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Based on observation, interview, record review, and policy review, the facility failed to ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to provide an environment aimed at preventing looping, hanging and cutting hazards.

Based on interviews with management, review of admission orders, review of psychiatric evaluations, and review of Behavioral Health Service Policy of "Special Precautions"' 10 of the 16 currently admitted patients were on suicide precaution observation. The process to keep patients safe from the environment was to observe the patient every 15 minutes.

Based on interview and record review the facility failed to provide care in a safe setting when a patient walked out of the hospital without facility intervention for one of one patients who left the facility.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.




12943

Based on record review, policy review and interviews the facility failed to inform patients of whom to contact for a grievance when this information failed to be in the admission information or the written patient rights provided to patients. Four (#15, #16, #23 and #25) of four patients interviewed failed to know who to contact to file a grievance.

The facility census was 146.

Findings included:

1. Record review of a policy titled, "Grievance Process for Patients"; Effective Date: 03/06; Revision Date: 02/11 showed the following direction;
-Section 2: Purpose: To provide patients, or their representatives, a forum for communicating concerns; and to provide staff a process for resolving grievances;
-Section 3: Procedure Forms:
-Admission Packet;
-Patient Response Line Flyer, "Your Guide To The [facility] Patient Response Line."

Record review of the Admission Packet, Rights and Responsibilities of Patients section (pages 4 and 5), item #26 stated: The patient has a right to be informed of the hospital's policies and procedures, including whom to contact and how. The facility failed to provide a phone number or address or who to contact at the facility regarding how to file a grievance.

During an interview on 12/21/11, at 4:54 PM, Staff A, Director of Quality, confirmed there is not a phone number or whom to contact at the facility to file a grievance in the patient rights. Staff A stated contact information of who to contact with a grievance is found on page 18 of the Admission Packet in the section titled, "How are we doing?" Staff A stated this information is also on a flyer that is in each patient's room. Staff A confirmed that the "How are we doing" section on page 18 of the Admission Packet and the flyer in the patient rooms failed to state the number provided is the number to call for a grievance.

2. Review of page 18 of the Admission Packet and the flyers in the patients rooms stated: "How are we doing? Are you having a positive experience with [the facility name]? Do you have a concern about any aspect of your care? We want to know? Your comments can help us recognize dedicated individuals while improving service to you and future patients. With this in mind, we invite you to call the [facility name] patient response line. You can make us aware of your positive experience, or, if you have concerns regarding your care, we will respond in a timely manner. Guaranteed. Call the 24-Hour [facility name] patient response line. We will make every effort to ensure you receive the best care possible." The number is then provided. The facility did not identify the number provided as whom to contact for a grievance.

3. During an interview on 12/28/11 at 4:04 PM, Patient #15 confirmed receiving the admission packet, but stated she did not know how to file a grievance.

During an interview on 12/28/11 at 4:30 PM, Patient #16 confirmed receiving the admission packet, but stated she did not know how to file a grievance.

During an interview on 12/29/11 at 1:51 PM, Patient #23 confirmed receiving the admission packet, but stated he did not know how to file a grievance.

During an interview on 12/29/11 at 2:31 PM, Patient #25 confirmed receiving the admission packet, but stated she did not know how to file a grievance.

29511

Based on observation, interview, record review and recognized standards of practice, the hospital failed to ensure patients are provided care in a safe setting in 20 of 20 patient rooms when the hospital failed to provide an environment aimed at preventing looping, hanging and cutting hazards. This had the potential to affect 16 of 16 patients on the Behavioral Health Unit with a census of 16.

Based on interview and record review the facility failed to provide care in a safe setting when a patient walked out of the hospital without facility intervention for one (Patient #14) of one patients who left the facility.

