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Based on observation, review of medical records, facility documents, and staff interview, the facility failed to safeguard and uphold the rights of patients in the facility.

This failure resulted in 11 patients on the facility's Unit 3 (PICU) being placed in rooms with observable ligature risks (toilets), and six out of 11 of these patients were currently on Suicide Precautions (Patients #'s 5, 6, 7, 8, 9, & 10). All eight rooms on Unit 3 had toilets that were not flush with the walls, creating an opening that could potentially be used as tie-off points ligature risks. These anchor points could be used to attach material for the purpose of hanging or strangulation. Such actions have the potential to cause serious injury, impairment, or death.

Based on observation, review of medical records, facility documents, and staff interview, the facility failed to safeguard and uphold the rights of patients in the facility.

This failure resulted in 11 patients on the facility's Unit 3 (PICU) being placed in rooms with observable ligature risks (toilets), and six out of 11 of these patients were currently on Suicide Precautions (Patients #'s 5, 6, 7, 8, 9, & 10). All eight rooms on Unit 3 had toilets that were not flush with the walls, creating an opening that could potentially be used as tie-off points ligature risks. These anchor points could be used to attach material for the purpose of hanging or strangulation. Such actions have the potential to cause serious injury, impairment, or death.


Findings:

Record review of facility policy titled "Cypress Creek Hospital Administrative Policy and Procedure on Suicide Precautions" dated 3/2019, stated that the purpose of the policy was to provide the patient with a protected environment by establishing external controls.

Observation on 6/7/19 at 10:00 AM of facility's PICU Unit 3 revealed that all eight rooms on the unit had toilets that where not flush with the wall, creating potential ligature risk spaces between the back bottom area of the toilets and walls, which could potentially be used to tie-off bedsheets, clothing, or other materials/articles.

Record review of Patient's #'s 5, 6, 7, 8, 9, & 10 revealed all had doctor's orders to be placed on Suicide Precautions. All of these patients were currently residing on PICU Unit 3.

Review of facility's document titled "CYPRESS CREEK HOSPITAL ACTION PLAN CHANGING OUT TOILETS-Potential Ligature Risk" had identified the toilets as ligature risks. Units 7 and 8 had already been replaced with ligature-resistant toilets prior to this document. This document was dated June 1, 2018, over a year prior to current survey. The document contained a mitigation plan, which was to train all direct care staff and new hire staff with a plan called Bathroom Competencies. The competency training included checking on patients who were on suicide precautions every 15 minutes.

In an interview on 6/7/19 at 11:00 AM, Staff #52 stated, the Bathroom Competency training included knocking on the doors of occupied patient bathrooms and making brief visual contact while the patient was in the bathroom.

In an interview on 6/7/19 at 11:15 AM, Staff #51 stated, the facility was aware of the toilets being ligature risks and had already replaced Units 7 and 8 with ligature resistant toilets. Staff #51 also stated that the facility's Units 1, 2, 3, 4, 5 (which was closed at time of survey), and 6, all had the same type of toilets as PICU Unit 3's, and they all needed to be replaced. When asked the reason for the long delay, Staff #51 stated the toilets were not available yet from vendors because there was a back-up with their inventory.

Record review of facility's Safety/EOC minutes dated April 23, 2019, stated under "Topic, New Business, #4, A discussion was started to look into replacing the toilets in units 1-6 to look like the ones in units 7 and 8. The plant Ops director will look into getting bids for this".