HospitalInspections.org

This condition level deficiency was cited based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, Quality and Patient Safety Program Plan, Policy, Hazard Risk Analysis Suicide/Safety Risk Assessment, Hazard Risk Analysis for Safety Risk Assessment, Environment of Care/Safety Committee meeting minutes, Risk Management Worksheets, Power Point slides entitled Electronic Incident Reporting System, Quality and Patient Safety Program 2013 Annual, Board of Directors Meeting minutes, medical records, observations and interviews. It was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury. Refer to A115 and A700 for findings.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room. Refer to A115 and A700 for findings.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards. Refer to A115 and A700 for findings.

4. The Quality Improvement, Risk Management and Patient Safety Committees addressed identified patient safety concerns and reported identified patient safety concerns. Refer to A263 for findings.

5. A policy was developed and implemented for occurrence reporting to include a defined system for reporting, investigating, implementing corrective actions to improve patient safety and monitoring of implemented actions. Refer to A263 for findings.

6. The Governing Body failed to address the identified patient / staff safety concerns of the Quality and Patient Safety Program, including addressing the nurses' station in the Psychiatric unit. Refer to A263 for findings.


This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

Refer to A0057, A115, A263 and A700 for findings.

Based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, Quality and Patient Safety Program Plan, Policy, Hazard Risk Analysis Suicide/Safety Risk Assessment, Hazard Risk Analysis for Safety Risk Assessment, Environment of Care/Safety Committee meeting minutes, Risk Management Worksheets, Power Point slides entitled Electronic Incident Reporting System, Quality and Patient Safety Program 2013 Annual, Board of Directors Meeting minutes, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury. Refer to A115 and A700 for findings.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room. Refer to A115 and A700 for findings.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards. Refer to A115 and A700 for findings.

4. The Quality Improvement, Risk Management and Patient Safety Committees addressed identified patient safety concerns and reported identified patient safety concerns. Refer to A263 for findings.

5. The Quality Improvement, Risk Management and Patient Safety Committees reported the identified patient safety concerns to the Governing Body to ensure they were addressed. Refer to A263 for findings.

6. A policy was developed and implemented for occurrence reporting to include a defined system for reporting, investigating, implementing corrective actions to improve patient safety and monitoring of implemented actions. Refer to A263 for findings.

7. The Governing Body failed to address the identified patient / staff safety concerns of the Quality and Patient Safety Program were addressed, including addressing the nurses' station in the Psychiatric unit. Refer to A263 for findings.


This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

Refer to A115, A263 and A700 for findings.

This condition is cited based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards.

This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

Refer to A144 for findings.

Based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards.

This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

A. Review of the Safety Management Plan:

I. Purpose
The purpose of the Mobile Infirmary Safety Management Program shall be to strive toward providing a safe environment for the delivery of quality healthcare. The program shall incorporate management systems, education programs, and problem monitoring and evaluation in an effort to provide a safe and hazard free environment for patients, employees, physicians, volunteers and visitors.

III. Responsibility

D. Safety Officer

1. Develops, implements, monitors and oversees the Safety Management Program.

2. Regularly participates in Environment of Care tours and incident reporting...

... 5. Coordinates ongoing, organization-wide collection of information about deficiencies and opportunities for improvement in the environment of care.

6. Through coordination with hospital Administrator, shall take command upon recognition of safety issues which present or may present a life-threatening/hazardous situation.

7. Recommends and/or initiates corrective actions related to safety. Intervenes whenever conditions pose an immediate threat to life or health or threaten damage to equipment or buildings.

8. Reports safety management issues, recommendations, actions taken, and results of measurement to the Environment of Care/Employee Safety Committee and participates as an active member...

IV. Environment of Care/Employee Safety Committee

The Environment of Care/Employee Safety Committee shall serve as the forum for review, discussion, trending and recommendations for corrective actions as related to the safety management program. Actions and recommendations shall be routed to applicable department heads, as indicated. Safety issues shall be communicated to the governing body on a quarterly basis.

V. General Safety Management

... C. Environment of Care Tour

Environment of Care tours shall be routinely conducted in order to perform proactive risk assessments of buildings, grounds, equipment, occupants and internal physical systems for their impact on patient and public safety. Patient care areas shall be inspected two times a year and non-patient care areas at least annually.

The tour team shall include members from the following areas: Safety, Infection Control, Security, Risk Management, Environmental Services, Compliance, Hazardous Materials/Waste, Plant Operations, Electronics/Biomedical Department and the Pharmacy, when appropriate. Each member is responsible for inspecting department based on established criteria and forwarding results to the Facilities Compliance Department. The Facilities Compliance Department forwards results to the applicable department manager. Each team member is responsible for monitoring identified problems until resolution. Results of the tours shall be forwarded for review by the Environment of Care/Employee Safety Committee...


B. Review of the Hazard Risk Analysis Suicide/Safety Risk Assessment dated 1/23/13 revealed the hospital identified the following safety concerns:

5 West (W) (Geriatric Psychiatric Unit):

1. Bath tubs in patient rooms could pose a safety risk to patients. Impacts: Potential for patient injury/death. Vulnerabilities: Patient could use the bathroom to drown. Action: Install covers over faucets.

9. Nurse's station is a non-secured, open area which exposes staff and patients to multiple risks. Impacts: This is a safety issue for patients and staff. Vulnerabilities: Patients could use items within the Nurses Station as weapons to harm themselves and others. Action: This does not tend to be an issue on 5 West. However, this issue will be addressed for the Nurses station on 5 Southeast.

5 Southeast (SE) (Adult Psychiatric Unit):

6. Nurse's station is a non-secured, open area which exposes staff and patients to multiple risks. There were many supplies and equipment including O2 (Oxygen) tanks, computer batteries, drugs in code carts, etc. Impacts: Patient could harm themselves or others. Vulnerabilities: Staff are vulnerable to patients using some these items as weapons. Action: Recommended closing off nurses station.

Psych Intake ED:

1. Unsecured ceiling tile in holding room. Impacts: Potential risk to patient. Vulnerabilities: Patient could escape into ceiling. Action: Install ceiling clips. Check with (Hospital name affiliated with Mobile Infirmary) on ceiling clips.

Review of the Risk Assessment of Suicide in Psych areas, which was undated revealed, no documentation of a resolution or type of work performed to resolve the above findings for 5 W or 5 SE units. The document also revealed the facility's plan for the unsecured ceiling tiles in the holding room in the Psych Intake ED area was to check on clips to secure ceiling tiles.

There was no documentation of a date completed for the above identified safety issue.


C. Review of the Hazard Risk Analysis for Safety Risk Assessment for Patients 5 W / 5 SE dated 5/6/13 revealed the hospital identified the following safety concerns:

2. Elopement risk for patients in acute adult psychiatric unit and Geriatric psychiatric unit - both 5 W and 5 SE. Impacts: Potential for patient/staff/other injury. Vulnerabilities: Patients may elope, get lost/ injured or cause injury to others. Patients with pending Probate commitment are required to remain in hospital. Action: Both 5SE and 5 are locked units and allow staff access through badge reader and door key code. The three hallway entrances are under camera supervision and can be opened remotely from nurse's station. Since all exits open when fire alarm activates on 5 SE and 5 W, staff must immediately report to exit doors. Daily monitoring occurs to ensure on duty staff have fire keys, stairwell key code, and understand importance of reporting immediately to exit doors if fire alarm is activated.

D. Review of the Patient and Staff Safety Review dated June 2014 revealed the hospital identified the following items of patient and staff safety issues:

... 8. Fire sprinkler heads are the type where the heads have pieces that can be removed and made into sharp objects that can be used as a weapon or pose ligature point. Recommend replace with tamper proof sprinkler heads.

9. Grab bars in hallways are not enclosed. Recommend replace with an enclosed style to reduce ligature risk.

10. Patient furniture is dated and light weight which can present a risk on the adult unit of patients picking up and using as a weapon. Replace with weighted chairs that decrease risk...

13. Nursing station on the adult unit is accessible by patients and in addition, the counter surface is low which exposes the risk of reach over to access computers or staff. Recommend a) bolting/securing computer screens to prevent removal b) increasing the height of the counter and installing half doors to prevent access and risk to staff and decrease risk of HIPAA (Health Insurance Portability and Accountability Act) violations.

Patient Rooms and Bathrooms

1. The doors on all observed patient accessible rooms present several potential hazards.

ii. Doors on all patient rooms swing into the room. This creates a potential for barricading of these doors. It is suggested that all doors be equipped with barcode resistant features such as double acting continuous hinges that facilitates removal or the wicket (door within a door) style door that allows a small panel to swing out in the event of an emergency.

v. Patient 'medical' beds did not have head and foot boards secured. These can be easily removed by patients and used as a weapon towards others. Use tamper proof screws and secure to post(s) and ensure there is a board on the crash cart in the event of emergencies.

x. Patient bathrooms have tubs. Although in some cases on the geriatric area the faucets have been enclosed, bathtubs still in use on the adult unit pose a potential risk. Recommend renovating and removing all tubs.


