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Based on document review, observation and interview, it was determined that for 1 of 1 Center for Mental Health Unit, the Hospital failed to ensure that ligature risks were removed as required. This has the potential to affect the safety of the current psychiatric patients (13 out of the 15 patients are on suicide precautions) and any future psychiatric patients who may become suicidal.

As a result, it was determined that the Condition of Participation for Patient Rights, 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.



An immediate jeopardy (IJ) began on 2/28/20, due to the Hospital's failure to remove ligature risks. The IJ was identified and announced on 3/3/20 at 2:30 PM, during a meeting with the Director of Quality, Director of Outpatient Services and Chief Operating Officer. The IJ was not removed by the survey exit date of 3/5/20.

Based on document review, observation and interview, it was determined that for 1 of 1 Center for Mental Health Unit, the Hospital failed to ensure that patient rooms on the Center for Mental Health Unit were free from ligature risks. This has the potential to affect the safety of the current psychiatric patients (13 out of the 15 patients are on suicide precautions) and any future psychiatric patients who may 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 7/29/19, 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 Environmental Assessment dated 11/19, of the Center for Mental Health Unit was reviewed on 3/3/20. The Assessment did not identify any ligature risks.

3. On 3/3/20 between 9:00 AM and 10:00 AM, an observational tour was conducted on the Center for Mental Health Unit. Ligature risks on the Center for Mental Health Unit were identified as the following:

-16 out of 16 rooms (400, 401, 402, 403, 404, 406, 423, 425, 427, 429, 430, 431, 432, 434, 436 and 438 had entrance doors with 3 separate hinges and closet doors with 3 separate hinges that could be used as anchor points for hanging.

-Rooms 400, 401, 402, 404, 423, 427, 429 and 432 had curtain rods that could be used as anchor points for hanging.

-Moveable beds in room 423-2, 425-2, 427-2, 429-2, 430-1 and 438-1 had 4 siderails with mechanical crank handles at the foot of each bed that could be used as an anchor point for hanging.


4. On 3/3/20, Pt #1's clinical record was reviewed. Pt #1 was admitted to the Center for Mental Health Unit on 3/2/20 with the diagnoses of bipolar disorder and suicidal ideation with plan to jump in the river or overdose. Pt #1's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:00 AM, Pt #1 was observed to be in bed. Pt #1's bed had the following ligature risks:

- moveable beds had 4 siderails with 3 mechanical crank handles at the foot of the bed
- entrance door had 3 separate hinges
- closet with 3 separate hinges on the door

5. On 3/3/20, Pt #2's clinical record was reviewed. Pt #2 was admitted to the Center for Mental Health Unit on 2/29/20 with the diagnosis of suicidal ideation with a plan to overdose or cut herself. Pt #2's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:05 AM, Pt #2's room had the following ligature risks:

-moveable bed had 4 siderails with 3 mechanical crank handles at the foot of the bed
-entrance door had 3 separate hinges
-closet door had 3 separate hinges

6. On 3/3/20, Pt #3's clinical record was reviewed. Pt #3 was admitted to the Center for Mental Health Unit on 2/29/20 with the diagnoses of bipolar, psychotic features and suicidal ideation with plan to stab self. Pt #3's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:10 AM, Pt #3's room had the following ligature risks:

-moveable bed had 4 siderails with 3 mechanical crank handles at the foot of the bed
-entrance door had 3 separate hinges
-closet door had 3 separate hinges

7. On 3/3/20, Pt #4's clinical record was reviewed. Pt #4 was admitted to the Center for Mental Health Unit on 3/1/20 with the diagnoses of bipolar disorder and suicidal ideation of walking on a bridge with intent of jumping (police department brought Pt #4 to Hospital). Pt #4's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:15 AM, Pt #4's room had the following ligature risks:

-moveable bed had 4 siderails with 3 mechanical crank handles at the foot of the bed
-entrance door had 3 separate hinges
-closet door had 3 separate hinges

8. On 3/3/20, Pt #5's clinical record was reviewed. Pt #5 was admitted to the Center for Mental Health Unit on 2/29/20 with the diagnoses of major depression and suicidal ideation with a plan to overdose or slit wrists. Pt #5's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:20 AM, Pt #5's room had the following risks:

-moveable bed had 2 long siderails with 3 mechanical crank handles at the foot of the bed
-entrance door had 3 separate hinges
-closet door had 3 separate hinges

9. On 3/3/20, Pt #6's clinical record was reviewed. Pt #6 was admitted to the Center for Mental Health Unit on 2/29/20 with the diagnosis of major depression and suicidal ideation with a plan to cut her wrists. Pt #6's suicide assessment, dated 3/3/20, indicated moderate risk (every 15 minute checks). On 3/3/20 at 10:30 AM, Pt #6's room had the following risks:

-moveable bed had 4 siderails with 3 mechanical crank handles at the foot of the bed
-entrance door had 3 separate hinges
-closet door had 3 separate hinges

10. On 3/3/20 at 10:45 AM, an interview was conducted with the Manager of Center for Mental Health Unit (E #2). E #2 stated that the Hospital will not implement physical changes for ligature risk removal until the Hospital receives the report from The Joint Commission.

11. On 3/5/20, an interview was conducted with the Director of Outpatient Services (E #6). E #6 stated that the moveable beds with siderails have been removed and the Hospital is implementing 1:1 monitoring for suicidal patient until the doors/closet hinges can be replaced.