HospitalInspections.org

Based on observations and interviews the Hospital failed to consistently provide a safe environment of care, free from ligature risks in the Psychiatric Triage area.

The Surveyor toured the Psychiatric Triage area at 10:30 A.M. on 10/13/2020 accompanied by the Emergency Department (ED) Director and the Director of Quality. The ED Director said the triage area had four private rooms with the potential to add two additional stretchers into the hallway. The Surveyor observed the stretchers that might be provided to a patient awaiting a psychiatric screening or an inpatient bed. The ED Director said the stretchers were the same ones that were used in the Emergency Department for medical patients. The surveyor noted an attached intravenous pole that was screwed into the head of the stretcher, full side rails and a foot pump that could be used to elevate the stretcher. The Surveyor expressed concerns about these stretchers as presenting a ligature risk. The ED Director said the triage area was staffed with a Registered Nurse (RN) and a trained Security person. The ED Director said the stretchers were under constant observation by either the RN or the Security person and pointed out a camera at the Nurse's station the was used to observe the hallway. The Director of Quality and the ED Director said that given the Security person who was stationed in the hallway the stretchers were under constant observation by the Security person.

The Surveyor returned to the Psychiatric Triage area at 10:00 A.M. on 10/14/2020 and accompanied Security Officer #2 while he performed his assignment for fifteen minute patient checks. Security Officer #2 said that the documentation was done for each patient on a separate sheet housed in a dedicated locked closet outside of each patient's room. Security Officer #2 said he was trained to observe each patient to be sure that he saw that the patient was breathing. The Security Officer then documented the check and returned the clipboard into the secured closet assigned to the patient assigned to room "A". Security Officer #2 then repeated the checks process for the patient assigned to room "B". Security Officer #2 said he performed these checks every fifteen minutes during his shift.

During this time the hallway space stretcher bed was out of the direct observation ability of Security Officer #2.