E. Review of the Risk Assessment of Psychiatric Unit dated 9/19/14 revealed items discussed included the risk for elopement. Discussion: Badge readers at doors provide access and egress control, but elopement concerns remain due to patient characteristics. Consideration/mitigation included: Consider adding a "man-trap" at the main entrance. The front door will not open if the 5W or 5SE door is open, and the 5W & 5 SE doors will not open if the main door is open. Requires install of 5 SE door. Consider adding an over-ride button at the unit secretary desk to prevent doors from opening if an elopement situation is developing.

F. Review of the Pro-Active Risk Assessment Form dated December 2014 revealed the hospital identified the following safety concerns:

Tubs in patient bath rooms. Type of injury: Falls, Drowning. Current control measures in place: Community shower. Further control measures required: remove Tubs.

Nurse's Station on Adult Unit: Type of injury: Any type. Current control measures in place: 24/7 coverage at desk, add gates to entrances, secure computers to desk, remove accessible office supplies and equipment. Further control measures required: Raise height of counter, add enclosure from ceiling, provide safe area for staff

Exits: Type of injury: Absconder. Current control measures in place: Locked entrance door with limited and controlled access. Further control measures required: Reinstall corridors with access control.

Patient Room furniture: Type of injury: Not weighted can be used as a weapon. Current control measures in place: None, most rooms are missing furniture or it is in poor condition. Further control measures required: New furniture requested.

Hallway handrails: Current control measures in place: 15 minute checks and located in common area. Further control measures required: Enclose.

Patient Room door swing: Type of injury which could result if harm occurs: Barricading. Current control measures in place: 15 minute checks and unoccupied rooms are locked. Further control measures required: Reverse door swing.

An initial tour of the Psychiatric Units was conducted on 3/9/15 at 10:45 AM. During this tour, the surveyors observed the following safety concerns:
Geriatric Unit/ 5 W: 3 buttons at the nurse's station for remote door access with covers available. Only one of the buttons was covered, which left the remote door access buttons vulnerable for unauthorized use.
Sprinkler heads were not tamper proof with the internal portion of the sprinkler extending out of the escutcheon.
Bath tub in patient room 5223, was operational with working faucets and could be used by patients. This room was assigned to a patient.
Hand rails in hallways not enclosed, which could pose a ligature threat.

The Unit Secretary accompanied the surveyors to the Adult Unit / 5 SE, which left the nurse's station without staff supervision.

Observed located on the Adult Unit / 5 SE: 2 buttons at the nurse's station for remote door access with covers available. None of the buttons were covered, which left the remote doors access buttons vulnerable for unauthorized use.
Hand rails in hallways not enclosed, which could pose a ligature threat.
Bath tub located in room 5127, was operational with working faucets and could be used by patients. This room was assigned to a patient.
Patient Room 5123: wooden dresser and bedside table, which the surveyor was able to move with little effort.

The surveyors returned to the Psychiatric Units on 3/10/15 at 8:35 AM and observed all of the buttons for remote door access were uncovered at the nurses stations in the Geriatric Unit / 5 W and Adult Unit / 5 SE. The surveyor entered patient room 5223 and observed both head and foot boards of the patient bed were able to be lifted off of the bed.

On 3/10/15 at 2:40 PM, the surveyors returned to the Psychiatric Units and observed that both of the counter tops at the nurse's station in the Geriatric Unit / 5 W and Adult Unit / 5 SE were approximately 4 feet high and easily accessible to patients. The surveyor was able to reach over to the "tube" chute in the Adult Unit / 5 SE and grab the tube from the chute without having to stretch to reach it.

On 3/12/15 at 9:05 AM, the surveyors returned to the Psychiatric Units. The surveyors observed 2 of the buttons for remote door access were uncovered in the Geriatric Unit / 5 W and both buttons for remote door access were uncovered in the Adult Unit / 5 SE.

On 3/12/15 at 4:15 PM, the surveyor observed located in the Psych Intake area of the ED, the door handles located on doors to patient rooms. The door handles located on the doors to patient Room # 1 and Room # 2 were sturdy metal handles, which could potentially be use as a ligature point.

Medical Record Review:

1. PI # 1 presented to the Emergency Department (ED) on 9/26/14 at 12:31 PM with chief complaint of Psychiatric Evaluation and multiple self-inflicted lacerations to the body. At 1:14 PM a Psychiatric consult was completed, which revealed the patient's cuts were superficial and there was gauze wrapped around the patient's forearms and dried blood on the patient's cheek. The patient was very vague about this being a suicide attempt and the patient was not really sure why (he/she) did it, was not feeling right and knew (he/she) needed help. The patient had been seen on the facility's psychiatric unit for the same complaint 10/5/13. At that time (10/5/13), the patient had reported a previous suicide attempt at the age of 17 that was an attempt to get attention. The patient had been diagnosed with schizo-effective disorder and was on Risperdal for a time.

On 9/26/14 ED visit, the patient's affect was documented as blunted and describes mood as depressed and remorseful. When asked if he/she felt he/she was a danger to self, if he/she left the hospital and replied "yes", I would hurt myself". These findings were discussed with the ED physician (medical doctor).

On 9/26/14 at 3:20 PM, the psychiatrist saw the patient, at which time, the patient told the psychiatrist he/she wanted to leave immediately. The patient was instructed he/she would have to leave AMA (against medical advice). The patient also told intake staff he/she was going to leave and run out into traffic. This was reported to the psychiatrist. The patient refused to sign AMA papers and requested a "regular discharge". The psychiatrist was informed and agreed with a regular discharge and for the patient to follow up with outpatient program. The nurse documented the outpatient program was discussed with the patient and the patient was not interested in this resource.

On 9/26/14 at 3:50 PM, the patient signed discharge papers and was given his/her clothing to change. Patient was standing on a chair in the room, attempting to hang (him/herself). (Patient) was gotten down by staff and the gauze was cut from around his/her neck. (Patient) became violent and attacked staff members. Pt (patient) was given Haldol, Ativan, and Benadryl IM (intramuscularly) as ordered for combative behavior.

On 9/26/14 at 5:07 PM, the RN documented the patient was sleeping in no obvious distress. Rouses to tactile stimulation, appropriate interaction with staff, compliant with the staff. breathing without difficulty... skin color indicative of adequate perfusion to face, neck... Slight redness/abrasion apparent at base of neck, just superior to clavicle on right side of neck extending anteriorly to midline, approximately 5-6 centimeters...

The patient was admitted to 5 SE (Adult psychiatric unit).

An adverse event debriefing of the above incident was conducted on an undocumented date at 7:00 AM. The Safety Issues & Concerns was also undated by an undocumented person. An action plan was prepared by Employee Identifier (EI) # 5, Director of Patient Safety. Review of this action plan revealed Identified Issues included: 2. Physical Environment of psychiatric rooms needs addressing: solid ceiling. Action Item # 2: Room renovations to install solid surface ceiling. Method: Room renovation. Timeframe for completion: Await recommendation from Plant Ops (operations). Progress: Construction to start 12/1/14, will take approximately 7 days and completed on 12/15/14. Identified issue: 3. Presence of linens and Kerlix in psychiatric area. Action Item # 3: Ensure psychiatric patients do not have access to regular line or Kerlix. Method: Substitution of other items in place of traditional linen. Progress: Regular linens are used on the stretchers. Staff monitor the amount of linen used in psych intake.

An interview was conducted on 3/11/15 at 10:53 AM with Employee Identifier (EI) # 12, Registered Nurse Emergency Department (ED), who stated one of the actions after the event above that was put in place, was to remove the linen from the room once the patient is discharged.

An interview was conducted on 3/11/15 at 3:29 PM with EI # 8, Nurse Manager, Emergency Department (ED). During this interview, the surveyor asked what were the changes made in the ED as a result of the above event. EI # 8 stated the ceiling was made solid in the Psych intake patient rooms.

2. PI # 12 presented to the ED on 1/1/15 at 11:31 AM with chief complaint of Manic Behavior with a history of anxiety issues and reports of not taking behavioral medicine for 3 weeks. The patient was cleared medically and admitted to Psychiatric services in the Adult Unit / 5 SE.

Review of the Nursing Note dated 1/3/15 at 6:45 PM revealed the Registered Nurse (RN) documented the patient was at the desk at 6:30 PM and interacting with peers in the hallway. The patient told one of peers "come on, let's go for a walk'. At 6:45 PM patient seemed to not be on the unit. It was reported by one of peers that he/she was going to take a bath. Room to room search was done, including all bathrooms and locked rooms. Security, supervisors and team leader and Psychiatrist were notified. Attempt was made to notify family. There was no answer to the patient's mother's phone number. The nurse was able to notify the patient's sister, who was notified that the patient was missing and will continue to attempt to locate the patient.

On 1/3/15 at 8:11 PM, the RN documented the patient's mother returned the phone call and stated the Psychiatrist had notified her that the patient had eloped.