The facility census was 146.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).
JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
-Use doors with piano hinges or other hardware that reduces the risk of the hardware being used as an anchor. Use anti-ligature doors for non-corridor doors (e.g. bathrooms, stalls, showers);
- Plumbing enclosed in a tamper-resistant enclosure to prevent access by patients. Plumbing fixtures should be enclosed to minimize risks. All supply and waste plumbing should be concealed and inaccessible with tamper resistant fasteners;
- Faucets and spouts in sinks and showers should be an institutional type. There should be no handheld shower devices and no temperature adjusting devices with in the showers (unless recessed). Shower heads should be institutional type. Institutional faucets will not provide an anchor point for hanging.

2. Observation of unit 2 North on 12/28/11 at 8:45 AM showed twelve patient rooms (rooms 200, 201, 202, 203, 204, 206, 207, 208, 209, 210, 211, and 212).
Each patient room included a sink with conventional plumbing fixtures including a six inch long faucet, hot and cold water control knobs extending horizontally approximately five inches, a "J" trap (drain pipe under the sink that curves to make it look like a "J"). The bottom of the "J" was approximately 20 inches above the floor. The faucet, knobs and "J" pipe could bear the weight of an adult and presented a looping, ligature hazard for a patient intent on self harm.

Every patient room contained two closet doors, 18 inches wide and 72 inches high. The top of the closet doors were 76 inches above the floor. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was three inches below the top of the closet door. The space between the top hinge and top of door frame presented an anchor point if a sheet or other item (such as clothing) was tied off and used by a patient as a ligature to harm self.

Each patient room contained an entry door and a bathroom door. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was four inches below the top of the door. The space between the top hinge and top of door frame presented an anchor point if a sheet or other item, such as clothing, was tied off and used by a patient as a ligature for self harm.

Each door (entry and bathroom) had a push lever used to open the door. The lever was attached to the door through a metal box three inches wide, six inches high and one inch deep. The top of the metal box was 40 inches off the floor. The box could bear weight of an adult and presented a looping, ligature hazard for a patient intent on self harm.

Rooms 200 and 202 shared a toilet, as did rooms 204 and 206, 207 and 209, 208 and 210. Rooms 201, 203, 211 and 212 had their own toilets. All eight toilets had a water fill pipe extending out from the wall six inches. The pipe was approximately one and a half inches in diameter. The pipe turned horizontally at a 90 degree angle for an additional 10 inches, had a flush handle and turned downward 90 degrees to enter the toilet. At the highest point the pipe was 25 inches from the floor. The pipe could bear weight of an adult and presented a looping, ligature hazard for a patient.

Light fixtures over each of these toilets were anchored to the ceiling with non tamper proof flat head screws. Each fixture was loose to the touch. Screws could be removed by a patient with an object such as a coin and used by a patient to cut self. Fixtures could be removed to expose electric wires which could be used by a patient for self harm.

Rooms 200, 201 and 202 had light fixtures over the sinks. Each fixture was anchored to the ceiling with non tamper proof flat head screws. Each fixture was loose to the touch. Screws could be removed by a patient with an object, such as a coin, and used by a patient to cut self. Fixtures could be removed to expose electric wires, which could be used for self harm.

Nine of 12 rooms (rooms 200, 201, 202, 203, 204, 206, 209, 210 and 211) each had 12 inch by 12 inch ceiling vents with air direction louvers. Each vent had several sharp points and edges which a patient could use to cut self.

Unit 2 North had two separate common showers. Each shower had water control knobs extending two inches from the wall. These knobs were approximately 50 inches from the shower bottom and presented a looping, ligature hazard. One shower room contained a rusty vent 15 inches wide, 30 inches high, firmly anchored into the wall and extending from the wall one and one half inches, which presented a looping, ligature hazard for a patient.

3. Record review of Psychiatric Evaluations and Admission Orders for ten patients (#36, #35, #34, #33, #32, #31, #30, #29, #28 and #27) on unit 2 North showed all ten of the patients had a physician's order for Suicide Precaution Level 1 (SP1) due to suicidal ideations (thoughts of harming self), a plan for suicide or an actual suicide attempt.

