practice affected all patients in the facility requiring respiratory procedures.

A. Review of policy titled "Scope of Services of Respiratory Care" received on 05/14/19 showed:
"Respiratory Therapy needs are met by the nursing staff ... with consultation or assistance provided by the Respiratory Therapy department."

B. During an interview on 05/14/19 at 1:20 PM the Nurse Executive provided a current list of training topics for new employee orientation and annual training of all nursing personnel which did not include respiratory procedures. He stated there is no documentation of training of respiratory procedures.