On 1/3/15 at 11:17 PM, the RN documented a call was received from the patient and said he/she was at home and that mother was bringing him/her back to the Unit. The RN documented she left a voice mail for the Psychiatrist and informed her that the patient was on his/her way back to the unit.

On 1/4/15 at 12:25 AM, the RN documented the patient was readmitted to the unit escorted by security and the house supervisor. Placed on 1:1 (One to one) observation. The patient was calm and coherent, bragging about his/her 'science experiment' and how he/she escaped. The patient explained that when he/she saw everybody distracted, he/she had another patient push the green buttons to the doors and walked out.

On 1/5/15 at 5:51 AM, the RN documented, "... Admitting just called saying they received a note in the tube system from (PI # 12), and thought we should know about it..."

On 1/5/15 at 2:12 PM, the RN documented, "Pt walked behind nurses station, took a staff members chair and sat in it refusing to move, grabbed water bottle and began shoving papers and bags off the nurses desk, threatening staff, cursing, grandiose, unable to redirect, loud, and belligerent, prn (as needed) Benadryl 50 mg (milligrams) IM given right hip..."

On 1/5/15 at 2:42 PM, the RN documented, the patient was flirtatious, intrusive, waving hands in staffs face in a striking, threatening manner, sexually inappropriate, groping staffs buttocks and attempting to grab at staff members breasts... continues coming into nurses station and sitting in staffs chairs.

On 1/6/15 at 3:47 AM, the RN documented the patient pounded his/her hand on the desk when told to get away from the desk and continued to keep trying to come behind the nurse's station, was taking papers off of the desk.

On 1/6/15 at 4:55 AM, the RN documented the patient rang the bell at the door entrance to be let out, cursed when the phone was answered and hung up. The RN documented, "... The patient attempted to watch pharmacist to see if he/she could sneak out of the door..."

At 5:51 AM, the RN documented the patient was at the desk at 5:15 AM, grabbed stickers out of the tube system and trying to get behind the nurse's station.

At 2:09 PM, the RN documented the patient slept for a while, but before he/she went to sleep he/she took the foot board off the bed.

A Debrief Analysis and Action Plan, prepared by EI # 4, Patient Safety Officer on 1/6/15 related to the patient's elopement included an Action Plan, which revealed the following:

1. Issue: No secretary on weekends. Resolution: Currently the 5 SE secretaries are working 8 hour shifts, Monday - Friday. Implementation of 12 hour shifts with rotating weekends to be implemented as soon as new staff can be hired. Completion/Follow up: Tentative Start date 2/15/15.

2. Issue: Entire nursing staff in breakroom receiving/giving report. Resolution: There are usually two or three RNs giving/receiving report. (1:7 ratio). Off-going nurses should rotate sitting at the desk while their peer gives report. This will prevent all nursing staff being off the unit during report.

5. Issue: Nurse's station is open with no privacy. Resolution: Placing some type of border or partition around nurses' station for privacy and protection.

9. Issue: Patient's ability to leave unit without staff being aware. Resolution: Armbands with sensors that will alarm if patient breaches the doors. Completion/Follow up was assigned to EI # 9, Program Director for the Psychiatric Units to check to see if this was an option.

On 3/10/15 at 11:05 AM, Employee Identifier (EI) # 1, Chief Nursing Officer presented to the surveyors an untitled document dated January 12, 2015 related to hiring Unit Secretaries to be able to have coverage for Psych services. This document defined plans to have all secretaries move to 12 hour shifts with rotating weekends and add 4 full time and 2 part time Unit Secretaries. Also presented at that time, was an Equipment Management Program Service Report dated 1/5/15, which outlined the service provided was to place plastic covers on all 5 exit push buttons on Geriatric Psychiatric Unit / 5 W and Adult Psychiatric Unit / 5 SE with a completion date of 1/20/15.

3. PI # 11 presented to the ED on 1/26/15 at 4:52 PM with chief complaint of Psychiatric Evaluation with a history of Schizo-affective disorder. The patient reported feeling depressed, decreased appetite, nausea, tangential speech and auditory hallucinations and was noncompliant with medications for the past couple of weeks.

The ED physician's examination revealed the patient was actively having auditory hallucinations, the patient's thought content was paranoid and expressed suicidal ideation. The patient was cleared medically and admitted to the Adult Psychiatric unit / 5 SE.

On 1/29/15 at 7:30 AM, the Registered Nurse (RN) documented the patient was lying in bed with his/her head at the foot of the bed, facing away from the door and had placed the tray table between the door and the bed so he/she could , "... shove table to the door if anyone opens the door..."

On 1/29/15 at 10:50 AM, the RN documented having heard a loud noise from the patient's room, attempted to open the door and the patient had barricaded him/herself in the room. The patient had pulled the tray table to the door and the bed next to the tray table. The patient would not speak with staff, the Physician was at the door trying to talk to the patient and the patient refused to speak to anyone. An order was received for 10 mg (milligrams) Zyprexa IM (intramuscularly). Security was called to the unit to assist with administration of IM Zyprexa. Upon opening the door, staff noted the patient had broken the screen from the window. (This window screen was a heavy metal screen, which was encased in a metal frame.) The patient was fighting, agitated and the RN was unable to administer IM medications at that time. The physician was notified.

On 1/29/14 at 12:00 PM, the RN documented the Physician ordered 10 mg Haldol/ 2 mg Ativan/ 50 mg Benadryl IM. Security was in the unit to assist with medication administration. The Physician ordered 4 point restraints for the patient, which were applied. IM medications were administered and the patient was agitated and fighting. The patient was moved to another room due to the window screen being broken.

There was no documentation of a Debrief Analysis and Action Plan for the above incident of the patient barricading him/herself in the room using movable furniture.

An interview was conducted on 3/19/15 at 3:15 PM with EI # 2, Executive Director of Nursing. During this interview, it was determined there was no formal investigation of the above incident and no plan put in place to prevent a patient from barricading themselves in their room.

Summary: The facility had knowledge of patient safety concerns regarding the ceilings in the Psych Intake area, which could potentially be removed. There was no documentation the ceilings were made safe for psychiatric patients until after the incident in which PI # 1 attempted to hang him/herself from the ceiling.

The facility had knowledge of patient safety concerns related to the nurse's station not being secure and was an open area with low counter tops, which increased the elopement risk for patients in acute adult psychiatric unit and Geriatric psychiatric unit. There was no documentation the nurse's station was made secure and PI # 12 was able to elope from a secured, locked unit of the facility. PI # 12 was also able to reach items located in the nurse's station and able to enter the nurse's station.

The facility had knowledge of patient safety concerns related to patient hospital beds located in the Adult Unit / 5 SE which are not stationary with head board and foot boards that could be easily removed. PI # 12 was able to remove the foot board from the bed during his/her admission. There was no documentation this concern was addressed. During the survey, the surveyors observed that both head and foot boards were easily removed.

The facility had knowledge of patient safety concerns related to the patient room furniture being light weight and the potential for barricading of the doors. PI # 11 was able to move furniture in the room and barricade self in the room, attempt to remove the screen from the window before staff was able to enter the room.

The facility had knowledge of the following patient safety concerns and has failed to take corrective actions prior to the surveyor's arrival:

1. Fire sprinkler heads are the type where the heads have pieces that can be removed and made into sharp objects that can be used as a weapon or pose ligature point.

2. Bath tubs in patient rooms, which could be filled and used for drowning or could increase the risk for falls.

On 3/12/15 at 12:30 PM, the surveyors met with Employee Identifier (EI) # 1, Chief Nursing Officer, EI # 2, Executive Director of Nursing, EI # 9, Program Director and EI # 10, Nurse Manager for Psychiatric Services. During this time, the surveyors above identified patient safety concerns were presented. An immediate action plan to correct concerns was submitted to the survey staff.

On 3/12/15 at 4:20 PM, EI # 1 presented to the surveyors a document entitled, Survey Follow-up 3/9/15 - 3/12/15, which outlined plans to remediate the above identified patient safety concerns. Review of this document revealed the following immediate actions to correct the problems until more permanent solutions could be put in place:

Access Buttons Adult Unit (March 12, 2015)
Immediately educate staff on importance of someone always being at the desk by 3/12/15 and ongoing

Immediately implement Log of who is at the desk monitoring patient activity and door access; sign log every hour

Hourly rounding to ensure access buttons are covered and document on log

Furniture is light weight - 3/12/15
Remove all furniture except the beds from the rooms immediately by 3/12/15

Patients will store their belongings in the closets

Tubs with faucets and shower heads not recessed
Adult/Geri
Immediately begin to evaluate safety of all patient bathrooms 3/12/15 and complete by 3/13/15
Remediate High Risk Showers/Tubs - 3/20/15 or close the room
Evaluate every patient room for patient safety risk with input from staff by 3/20/15
Review plan with (EI # 11, Medical Director) for input into patient room safety by 3/20/15

Hallway Handrails - 2 weeks (March 26, 2015)
Put a plate between the handrail and the wall so patients cannot put anything through the handrail.