Review of facility document titled, "BHS (Behavioral Health Services) Special Precautions", undated, defines Suicide Precaution Level 1 as a level of precaution that indicates suicide ideation with a vague plan, and able to contract for safety. Patient will be visualized every 15 minutes and documentation will occur.

4. Review of facility document titled, "Risk Management Worksheet", dated 12/22/11, showed that on 12/22/11 at 9:45 AM Patient #21 became angry and could not be verbally redirected. Patient #21 stormed off to his room and staff found him standing on the toilet with a shirt tied into a circle and attempting to put the shirt over his neck. Staff placed Patient #21 into seclusion (the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving.) Review of the physician's orders for Patient #21 showed the patient was on SP1 precautions at the time of this incident.

5. Observation of unit 3 West on 12/28/11 at 10:00 AM showed eight patient rooms,
(#369, 370, 371, 372, 375, 376, 377 and 378.) The unit was closed with no current patients.

Each patient room contained a sink with conventional plumbing fixtures including a goose neck faucet extending up nine inches from the sink top and then turning downward toward the sink basin, with hot and cold water control knobs extending horizontally approximately five inches, which presented a looping, ligature hazard for patients with an intent for self harm.
.
Each patient room had a bathroom with a toilet and a shower (except room 376 did not have a shower.) Over the top of each toilet was a ceiling light fixture anchored to the ceiling with non tamper proof flat head screws. Each fixture was loose to the touch. Screws could be removed by a patient with an object such as a coin. Screws could be used by a patient to cut self. Fixtures could be removed to expose electric wires that could be used by a patient for self harm.

On the wall in each bathroom was a pipe with a metal cap extending approximately two inches from the wall. The pipes were approximately one inch in diameter, firmly anchored behind the wall and presented a looping, ligature hazard for patients.

In each shower was a water control knob extending approximately two inches from the wall. These knobs were approximately 50 inches from the shower bottom and presented a looping, ligature hazard for patients.

Each bathroom contained a toilet paper dispenser firmly anchored in the wall. The dispenser box was six inches high, four inches wide and extended out from the wall three inches and presented a looping, ligature hazard for patients.

Each patient room contained two closet doors, 18 inches wide and 72 inches high. The top of the closet doors were 76 inches above the floor. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was three inches below the top of the closet door. The space between the top hinge and top of door frame presented an anchor point if a sheet or other item, such as clothing, was tied off and used as a ligature by a patient with an intent for self harm.

Each patient room contained an entry door and a bathroom door. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was four inches below the top of the door. Each door had a push lever used to open the door. The lever was attached to the door through a metal box three inches wide, six inches high and one inch deep. The top of the metal box was 40 inches off the floor. These doors and handle casings presented a looping, ligature hazard for patients.

6. During an interview on 12/28/11 at 8:40 AM Staff E, Director of Behavioral Health, stated that the Behavioral Health units do admit suicidal patients. Staff E stated that currently 10 of the 16 patients are on suicide precautions. Staff E stated that patients are kept safe because Mental Health Technicians (MHT) observe patients every 15 minutes. Staff E stated that patients could be placed on 1:1 close observation (a MHT would maintain visual observation at all times), if needed. Staff E stated that the rusty vent in the shower room on unit 2 North had no use. Staff E stated that she understands the patient safety concerns regarding the plumbing, light fixtures, doors, and ceiling vents but she does not recall any bad outcomes. Staff E stated that units 2 North and 3 West are scheduled for renovation in February 2012 because she has made the facility aware of the potential dangers to patients.

7. During an interview on 12/28/11 at 10:25 AM Staff E stated that unit 3 West was closed about one week ago due to low holiday census but she fully expected patients would be admitted to this unit very soon. Staff E stated that she did not know the purpose of the capped pipes that extended from the wall in the bathrooms on unit 3 West.

