HospitalInspections.org

Based on observations, record review, and interview, the facility failed to maintain the condition of the physical plant (shattered window glass pane at the Voluntary entrance of the Crisis Unit) in such a manner that the safety and well-being of patients and visitors is assured.

Findings include:

Observation conducted at the Behavioral Crisis Unit on 10/21/2020 from 11:30 AM to 1:25 PM. The Voluntary entrance of the Crisis Unit observed 3 window panels with cracks. Photographic evidences taken and submitted

At 12:15 PM, on 10/21/2020, observation of the window panel closes to the ground, next to the entrance/ exit door has a hole and surrounding hole has stable shattered glass parts. Photographic evidences taken.

At 12:20 PM on 10/21/2020, the facility Superintendent stated: I was not here but I heard the patient started throwing rocks at the windows. They called me right away. The window is a hurricane impact window. It must be custom made. I called the company immediately and gave them the proposal. The order takes time because of the pandemic.

Around 1:00 PM on 10/21/2020, during the survey, a clear plexiglass was glued on both the inside and outside part of the windowpane by the Superintendent and his team.

Review of a copy of an e-mail from the Director, to the Superintendent, regarding policy #233 ...requirement to be distributed and training provided to his team which emphasizes .... When you find an issue patient related, that could be patient safety or potential to harm a patient, it has to be prioritized by doing a risk assessment and to determine the action to be taken to mitigate the risk to the patient population. Any broken glass has to be a priority to correct the exposure by boarding up the window/door to protect the patients from injuries or further damage. Date 10/22/2020 at 10:53 AM.

There was no Risk Assessment documented regarding this shattered window glass pane.