Sprinkler head - 30 days (April 10, 2015)
Thought these were psych safe
Research current head and possible replacement

Head and Foot boards - 30 days (April 10, 2015)
Secure to the bed with non-tamper screws

Hinges on Doors - 60 days (May 11, 2015)
Replace with continuous hinges (contractor here 3/13/15 to measure)
Evaluate reversing the hinges on the doors

Other follow-up
Educate staff on Environmental Safety - 30 days (April 10, 2015)
Document Debrief on every psych patient - 1 week (March 19, 2015)

The following items will also be re-addressed with the upcoming construction/renovation project:
Tubs with faucets
Shower heads not recessed
Hallway handrails
Sprinkler heads
Head and foot boards - New psych safe low beds
Hinges on doors
Furniture - purchase psych safe furniture

The immediate jeopardy threat was removed at that time.

On 3/17/15 at 4:05 PM, Employee Identifier (EI) # 1, Chief Nursing Officer presented to the surveyors a copy of Purchase Order (PO) Number dated 3/17/15 for the purchase of 30 beds for the Psychiatric Units, with an anticipated delivery date of 3/25/15. An interview was conducted on 3/17/15 at 4:05 PM with EI # 1, who stated the facility had ordered tamper proof screws to secure the head and foot boards to the beds until the new beds could be delivered.

This condition level deficiency is cited based on review of the Quality and Patient Safety Program Plan, Policy, Hazard Risk Analysis Suicide/Safety Risk Assessment, Hazard Risk Analysis for Safety Risk Assessment, Environment of Care/Safety Committee meeting minutes, Risk Management Worksheets, Power Point slides entitled Electronic Incident Reporting System, Quality and Patient Safety Program 2013 Annual, Board of Directors Meeting minutes, observations and interviews with facility staff, it was determined the facility failed to ensure:

1. The Quality Improvement, Risk Management and Patient Safety Committees addressed identified patient safety concerns, including:

a. The ceiling in the Psych Intake area for the Emergency Department (ED) was not maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

b. The Inpatient Psychiatric Units were not maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

c. The Inpatient Psychiatric Units were not maintained with tamper proof sprinkler heads, bath tubs in patient rooms that were not operational, hand rails that were enclosed and patient beds that were equipped with non-removable head and foot boards.

2. The Quality Improvement, Risk Management and Patient Safety Committees reported the identified patient safety concerns to the Governing Body to ensure they were addressed.

3. A policy was developed and implemented for occurrence reporting to include a defined system for reporting, investigating, implementing corrective actions to improve patient safety and monitoring of implemented actions.

4. The Governing Body failed to address the identified patient / staff safety concerns of the Quality and Patient Safety Program were addressed, including addressing the nurses' station in the Psychiatric unit


This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.


Findings include:

Refer to A286 and A309 for findings.

Based on review of the Quality and Patient Safety Program Plan, Policy, Hazard Risk Analysis Suicide/Safety Risk Assessment, Hazard Risk Analysis for Safety Risk Assessment, Environment of Care/Safety Committee meeting minutes, Risk Management Worksheets, Power Point slides entitled Electronic Incident Reporting System, observations and interviews with facility staff, it was determined the facility failed to ensure:

1. The Quality Improvement, Risk Management and Patient Safety Committees addressed identified patient safety concerns, including:

a. The ceiling in the Psych Intake area for the Emergency Department (ED) was not maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

b. The Inpatient Psychiatric Units were not maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

c. The Inpatient Psychiatric Units were not maintained with tamper proof sprinkler heads, bath tubs in patient rooms that were not operational, hand rails that were enclosed and patient beds that were equipped with non-removable head and foot boards.

2. The Quality Improvement, Risk Management and Patient Safety Committees reported the identified patient safety concerns to the Governing Body to ensure they were addressed.

3. A policy was developed and implemented for occurrence reporting to include a defined system for reporting, investigating, implementing corrective actions to improve patient safety and monitoring of implemented actions.


This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.


Findings include:

A. Quality and Patient Safety Program Plan

4. Scope

The Quality and Patient Safety program will encompass all functions of patient care and services provided within this organization including contract services. The program addresses improvement in performance and patient safety issues in every department throughout the organization.

5. Objectives
5.1 To establish a comprehensive, organization-wide quality and patient safety program that supports the delivery of quality care and services as well as improve patient safety and reduce the risk of medical / health errors...

5.7 To implement a formal, timely process of intensive analysis for sentinel events and near miss occurrences that focuses on process and systems and not individuals...

... 6 Responsibility

6.4 The Hospital Quality Improvement Committee is responsible for implementing the Quality and Patient Safety Program throughout the organization. Other responsibilities include:

6.4.1 Support an ongoing proactive patient safety program. This includes the review of patient safety data, including root cause analyses, sentinel event alerts, failure mode effects analyses, Joint Commission National Patient Safety Goals and other patient safety measures.

6.4.2 Review and analyses of organizational quality and patient safety activities and identification of opportunities for improvement...

6.4.5 Communication about quality and patient safety activities throughout the organization...

6.5 The Patient Safety Officer is responsible for coordinating the organization-wide Patient Safety program. Responsibilities include:

6.5.1 Response to all patient safety issues or identified concerns, communication about patient safety issues throughout the organization...

6.7 Quality / Patient Safety are responsible for focusing on process and outcomes for organization-wide quality and assuring that improvements are sustained... They have the responsibility to evaluate and improve current processes and design or establish new processes and services utilizing performance improvement tools and techniques.

6.8 The Quality and Patient Safety Departments have the responsibility for coordinating the organization-wide quality and patient safety activities. Responsibilities include the management and coordination of Quality / Patient Safety committees... patient safety activities... review of organizational functions and committees that contribute to the overall quality of care...

6.10 Root Cause Analysis (RCA) and intense analysis teams are responsible for focusing on processes involved in a near miss or sentinel event and identifying improvement actions and measurement of improvements...

7 Organization and Structure

The Quality and Patient Safety Program utilizes an organizational, integrated approach with emphasis on system improvements, process design, analyzing data and initiation of actions when an opportunity for improvement is identified... Emphasis is on proactive quality improvement and strategies such as teamwork and communication to promote patient safety medical/health care error reduction efforts. At a minimum, the following activities are included:

7.2 Analysis of sentinel events and other undesirable patterns or trends and implementation of corrective actions...

7.4 Proactive identification and reduction of unanticipated adverse events and safety risks to patients...

8 Reporting

The reporting of quality information and patient safety information is both through formal reporting structures and informal information sharing... Quality and patient safety teams report to the Quality/Patient Safety Committee at least quarterly. A summary of these team activities are reported to the Board Quality Committee and Board of Directors...

All staff should report any adverse occurrences to Risk Management as described in the Incident / Occurrence Reporting Policy. Concerns or issues regarding patient safety and risk of medical/health care errors are reported to Administration, Patient Safety Officer and/or Risk Management...

B. Facility Policy:

Infirmary Health System Risk Management:

Report of Unusual Occurrence to the System Attorney

Objectives:
To notify the System attorney of an unusual or unexpected occurrence...
To establish a consistent mechanism for reporting occurrence data for the purpose of identifying opportunities for quality and process improvement.

Terms:
Unusual occurrence- Any happening out of the ordinary, unsafe or not consistent with the routine care of a patient or routine operation of the hospital or clinic which results in a potential or actual injury or damage to a patient, visitor or hospital property.


C. Review of the Hazard Risk Analysis Suicide/Safety Risk Assessment dated 1/23/13 revealed the following:

5 West (W) (Geriatric Psychiatric Unit):

1. Bath tubs in patient rooms could pose a safety risk to patients. Impacts: Potential for patient injury/death. Vulnerabilities: Patient could use the bathroom to drown. Action: Install covers over faucets.

9. Nurse's station is a non-secured, open area which exposes staff and patients to multiple risks. Impacts: This is a safety issue for patients and staff. Vulnerabilities: Patients could use items within the Nurses Station as weapons to harm themselves and others. Action: This does not tend to be an issue on 5 West. However, this issue will be addressed for the Nurses station on 5 Southeast.

5 Southeast (SE) (Adult Psychiatric Unit):

6. Nurse's station is a non-secured, open area which exposes staff and patients to multiple risks. There were many supplies and equipment including O2 (Oxygen) tanks, computer batteries, drugs in code carts, etc. Impacts: Patient could harm themselves or others. Vulnerabilities: Staff are vulnerable to patients using some these items as weapons. Action: Recommended closing off nurses station.

Psych Intake ED:

1. Unsecured ceiling tile in holding room. Impacts: Potential risk to patient. Vulnerabilities: Patient could escape into ceiling. Action: Install ceiling clips. Check with (Hospital name affiliated with Mobile Infirmary) on ceiling clips.

Review of the Risk Assessment of Suicide in Psych areas, which was undated revealed There was no documentation of a resolution or type of work performed to resolve the above findings for 5 W or 5 SE units. The document also revealed the facility's plan for the unsecured ceiling tiles in the holding room in the Psych Intake ED area was to check on clips to secure ceiling tiles.