8. Review of the policy titled, "Wandering/Lost Patient (Code Green)," dated: 09/25/96; Revision Date: 01/09 showed the following direction:
-Section 2: Purpose: To ensure that all facility personnel and outside agencies are notified appropriately with the goal being to locate the missing patient as quickly as possible. Effective crisis management requires close cooperation between nurses, aides, administrators, security, law enforcement personnel and the media. Given the possibility of harm to the patient, time becomes critical and decisions must be made quickly and in cooperation with all involved;
-Section 3: Procedure:
(A) Staff Nurse:
1. When a staff nurse suspects a patient is missing, he/she will immediately notify and collaborate with the Nursing Shift Supervisor and Security as well as search the entire unit and do a complete count of all patients on the unit;
2. If the patient cannot be found, call extension 3333 (in-house operator) and advise the operator of the CODE GREEN and give the name, description and last known location of the patient;
(B) Nursing Shift Supervisor/Security:
1. If the incident occurs during shift change, personnel scheduled to leave should stay and assist in the search for the missing patient;
2. If the patient cannot be located within 15 minutes notify the Administrator on Call and contact the local police department for their assistance (give them all necessary information) then complete an incident report.
(C) Operator: When advised by the Nursing Shift Supervisor or Security of a CODE GREEN you will overhead page for the code and give the floor an area the patient has left (NO OTHER INFORMATION IS TO BE OVERHEAD PAGED). The operator will enter an "urgent" message on the email system;
(D) Administration:
1. May (if needed) develop a plan to meet the needs of each situation. This plan may include the following:
-Additional nursing personnel or security personnel;
-Administrative coverage during this crisis; and
-Assessing the need for media coverage and assistance from other agencies.

9. Review of physician assessment for Patient #14 on 11/13/11 at 2:00 PM, showed the following:
-Delirium (a confused state)-continue with Haldol (used to treat psychotic disorders [conditions that cause difficulty telling the difference between things or ideas that are real and things or ideas that are not real]) and Ativan (used to treat anxiety);
-Improved, but still needing Ativan as needed (PRN)/ Haldol PRN;
-Agitated this afternoon, quiet throughout the morning, eager to go home;
-Neurologic: Alert, no focal signs (no problem with nerves, the spinal cord, or brain function);
-Psychiatric (mental state) : Affect (refers to the experience of feeling or emotion) appropriate; Mood (a conscious state of mind) appropriate;
-Disposition (referring to when Patient #14 will be discharged): Await recovery.

Review of the medical record showed on 11/13/11 at 2:30 PM, Staff K, Charge Nurse, 4th floor, documented: Patient #14 left the floor without signing out or without the knowledge of any one on the floor.

During an interview on 12/28/11 at 10:00 AM, Staff I, Registered Nurse (RN), Director of 2 East and the 4th floor, stated the following in regards to the elopement (to run away and to not come back to the point of origination) of Patient #14 on 11/13/11 at approximately 2:30 PM:
-Patient #14 had been received to the 4th floor from CCU (intensive care is administered in a specialized unit of a hospital called the intensive-care unit CCU or critical-care unit CCU) during the night shift of 11/13/11;
-There had been no report from CCU that Patient #14 had been confused or not oriented;
-Staff I stated she interviewed Patient #14 on 11/14/11 regarding his elopement from the fourth floor on 11/13/11 and Patient #14 stated he:
-Remembered the whole thing;
-Remembered everything he did;
-Was determined to go home and nothing was going to stop him;
-Avoided going past the nurses' station by taking the back stairwell;
-Snuck out the back stairwell and was stopped a few times by staff asking him what he was doing and where he was going;
- Patient #14 stated he told the staff he was going back to his room and kept walking;
- Patient #14 stated hospital security and the police found him;
Staff I stated that upon return to the hospital Patient #14 was placed on 1:1 (staff assigned to stay bedside with Patient #14 24 hours a day).

Observation on 12/28/11, at approximately 11:00 AM, showed a back stairwell on the 4th floor with access to a flight of stairs.