There was no documentation of a date completed for the above identified safety issue. There was no documentation corrective actions were taken, nor was a follow up assessment completed related to the unsecured ceiling tile in the holding room of the ED Psych Intake area.

Review of the Environment of Care/Safety Committee meeting minutes dated 4/9/13 revealed the following documentation: "... Suicide Risk Assessment for Psych Area - Tabled to a later date..." There was no documentation the patient safety concerns in the Psych Intake ED, 5 W or 5 SE were addressed during the Environment of Care/Safety Committee meeting.

D. Review of the Hazard Risk Analysis for Safety Risk Assessment for Patients 5 W / 5 SE dated 5/6/13 revealed the following Hazard/Risk:

2. Elopement risk for patients in acute adult psychiatric unit and Geriatric psychiatric unit - both 5 W and 5 SE. Impacts: Potential for patient/staff/other injury. Vulnerabilities: Patients may elope, get lost/ injured or cause injury to others. Patients with pending Probate commitment are required to remain in hospital. Action: Both 5SE and 5 are locked units and allow staff access through badge reader and door key code. The three hallway entrances are under camera supervision and can be opened remotely from nurse's station. Since all exits open when fire alarm activates on 5 SE and 5 W, staff must immediately report to exit doors. Daily monitoring occurs to ensure on duty staff have fire keys, stairwell key code, and understand importance of reporting immediately to exit doors if fire alarm is activated.


Review of the Environment of Care/Safety Committee meeting minutes revealed there was no documentation the committee met for the month of May.

Review of the Environment of Care/Safety Committee meeting minutes for the month of 6/1/13 and 7/9/13 revealed no documentation the Suicide Risk Assessment for the Psych Area was discussed during this meeting. There was no documentation the patient safety concerns in the Psych Intake ED, 5 W or 5 SE were addressed during the Environment of Care/Safety Committee meeting.


Review of the 8/13/13 Environment of Care/Safety Committee meeting minutes revealed the following documentation, "...the Risk Assessments of the Psych areas that have been reported. Work orders have been written for work to be completed. A spreadsheet of the work orders is on file along with the risk assessment..." The surveyors were not provided a copy of the spreadsheet or the risk assessment. There was no documentation the Suicide Risk Assessment for Psych Area was discussed during this meeting.


Review of the Environment of Care/Safety Committee meeting minutes dated 2/11/14 revealed a Risk Assessment for doors located in Psych area was discussed with the following documentation, " ... The Joint Commission survey was discussed concerning the door handles in the psych area. A meeting will be set up to assess this finding. Follow-up will be at the February meeting... " There was no documentation the Environment of Care/Safety Committee addressed any other patient safety concerns other than doors in Psych area during this meeting.


Review of the 3/11/14 Environment of Care/Safety Committee meeting minutes revealed a Risk Assessment for Doors in Psych was discussed with the following documentation, "... The Risk Assessment on the door handles in the Psych area has been completed. A full risk assessment by a third party will be set up. Follow-Up in March... " There was no documentation the Environment of Care/Safety Committee addressed any other patient safety concerns other than doors in Psych area during this meeting.


Review of the 4/8/14 Environment of Care/Safety Committee meeting minutes revealed a Risk Assessment for Doors in Psych Area was discussed with the following documentation, "... This was tabled until the April Environment of Care/Safety Committee... " There was no documentation the Environment of Care/Safety Committee addressed any other patient safety concerns other than doors in Psych area during this meeting.


There was no documentation of the Environment of Care/Safety Committee meeting minutes for May 2014.

Review of the Environment of Care/Safety Committee meeting minutes dated 6/10/14 revealed a Risk Assessment of Door handles in Psych was discussed with the following documentation, "... It was reported a risk assessment was completed on the door handles and there was only one left to replace. Parts have been ordered... " There was no documentation the Environment of Care/Safety Committee addressed any other patient safety concerns other than doors in Psych area during this meeting.


E. Review of the Patient and Staff Safety Review dated June 2014 revealed the following items of patient and staff safety issues:

... 8. Fire sprinkler heads are the type where the heads have pieces that can be removed and made into sharp objects that can be used as a weapon or pose ligature point. Recommend replace with tamper proof sprinkler heads.

9. Grab bars in hallways are not enclosed. Recommend replace with an enclosed style to reduce ligature risk.

10. Patient furniture is dated and light weight which can present a risk on the adult unit of patients picking up and using as a weapon. Replace with weighted chairs that decrease risk...

13. Nursing station on the adult unit is accessible by patients and in addition, the counter surface is low which exposes the risk of reach over to access computers or staff. Recommend a) bolting/securing computer screens to prevent removal b) increasing the height of the counter and installing half doors to prevent access and risk to staff and decrease risk of HIPAA (Health Insurance Portability and Accountability Act) violations.

Patient Rooms and Bathrooms

1. The doors on all observed patient accessible rooms present several potential hazards.

ii. Doors on all patient rooms swing into the room. This creates a potential for barricading of these doors. It is suggested that all doors be equipped with barcode resistant features such as double acting continuous hinges that facilitates removal or the wicket (door within a door) style door that allows a small panel to swing out in the event of an emergency.

v. Patient 'medical' beds did not have head and foot boards secured. These can be easily removed by patients and used as a weapon towards others. Use tamper proof screws and secure to post(s) and ensure there is a board on the crash cart in the event of emergencies.

x. Patient bathrooms have tubs. Although in some cases on the geriatric area the faucets have been enclosed, bathtubs still in use on the adult unit pose a potential risk. Recommend renovating and removing all tubs.

Review of the Environment of Care/Safety Committee meeting minutes dated 7/15/14 revealed a Risk Assessment of Door Handles in Psych was discussed with the following documentation, "... The risk assessment has been completed. There was (1) door hinge to be swapped out along with the hardware this has been completed. According to AIA standards the door handles on the bathroom door are in compliance... "

F. Review of the Risk Assessment of Psychiatric Unit dated 9/19/14 revealed items discussed included the risk for elopement. Discussion: Badge readers at doors provide access and egress control, but elopement concerns remain due to patient characteristics. Consideration/mitigation included: Consider adding a "man-trap" at the main entrance. The front door will not open if the 5W or 5SE door is open, and the 5W & 5 SE doors will not open if the main door is open. Requires install of 5 SE door. Consider adding an over-ride button at the unit secretary desk to prevent doors from opening if an elopement situation is developing.

Review of the Risk Management Worksheet dated 9/26/14 related to Patient Identifier (PI) # 1 revealed, "... Pt (patient) was in psych intake for eval (evaluation) and pt was cleared to leave AMA (Against Medical Advice) and then was changed to discharge. Pt was given back belongings to change back into close (clothes) and get ready for d/c (discharge) security in psych intake. tech (Technician) went into room to see if pt was dressed and (patient) was standing on bed tieing (tying) gauze to ceiling and trying to put it around (his/her) neck. psych tech and security grabbed pt and lifted (patient) up and cut gauze off pt and removed from neck. then pt became physically aggressive and code gray was called and pt was assisted to floor and began to calm and was medicated..." The type of injury was documented as "Patient, Inappropriate Behavior" with the Significance rating of Moderate and received in Risk Management on 9/26/14. Further review of the Risk Management Worksheet dated 9/26/14 revealed, Employee Identifier (EI) 2, Executive Director of Nurses documented on 10/6/14 at 12:43 (PM), "Debrief was completed with staff, safety and risk. Patient has manipulative behavior. Patient was admitted to 5 SE (Adult Psychiatric Unit)... discharged on 9/29/14..." On 10/15/14 at 10:04 (AM), which revealed, "... The Serious Safety Event (SSE) Committee has reviewed and deemed this event to be an SSE 5..."

A Debrief of the above incident was conducted on an undocumented date at 7:00 AM. The Safety Issues & Concerns was also undated by an undocumented person. An action plan was prepared by EI # 5, Director of Patient Safety. Review of this action plan revealed Identified Issues included: 2. Physical Environment of psychiatric rooms needs addressing: solid ceiling. Action Item # 2: Room renovations to install solid surface ceiling. Method: Room renovation. Timeframe for completion: Await recommendation from Plant Ops (operations). Progress: Construction to start 12/1/14, will take approximately 7 days and completed on 12/15/14. Identified issue: 3. Presence of linens and Kerlix in psychiatric area. Action Item # 3: Ensure psychiatric patients do not have access to regular line or Kerlix. Method: Substitution of other items in place of traditional linen. Progress: Regular linens are used on the stretchers. Staff monitor the amount of linen used in psych intake.

An interview was conducted on 3/11/15 at 10:53 AM with Employee Identifier (EI) # 12, Registered Nurse Emergency Department (ED), who stated one of the actions after the event above that was put in place, was to remove the linen from the room once the patient is discharged.

G. Review of the Pro-Active Risk Assessment Form dated December 2014 revealed the following identified hazards:

Tubs in patient bath rooms. Type of injury: Falls, Drowning. Current control measures in place: Community shower. Further control measures required: remove Tubs.

Nurse's Station on Adult Unit: Type of injury: Any type. Current control measures in place: 24/7 coverage at desk, add gates to entrances, secure computers to desk, remove accessible office supplies and equipment. Further control measures required: Raise height of counter, add enclosure from ceiling, provide safe area for staff

Exits: Type of injury: Absconder. Current control measures in place: Locked entrance door with limited and controlled access. Further control measures required: Reinstall corridors with access control.

Patient Room furniture: Type of injury: Not weighted can be used as a weapon. Current control measures in place: None, most rooms are missing furniture or it is in poor condition. Further control measures required: New furniture requested.

Hallway handrails: Current control measures in place: 15 minute checks and located in common area. Further control measures required: Enclose.

Patient Room door swing: Type of injury which could result if harm occurs: Barricading. Current control measures in place: 15 minute checks and unoccupied rooms are locked. Further control measures required: Reverse door swing.


Review of the Risk Management Worksheet dated 1/6/15 related to PI # 12 related to an incident that occurred on 1/3/15 revealed, "... Patient eloped off the unit and was abscent (absent) nearly 5 hours due to having peer push button to let (him/her) out..." The type of injury was documented as an Elopement with a significance of "No apparent injury" and was received in Risk Management on 1/6/15. On 1/6/15 at 5:16 PM, Employee Identifier (EI) # 4, Patient Safety Officer documented, "Debrief held with staff on Sunday, January 4, 2015. Action Plan developed and reviewed with Nursing/Patient Safety on Tuesday, January 6. Will implement action plans when finalized..." On 1/15/15 at 7:58 AM, EI # 13, Interim Nurse Manager/ Psychiatric Units documented, "... Plans are in place to border or partition nurses' station, vital signs chair has been removed from nursing station. Plans in place for remodeling unit..." On 1/27/15 at 2:15 PM, EI # 13 documented, "... Protective covers have been placed over buttons to open doors. Staff can only enter through 5 West (Geriatric Unit) door..."

Review of the Risk Management Worksheet dated 1/29/15 related to PI # 11 revealed, "... Pt (patient) was agitated, fighting staff, acquired an abrasion on the top of right foot from bed during struggle." The type of injury was documented as an Unexpected Injury of Minor significance and was received in Risk Management on 1/29/15. Further review of the Risk Management Worksheet dated 1/26/15 revealed, EI 2, Executive Director of Nurses documented on 1/30/15 at 10:18 (AM), "Patient has missed several doses of medication... refused to take medications. Patient became agitated. Patient tore up the protective scree/lock over the window in (his/her) room. Security and 2 male MICU (Medical Intensive Care Unit) nurses were called to assist in restraining patient. Patient was place in 4 point double lock velcro restraints and was medication for (his/her) agitation... Plants Ops had moved a screen from the break room to the patient's room to fix (his/her) window..." There was no documentation Risk Management followed up with this incident/occurrence.


There was no documentation of follow up by Risk Management concerning this potentially adverse incident of an agitated patient who had managed to damage a protective screen on the window and had to be restrained to prevent further injury.

There was no documentation the Environment of Care/Safety Committee met in January 2015.

Review of the Environment of Care/Safety Committee meeting minutes dated 2/24/15 revealed a the items discussed during this meeting were dated 1/20/15 and included the following discussion "... Risk Assessment of Psych Area - Tabled until February meeting..."


Surveyor Observations:

An initial tour of the Psychiatric Units was conducted on 3/9/15 at 10:45 AM. During this tour, the surveyors observed the following safety concerns:
Geriatric Unit/ 5 W: 3 buttons at the nurse's station for remote door access with covers available. Only one of the buttons was covered, which left the remote door access buttons vulnerable for unauthorized use.
Sprinkler heads were not tamper proof with the internal portion of the sprinkler extending out of the escutcheon.
Bath tub in patient room 5223, was operational with working faucets and could be used by patients. This room was assigned to a patient.
Hand rails in hallways not enclosed, which could pose a ligature threat.

The Unit Secretary accompanied the surveyors to the Adult Unit / 5 SE, which left the nurse's station without staff supervision.

Observed located on the Adult Unit / 5 SE: 2 buttons at the nurse's station for remote door access with covers available. None of the buttons were covered, which left the remote doors access buttons vulnerable for unauthorized use.
Hand rails in hallways not enclosed, which could pose a ligature threat.
Bath tub located in room 5127, was operational with working faucets and could be used by patients. This room was assigned to a patient.
Patient Room 5123: wooden dresser and bedside table, which the surveyor was able to move with little effort.

The surveyors returned to the Psychiatric Units on 3/10/15 at 8:35 AM and observed all of the buttons for remote door access were uncovered at the nurses stations in the Geriatric Unit / 5 W and Adult Unit / 5 SE. The surveyor entered patient room 5223 and observed both head and foot boards of the patient bed were able to be lifted off of the bed.

On 3/10/15 at 2:40 PM, the surveyors returned to the Psychiatric Units and observed that both of the counter tops at the nurse's station in the Geriatric Unit / 5 W and Adult Unit / 5 SE were approximately 4 feet high and easily accessible to patients. The surveyor was able to reach over to the "tube" chute in the Adult Unit / 5 SE and grab the tube from the chute without having to stretch to reach it.

On 3/12/15 at 9:05 AM, the surveyors returned to the Psychiatric Units. The surveyors observed 2 of the buttons for remote door access were uncovered in the Geriatric Unit / 5 W and both buttons for remote door access were uncovered in the Adult Unit / 5 SE.

On 3/12/15 at 4:15 PM, the surveyor observed located in the Psych Intake area of the ED, the door handles located on doors to patient rooms. The door handles located on the doors to patient Room # 1 and Room # 2 were sturdy metal handles, which could potentially be use as a ligature point.


An interview was conducted on 3/17/15 at 2:00 PM with Employee Identifier (EI) # 1, Chief Nursing Officer, who verified there was no other policy related to Occurrence Reports, investigation and follow up.

An interview was conducted on 3/18/15 at 3:30 PM with EI # 3, Corporate Director of Risk Management. During this interview, EI # 3 stated the facilty had been using the electronic Incident/Occurrence reporting system for about a year. The incident/occurrence reports are electronically sent to Risk Management, Quality Assurance, Patient Safety, Manager, Director and Vice President of the area in which the incident occurred.

EI # 3 stated the Managers and Directors of the area in which the incident occurred, reviews the incident and places comments in the incident report. Risk Management reviews the incident to make sure it has been followed up on and the appropriate person has made comments. If the appropriate person has made comments, Risk Management nothing else is done with the electronic incident report.

EI # 3 stated Incidents related to medications are looked at monthly by Pharmacy, Patient Safety and Risk Management and Incidents related to falls are reviewed by Nursing, Patient Safety and Risk Management. EI #3 stated only incidents with significance of major injury and death (Serious Safety Events - SSE) are investigated by Risk Management. SSE committee reviews occurrence and places a rating on the occurrence, once this is determined, a Root Cause Analysis team is formed and a root cause analysis is completed.

EI # 3 verified there was no policy related to this electronic incident/occurrence reporting system. EI # 3 stated the only thing in relationship to the electronic reporting system is employee training Power Point slides entitled Electronic Incident Reporting System.A review of the Power Point slides entitled Electronic Incident Reporting System revealed the following:

"... What happens next? After you have submitted the occurrence report the Manager and Director over the department where the occurrence took place and the Manager and Director over the department where the variance began are notified of the occurrence via a worklist. The worklist provides Managers and Directors a tool for completing follow-up for all occurrences relating to their department(s). The worklists also allows Managers and Directors to refer the occurrence to upper level management. Quality Management and Risk Management are notified about the occurrence..."

A telephone interview was conducted on 3/20/15 at 8:20 AM with EI # 14, Director of Facility Compliance. The surveyor asked EI # 14 what happens to the Environment of Care (EOC) tour information when patient safety issues are identified. EI # 14 stated the findings are presented to the EOC committee and we work to make repairs. If there are problems that can not be fixed or handled, the EOC committee evaluates the issue to see if it is required or not, the best way to mitigate the safety issue or take the room out of service until the safety issue could be repaired permanently.




32470

An interview was conducted on 3/19/15 at 10:45 AM with Employee Identifier (EI) # 5 Director of Patient Safety.

During the interview EI # 5 stated the primary duties consist of Healthcare Performance Improvement for the system.

EI # 5 stated that Quality Performance and Patient Safety work closely together and have a joint Quality Assurance/Patient Safety Plan that is completed together.

EI # 5 stated that when considering safety issues anything that causes harm is considered a safety issue. When asked if there is a potential to cause harm what is discussed. EI # 5 stated the SSE (Serious Safety Event) committee determines whether the incident caused harm or not.

EI # 5 stated that she does get a copy of the Occurrence Reports but only the ones that actually caused harm. The classification is 1-5 with 4 being severe harm and 5 being death. Only the 4 and 5's are received.