During an interview on 12/28/11 at 11:00 AM, Staff J, Licensed Practical Nurse (LPN), staff nurse 4th floor for Patient #14 at the time of the elopement stated Patient #14:
-Eloped in the afternoon;
-Had a continuous tube feeding (a medical device used to provide nutrition to a patient who cannot obtain nutrition by swallowing) via G-tube (a tube inserted through a small incision in the abdomen into the stomach and is used for long-term nutrition feeding) running with a pump;
-Had a central line (a long, thin, flexible tube passed through a vein and used to give medicines, fluids, nutrients, or blood products over a long period of time) , with intravenous (IV) antibiotics (medications to treat infections) running intermittently (not continuous) with the IV line disconnected between IV doses;
-Was alert and oriented times three (oriented to person, place and time) the day of the elopement;
-Had been up walking the halls a lot the morning of the event, pushing his tube feeding pole (the medical pole the IVs and the tube feeding hang from) along with him as he walked;
-Had been in and out of his room and sticking his head out of his room;
- The aide entered the room and noticed the tube feeding running on the floor and told the charge nurse;
-When Staff K, charge nurse returned from lunch the charge nurse said the staff was looking for Patient #14 in room 467, Patient #14 wasn't in the chair and wasn't in the bathroom;
-Patient #14 had not received Ativan or Haldol since he was transferred to the 4th floor.
-Staff K was at the nurses' station talking on the phone to Staff Z from Security. Staff Z had stated that he "hollered" at Patient #14 and he took off running; they ended up at a mobile home park a quarter mile past the hospital;
-None of Patient #14's family was present at the time;
-Shortly after that time the brother and sister-in-law, came to the nurses' station wanting to know where Patient #14 was as he was not in his room;
-The staff informed the family what security said and they took off to find Patient #14;
-Security had called the police as Patient #14 was running from security;
-Police secured Patient #14;
-Patient #14's wife took the patient back to the hospital;
-Staff K, charge nurse and Staff L, hospital supervisor, met Patient #14 and his family at the hospital front doors upon return to the hospital;
-Upon return to the hospital Patient #14 stated he called his brother from the hospital and asked his brother to come pick him up from the hospital, but the brother refused making Patient #14 angry;
-Upon return Patient #14 stated he was sorry and didn't mean to cause any trouble - he just wanted to go home;
-Patient #14 stated he had enough and wanted to go home one way or the other since the doctor wasn't going to let him go home;
-Patient #14 stated he would not run away again; and
-Patient #14 was placed on 1:1 observation.

During an interview on 12/28/11 at 2:30 PM, Staff L, RN, House Supervisor, stated that:
-CCU staff called and asked her if she lost a patient as the operator just called;
- The operator had been in phone contact with security stating that a patient was on the road;
- The 4th floor had already communicated through the operator that Patient #14 was missing;
-The operator had already called security regarding calls coming in from the community about a patient on the road. The operator had also called security about Patient #14 being missing from the 4th floor;
-Once patients are off hospital grounds hospital security can't bring the patients back so Staff Z from security had already called the police;
-The police stayed with Patient #14 until Patient #14's family arrived;
-Patient #14's family talked Patient #14 into coming back to the hospital;
-Patient #14's wife drove Patient #14 back to the hospital;
-Staff K and Staff L met Patient #14 and family at the main entrance to the hospital;
-Patient #14 knew where he was, he knew his name and he knew what he had done;
-1:1 observation was started for Patient #14.