When asked if EI # 5 received the occurrence report about PI # 11 who barricaded him/her self in the room with the potential for harm EI # 5 stated no it was not classified as a 4 - severe harm or a 5 - death.

An interview conducted on 3/19/15 at 11:20 AM with EI # 4 Patient Safety Officer.

During the interview EI # 4 was asked what are the duties of the Patient Safety Officer. EI # 4 stated that EI # 4 investigates the root cause of the occurrence reports.

EI # 4 first stated that she receives all of the occurrence reports on a weekly basis from Risk Management and then stated EI # 4 only receives the occurrence reports that caused harm.

EI # 4 stated he/she reviews the occurrences that caused harm to be sure that the manager has reviewed the occurrence report and made a comment. EI # 4 stated on a scale rating of 1-5, he/she only receives the 4's which are severe harm the the 5's which are deaths.

When asked what is done with the occurrences rated 1 through 3 and EI # 4 stated nothing is done if there was no harm or death.

During the interview EI # 4 was showed the occurrence report the surveyors received by the facility on PI # 11 and was to review the occurrence. When complete EI # 4 stated that she saw this report but did not investigate it because it was not a severe harm or death occurrence and that the manager of the unit had made a comment and that is a clue that the problem was taken care of at that time.

During the interview EI # 4 was asked if the occurrences were tracked and trended and EI # 4 responded stating there is a Safety Leadership Team that meets monthly to review the occurrences. EI # 4 stated the team consists of 22 members with the majority of the members consisting of nurse managers. EI # 4 stated topics are discussed in the meeting including occurrence reports and one member of the team does the tracking and trending of information. When asked if all occurrence reports are discussed at the meeting EI # 4 stated only the top 3 occurrences are reviewed.

An interview was conducted on 3/19/15 at 3:15 PM with EI # 2, Executive Director of Nursing.

During the interview EI # 2 was asked what happens to the occurrence report when it is generated. EI # 2 stated the reports go to upper management, the Administrator and Patient Safety.

EI # 2 was asked what is expect of him/her when receiving an occurrence report. EI # 2 stated that she reviews each occurrence he/she receives and EI # 2 stated he/she would expect to see a comment made by the manager. EI # 2 stated if he/she is unsure of the occurrence a phone call is made to the manager and EI # 2 stated he/she does not get involved that it is left up to the nurse manager and the education person of the unit to handle the occurrence.

During the interview EI # 2 was asked if there is a follow-up completed on the occurrences and what occurrences are investigated and EI # 2 stated that there was no follow-up documented on the occurrence report itself and there are no specific guidelines on which occurrences are investigated. When asked

Based on review of the Quality and Patient Safety Program 2013 Annual and Board of Directors Meeting minutes, medical records, observations and interview with facilty staff, it was determined the Governing Body failed to address the identified patient / staff safety concerns of the Quality and Patient Safety Program were addressed, including addressing the nurses' station in the Psychiatric unit. This affected Patient Identifier (PI) # 12, in that PI # 12 was able to have one of his/her peers reach over the counter, press the remote door unlock button and elope from the Adult Psychiatric Unit / 5 SE. PI # 12 was able to reach items in the nurse's station area and enter the nurse's station. This affected 1 of 5 patients (PI # 12) admitted to the Psychiatric Unit and has the potential to negatively affect all patients and staff admitted to the Geriatric and Adult Psychiatric Units.

Findings include:

Review of the Quality and Patient Safety Program 2013 Annual report revealed documentation of what the committee presented to the board of directors. Documentation under Process Improvements revealed providing a safe environment for the Psychiatric patient, revise the Environment Safety Rounds Checklist, Staff re-educated on the proper items that are allowed to be brought into the psych unit and Evaluate the possibility of a closed in nurses station.

Review of the Board of Directors Meeting minutes dated 7/21/14 revealed the Administrator presented the Mobile Infirmary Quality and Patient Safety Program 2013 Annual report for review and approval.

Following the review, a motion was made followed by a second motion to approve the Quality and Patient Safety Program 2013 Annual Report...The motion passed unanimously.

Refer to A144 Medical Record review, example # 2 for medical record findings.

An initial tour of the Psychiatric Units was conducted on 3/9/15 at 10:45 AM. During this tour, the surveyors observed the following safety concerns:
Geriatric Unit/ 5 W: 3 buttons at the nurse's station for remote door access with covers available. Only one of the buttons was covered, which left the remote door access buttons vulnerable for unauthorized use.

The Unit Secretary accompanied the surveyors to the Adult Unit / 5 SE, which left the nurse's station without staff supervision.

Observed located on the Adult Unit / 5 SE: 2 buttons at the nurse's station for remote door access with covers available. None of the buttons were covered, which left the remote doors access buttons vulnerable for unauthorized use.

The surveyors returned to the Psychiatric Units on 3/10/15 at 8:35 AM and observed all of the buttons for remote door access were uncovered at the nurses stations in the Geriatric Unit / 5 W and Adult Unit / 5 SE.

On 3/10/15 at 2:40 PM, the surveyors returned to the Psychiatric Units and observed that both of the counter tops at the nurse's station in the Geriatric Unit / 5 W and Adult Unit / 5 SE were approximately 4 feet high and easily accessible to patients. The surveyor was able to reach over to the "tube" chute in the Adult Unit / 5 SE and grab the tube from the chute without having to stretch to reach it.

An interview was conducted on 3/19/15 at 3:15 PM with Employee Identifier, (EI) # 2, Executive Director of Nursing stated a plexi-glass door has been ordered to cover the "tube" chute and will be installed once it arrives.

Based on review of facility policies, medical records, and interviews with facility staff, it was determined the nursing staff failed to ensure Patient Identifier (PI) # 11's psychiatric needs were met, interventions were taken to de-escalate or redirect the patient, thus allowing PI # 11's psychological condition to further deteriorate to the point the patient had to be restrained.

This deficient practice affected 1 of 5 inpatient psychiatric patients, (PI # 11) and had the potential to negatively affect all patients requiring inpatient psychiatric services.

Findings include:

Facility Policy:

Behavior Management- Psychiatric Services
Approval Date 2/2011

Purpose: To establish process for incorporating Behavior Management Plans in Patient treatment as appropriate.

Policy: ... Acute psychiatric stabilization is provided on the in-patient adult and geriatric psychiatric units... Specific Behavioral Management Plans when used are part of the patient's plan of care...

Procedure: ... The Interdisciplinary Team incorporates behavior management techniques as appropriate into the patient's plan of care...The plan of care is reviewed, evaluated and approved by the psychiatrist, RN (registered Nurse), Social Worker and OT (Occupational Therapist) (when applicable).

Behavior Management Plans include:
Targeted maladaptive behaviors
Adaptive or replacement behaviors
Intervention to reduce/eliminate behaviors
Criteria for discontinuation of behavior management procedures
Behavior management techniques used

The following behavioral management techniques may be utilized:
Education...
Redirection of inappropriate behavior...
Time outs in an unlocked area for no more than 30 minutes in duration. Patient shall receive education about the conditions under which time-outs are used...

Facility Policy:

Physician Notification System
Approval date: 05-31/2013

Purpose: To establish guidelines for the notification of physician.

Policy:
Physicians are notified according to the following guidelines:
A. Attending Physician: The attending physician should be notified for admission/transfer/discharge of a patient and/or for clinically significant changes in a patient's condition...




32470

1. PI # 11 was admitted to the Adult Psychiatric Unit 5 SE (South East) on 1/26/15 with an admitting diagnosis of Delusional Disorder.

Review of the nurse note dated 1/26/15 at 11:52 PM revealed the nurse documented the patient refuses to make eye contact or speak with staff and was unable to do admission history. The nurse documented the patient appeared to be very anxious and psychotic and was medicated with Ativan 1 mg (milligram) PO (by mouth) to help with anxiety.

Review of the nurse note dated 1/27/15 at 6:30 AM revealed the patient's mental status was as follows:
appearance: Disheveled
Mood: Anxious; Guarded
Affect: Constricted
Thought Process: Guarded
Thought Content: Delusions
The nurse documented the frequency of checks were every 15 minute observations.

Review of the nurse note dated 1/28/15 at 1:02 AM revealed the nurse documented the patient was adamant about not having anyone sleep in the room with him/her although he/she had a room mate last night. The patient refused vital signs and was asking strange questions and constantly calling the nurse to the room. The nurse documented the patient is anxious, irritable and illogical. The patient was refusing medications.

Further review of the documentation revealed the nurse documented under depression symptoms, the patient had a change in energy level, feelings of helplessness, increased irritability, sleep disturbance and visual hallucinations. The frequency of checks remained every 15 minutes by observation.

On 1/28/15 at 1:10 AM, the patient remained paranoid with a high level of anxiety stating again he/she did not want to be in a room with anyone else and was moved to a new room at the patient's request.

Review of the nurse note dated 1/28/15 at 9:53 AM revealed the nurse documented the patient was lying on the bed when nurse tried to enter room patient waved the nurse away refusing medication and any treatment.