Review of the clinical record for Patient #14 showed:
-Patient #14 was admitted on 11/01/11 with the diagnosis of a duodenal (the first section of the small intestine) perforation (a small hole) and septic shock (life-threatening infection that gets worse very quickly and is often fatal);
- On 11/12/11 at 11:15 PM, Staff O, 4th floor RN, documented Patient #14 was alert and oriented, able to make his needs known, oriented to his room and policy/procedures, all needs met and will continue to monitor closely;
-Patient #14 did not receive Ativan or Haldol after being transferred to the 4th floor and prior to the time Patient #14 left the hospital;
-The nursing assessment of Patient #14 the day of the elopement (11/13/11) showed Patient #14 was alert (quick to perceive and act) and oriented (the knowledge of one's own relationship to time, social, and practical circumstances in life) times three (oriented to person, place and time);
-On 11/13/11 at 2:30 PM, Staff K, charge nurse, on the 4th floor, documented:
-Patient #14's brother and sister-in-law walked into room to visit Patient #14 at the same time staff was looking for Patient #14;
-Patient #14 was not found in his room by the brother and sister-in-law;
-Staff K called security to inform security the wandering Patient #14 may be from 467-B;
-The situation was explained to family and the shift supervisor was notified;
-Staff K and family went to the parking lot. The family drove to find Patient #14 and bring Patient #14 back to the hospital;
-Patient #14 returned with his spouse;
-Patient #14 willingly stepped out of the vehicle and walked into hospital;
-Patient #14 willingly returned to room 467 with family, shift supervisor and Staff K; and
-Patient #14 was made a 1:1 for elopement precautions (monitoring Patient #14 to ensure he doesn't leave the hospital again).

Review of the clinical record showed the time from when the physician finished examining Patient #14 to the time Patient #14 returned to the hospital was 19 minutes which showed Patient #14 was gone from the hospital 19 minutes or less.

During an interview on 12/29/11 at 8:57 AM, Staff Z, hospital Security Officer, stated that:
-The operator received several calls from people in the community stating they saw a person in hospital pants and hospital top hitchhiking on Highway 61;
-The operator notified him about the calls and he drove to Highway 61;
-He saw Patient #14 on the side of the road on Highway 61;
-He passed Patient #14 and pulled off the road and got out of the truck;
-Patient #14 ran across the highway into the woods;
-He called the police and requested two police cars - one car for Highway 61 and another car for the Highway 55 overpass that crossed over Highway 61;
-He and the police walked through the woods and saw Patient #14 running out of the other side of the woods toward Highway 55 overpass;
-When Patient #14 saw the police car on the Highway 55 overpass he turned around and ran back into the woods;
-Patient #14's brother showed up and told Patient #14 to go back to the hospital;
-Patient #14 also had a hospital bag with his belongings in it;
-He had this planned - he had already called his wife with a cell phone he had so she would pick him up and he had taken his belongings from the hospital;
-Patient #14 lives down Highway 61 and was going the right direction to go home;
-Patient #14 had already traveled about one half of a mile from the hospital;
-Patient #14 explained he wanted to go home and was determined to go home;
-Patient #14 presented aware of who he was, where he was and what he was doing.
-Patient #14 gave a straight answer to everything asked to him;
-Patient #14 stated he knew the security officer, his wife and his brother;
-The security officer explained to Patient #14 he needed to go back to the hospital because he still had IV's in and the nurses needed to take the IV's out if he wanted to leave the hospital;
-Patient #14's wife talked Patient #14 into going back to the hospital in her car.

10. Review of the facility's complaint and investigation documentation dated 12/12/11 through 12/19/11 regarding Patient #14 walking out of the hospital without facility intervention showed no staff were identified that may have talked to Patient #14 in the stairwell.

11. During an interview on 12/28/11 at 5:00 PM, Staff A, Director of Quality stated elopements are not tracked or trended and no interventions have been taken by the facility to decrease elopements.

Based on record review, observation and interview the facility failed to remove expired supplies from Behavioral Health Unit (2 North) stock. Facility census was 146.

Findings included:

1. Record review of facility policy titled, "Par Restocking" dated 02/13/09 showed direction for store room staff to check supplies for outdates. It should be noted that 2 North is not listed on the policy as an area to be checked.

2. Observation in the Behavioral Health Unit (2 North) Medication Room cabinet on 12/28/11 at 9:10 AM showed seven packages (each package contained 5 connectors) of electrode connectors (used to visualize cardiac electrical activity on a heart monitor) with manufacturers expiration dates of 10/11 (2 packs), 08/11 (2 packs), 04/11 (2 packs), and 09/10 (1 pack) and eight packages of defibrillator pads (each package contained 2 pads and are used during cardiac resuscitation to shock patients heart) with manufacturers expiration dates of 01/11 (4 packs), 04/10 (2 packs), 01/10 (2 packs). Expired supplies could be defective during cardiac emergency and delay care to a critically ill patient.

3. During an interview on 12/28/11 at 9:15 AM Staff E, Director of Behavioral Health Unit, stated that those supplies belong to the Respiratory Therapy (RT) Department and expiration dates should be checked by them. Staff E stated that these must have been missed.

During an interview on 12/29/11 at 12:40 PM Staff BB, Director of RT Department, stated that those supplies do not belong to the RT Department. Staff BB stated that other supplies in that cabinet do belong to RT but not those identified. Staff BB stated she was not sure who should have checked expiration dates on the items.

Based on observation, interview, record review, and policy review, the facility failed to ensure patients admitted with suicidal ideation and/or a history of suicidal ideation, were provided care in a safe setting when it failed to provide an environment aimed at preventing looping, hanging and cutting hazards.

Based on interviews with management, review of admission orders, review of psychiatric evaluations, and review of Behavioral Health Service Policy of "Special Precautions"' 10 of the 16 currently admitted patients were on suicide precaution observation. The process to keep patients safe from the environment was to observe the patient every 15 minutes.

Based on interview and record review the facility failed to provide care in a safe setting when a patient walked out of the hospital without facility intervention for one of one patients who left the facility.

The severity and cumulative effect of these systemic practices resulted in the overall non-compliance with 42 CFR 482.13, Condition of Participation: Patient's Rights.




12943

29511

Based on observation, interview, record review and recognized standards of practice, the hospital failed to ensure patients are provided care in a safe setting in 20 of 20 patient rooms when the hospital failed to provide an environment aimed at preventing looping, hanging and cutting hazards. This had the potential to affect 16 of 16 patients on the Behavioral Health Unit with a census of 16.

Based on interview and record review the facility failed to provide care in a safe setting when a patient walked out of the hospital without facility intervention for one (Patient #14) of one patients who left the facility.

The facility census was 146.

Findings included:

1. Recognized standards of practice for a psychiatric facility include:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064 -2074).
JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:
-Use doors with piano hinges or other hardware that reduces the risk of the hardware being used as an anchor. Use anti-ligature doors for non-corridor doors (e.g. bathrooms, stalls, showers);
- Plumbing enclosed in a tamper-resistant enclosure to prevent access by patients. Plumbing fixtures should be enclosed to minimize risks. All supply and waste plumbing should be concealed and inaccessible with tamper resistant fasteners;
- Faucets and spouts in sinks and showers should be an institutional type. There should be no handheld shower devices and no temperature adjusting devices with in the showers (unless recessed). Shower heads should be institutional type. Institutional faucets will not provide an anchor point for hanging.

2. Observation of unit 2 North on 12/28/11 at 8:45 AM showed twelve patient rooms (rooms 200, 201, 202, 203, 204, 206, 207, 208, 209, 210, 211, and 212).
Each patient room included a sink with conventional plumbing fixtures including a six inch long faucet, hot and cold water control knobs extending horizontally approximately five inches, a "J" trap (drain pipe under the sink that curves to make it look like a "J"). The bottom of the "J" was approximately 20 inches above the floor. The faucet, knobs and "J" pipe could bear the weight of an adult and presented a looping, ligature hazard for a patient intent on self harm.

Every patient room contained two closet doors, 18 inches wide and 72 inches high. The top of the closet doors were 76 inches above the floor. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was three inches below the top of the closet door. The space between the top hinge and top of door frame presented an anchor point if a sheet or other item (such as clothing) was tied off and used by a patient as a ligature to harm self.

Each patient room contained an entry door and a bathroom door. Each door was anchored to the frame with three hinges. The top of the uppermost hinge was four inches below the top of the door. The space between the top hinge and top of door frame presented an anchor point if a sheet or other item, such as clothing, was tied off and used by a patient as a ligature for self harm.

Each door (entry and bathroom) had a push lever used to open the door. The lever was attached to the door through a metal box three inches wide, six inches high and one inch deep. The top of the metal box was 40 inches off the floor. The box could bear weight of an adult and presented a looping, ligature hazard for a patient intent on self harm.

Rooms 200 and 202 shared a toilet, as did rooms 204 and 206, 207 and 209, 208 and 210. Rooms 201, 203, 211 and 212 had their own toilets. All eight toilets had a water fill pipe extending out from the wall six inches. The pipe was approximately one and a half inches in diameter. The pipe turned horizontally at a 90 degree angle for an additional 10 inches, had a flush handle and turned downward 90 degrees to enter the toilet. At the highest point the pipe was 25 inches from the floor. The pipe could bear weight of an adult and presented a looping, ligature hazard for a patient.

Light fixtures over each of these toilets were anchored to the ceiling with non tamper proof flat head screws. Each fixture was loose to the touch. Screws could be removed by a patient with an object such as a coin and used by a patient to cut self. Fixtures could be removed to expose electric wires which could be used by a patient for self harm.

Rooms 200, 201 and 202 had light fixtures over the sinks. Each fixture was anchored to the ceiling with non tamper proof flat head screws. Each fixture was loose to the touch. Screws could be removed by a patient with an object, such as a coin, and used by a patient to cut self. Fixtures could be removed to expose electric wires, which could be used for self harm.

Nine of 12 rooms (rooms 200, 201, 202, 203, 204, 206, 209, 210 and 211) each had 12 inch by 12 inch ceiling vents with air direction louvers. Each vent had several sharp points and edges which a patient could use to cut self.

Unit 2 North had two separate common showers. Each shower had water control knobs extending two inches from the wall. These knobs were approximately 50 inches from the shower bottom and presented a looping, ligature hazard. One shower room contained a rusty vent 15 inches wide, 30 inches high, firmly anchored into the wall and extending from the wall one and one half inches, which presented a looping, ligature hazard for a patient.

3. Record review of Psychiatric Evaluations and Admission Orders for ten patients (#36, #35, #34, #33, #32, #31, #30, #29, #28 and #27) on unit 2 North showed all ten of the patients had a physician's order for Suicide Precaution Level 1 (SP1) due to suicidal ideations (thoughts of harming self), a plan for suicide or an actual suicide attempt.

Review of facility document titled, "BHS (Behavioral Health Services) Special Precautions", undated, defines Suicide Precaution Level 1 as a level of precaution that indicates suicide ideation with a vague plan, and able to contract for safety. Patient will be visualized every 15 minutes and documentation will occur.

4. Review of facility document titled, "Risk Management Worksheet", dated 12/22/11, showed that on 12/22/11 at 9:45 AM Patient #21 became angry and could not be verbally redirected. Patient #21 stormed off to his room and staff found him standing on the toilet with a shirt tied into a circle and attempting to put the shirt over his neck. Staff placed Patient #21 into seclusion (the involuntary confinement of a person alone in a room or an area where the person is physically prevented from leaving.) Review of the physician's orders for Patient #21 showed the patient was on SP1 precautions at the time of this incident.

5. Observation of unit 3 West on 12/28/11 at 10:00 AM showed eight patient rooms,
(#369, 370, 371, 372, 375, 376, 377 and 378.) The unit was closed with no current patients.

Each patient room contained a sink with conventional plumbing fixtures including a goose neck faucet extending up nine inches from the sink top and then turning downward toward the sink basin, with hot and cold water control knobs extending h