On 1/28/15 at 5:33 PM, the nurse documented the patient was delusional and stated, "I feel like I'm on fire, I'm being tormented by hell". Nurse informed the patient that he/she has been refusing medication and needs to take the medicine to help with this but patient continued to refuse.

On 1/28/15 at 8:41 PM, the nurse documented the patient was moaning and saying "Oh god, Oh god" and went to air conditioner and turned it on. The nurse asked if he was going to take his medication and the patient waved the nurse out of the room.

On 1/28/15 at 9:53 PM, the nurse documented the patient went in to room 5125 D, which was an occupied room not assigned to PI # 11. The patient continued to be paranoid and delusional and laid across the unoccupied bed. The patient stated he/she wanted to stay there, that the roommate needed him/her there. The staff insisted he/she return to his/her room. The patient then crawled on his/her hands and knees back to his/her room 5123 and sat in the doorway on the floor. The nurse documented the patient will not engage in conversation and makes minimal to no eye contact and that he/she remained in the doorway and refused to go into the room.

On 1/28/15 at 10:07 PM, the nurse notified the House Supervisor that the patient wanted to move to another room. When nurse went to patient's room the patient was in the bed and stated, "It's over and done with now" and refusing to move to another room.

On 1/28/15 at 10:24 PM, the nurse documented the patient wanted the nurse to sit by the patient's room all night. The nurse informed the patient that the nurse could not do that. The patient then stated, "It's the devil himself, you might as well face what's coming to you".

On 1/28/15 at 10:49 PM, the nurse documented the patient was sitting on the floor in doorway of room again.

Review of the nurse noted dated 1/29/15 at 5:57 AM revealed the nurse documented the patient slept one half hour during the night and every time staff would check on him/her he/she would kick the wall and wave the staff away.

On 1/29/15 at 7:30 AM, the nurse documented the patient was lying in bed with head at foot of bed and the patient placed the tray table between door and the bed so it can be shoved to the door if anyone opened the door. The patient was awake but the nurse was unable to complete assessment because the patient refused to let anyone in or talk to anyone. Will report patient behavior to MD (Medical Doctor) for recommendations on different approach.

On 1/29/15 at 10:50 AM, the RN documented having heard a loud noise from the patient's room, attempted to open the door and the patient had barricaded him/herself in the room. The patient had pulled the tray table to the door and the bed next to the tray table. The RN documented that Security was called to the unit to assist. Upon opening the door, staff noted the patient had broken the screen from the window. The patient was fighting and agitated.

On 1/29/15 at 12:00 PM, the RN documented the patient had to be retrained with 4 point restraints due to the patient was agitated and fighting. Haldol 10 mg (milli-grams)/Ativan 2 mg/Benadryl 50 mg IM (Intramuscularly) was given after MD was notified. The patient was moved to another room due to the window screen being broken.

Review of the flow sheet for restraints dated 1/29/15 revealed the patient was placed in 4 point restraints at 12:00 PM and the 4 point restraints were discontinued at 2:30 PM and left in 3 point restraints until 4:15 PM when the patient was placed on 1:1 (one on one) observation. Patient continued to refuse medications on occasion and continued to wave staff out of the room. On 1/31/15 at 12:37 PM the patient was taken off of 1:1 observation and placed back on every 15 minute observations and remained on the every 15 minute observation until discharged on 2/4/15 at 7:10 AM with Deputy Sheriff to Probate Court.

Summary: Review of the medical record revealed no documentation the staff attempted to de-escalate the patient prior to patient barricading himself/herself in the room. There was no documentation the staff attempted to redirect the patient or provide a quiet, safe room when the patient was not satisfied with his/her room. There was no documentation the staff initiated 1:1 with the patient as his/her anxiety level increased. There was no documentation that the physician was notified to inform of patient's condition and obtain new orders for treatment. The staff failed to intervene on behalf of the patient's safety.

Based on facility policies and interviews with facility staff, it was determined the facility failed to ensure The Interdisciplinary Team followed the facility's policy related to the development and review of the Interdisciplinary Plan of Care on patients admitted to in-patient psychiatric units, including short/long term goals and interventions to facilitate goal achievement in discharge planning.


Findings include:

Facility Policy:

Program Description, Admission, Discharge Criteria
Approval Date 2/2011

Purpose: To describe program of care and establish criteria for patient admissions and discharge.

Policy: The Psychiatric Services Division of Mobile Infirmary Medical Center provides confidential quality services with respect and dignity to the individuals seeking treatment for primary psychiatric illnesses...

... Psychiatric Services offers a treatment environment which provides a thorough and individualized assessment of each patient's psychiatric disorder and level of functioning by a multi-disciplinary team. The team
consists of physicians, registered nurses, social workers, occupational therapists and other ancillary staff. This assessment also includes identification of reasonable, attainable short and long term goals that allow the patient to achieve the highest level of functioning within the limitations of the illness. Reassessment is on-going and is reviewed at least weekly in the treatment team meeting...

Criteria for Admission
... A psychiatric consult is required within twenty-four hours of admission...Patients may be admitted involuntarily only in the case of extreme safety risk and by signature of two physicians, one of which must be a psychiatrist.

Admission- Either A, B or C must be met to satisfy the criteria for admission.

A. Patient is considered to be at risk for harm to self or others as indicated by one of the following:
1. A current plan or intent for serious harm to self or others, or
2. A recent attempt to inflict harm...
3. Demonstration of behavior (violence, agitation, etc) that presents a risk of harm to self or others.
4. Evidence that the patient is having disorganized or bizarre thoughts that might lead to harm to self or others.

B. The patient demonstrates an impairment of daily functions that the psychiatric assessment indicates may have a seriously endangering impact to their physical or mental health. Examples: Non-compliance with medical treatment...

C. The patient's psychiatric condition is not responding to adequate therapeutic trial of treatment in a less intensive setting...

Criteria for Continued Stay
Daily documentation by a physician and providers of continued presence of endangering behaviors and documentation of the patient's response to the treatment plan, including individualized goals of treatment, twenty-four hour treatment modalities, discharge planning and the patient support system involvement...

Discharge Criteria
... The goals of the treatment have been substantially met at this level of care.
Follow-up and treatment plans for a lesser level of care have been established.
Releasing or transferring the patient to a less intensive level of care does not pose a threat to patients, others, or property.

Facility Policy:

Interdisciplinary Plan of Care- Psychiatric Services
Approval Date 04/15/14

Purpose: To establish process for development of Interdisciplinary Plan of Care on patients admitted to in-patient psychiatric units.

Policy: Based on the individual assessments and reassessments by the members of the interdisciplinary treatment team, an individualized comprehensive plan of care is developed. The plan of care should include: the problems identified, short/long term goals, and specific interventions to facilitate goal achievement in discharge planning.

Procedure:

4. The Treatment team including the physician and/or their licensed independent practitioners shall meet twice weekly or more often as necessary to review and revise the patient's plan of care as indicated.

6. Re-assessments...
a. Nursing should document re-assessment each shift.
b. Social workers shall document pertinent data including individual, family and group sessions and discharge plan.
c. Occupational Therapist shall document pertinent data including group evaluations.
d. The attending physician/licensed independent practitioner shall provide ongoing re-assessment according to the Bylaws, Rules and Regulations of the Medical Staff of the Mobile Infirmary.

An interview was conducted on 3/17/15 at 4:05 PM with Employee Identifier (EI) # 15, Registered Nurse (RN). During this interview, the surveyor asked, "How often are care team meetings conducted?" EI # 15 stated, "... I don't know that they are doing them any more..."

An interview was conducted on 3/17/15 at 4:30 PM with EI # 16, RN. During this interview, the surveyor asked, "How often are care team meetings conducted?" EI # 16 stated, "... The actual care team meetings, I have not known of one for several months. We used to meet with the physician, social worker, registered nurses and we would meet two times a week..."



32470

An interview was conducted on 2/17/15 at 11:45 AM with EI # 19, Registered Nurse.

During the interview with the surveyors EI # 19 was asked how often care team meetings are conducted. EI # 19 stated they are held once a month.

An interview was conducted on 3/17/15 at 3:05 PM with EI # 18, Registered Nurse.

During the interview with the surveyors EI # 18 was asked how often care team meetings were conducted. EI # 18 stated " Well to be honest it use to be twice a week with the Social Worker, Physician and nursing staff but now I haven't been to one since January".

An interview was conducted on 3/18/15 at 10:00 AM with EI # 17, Social Worker.

During the interview with the surveyors EI # 17 was asked how often care team meetings were conducted. EI # 17 stated they have been struggling with the team meetings. EI # 17 stated "we had a couple and probably not up to standards". EI # 17 stated the care team meetings were conducted frequently until one of the physicians left in November. After November there was no care team meeting in December and in January there was approximately 2 meetings with the current physician. EI # 17 stated " our plan is to institute team meetings Monday, Wednesday and Fridays but it has not started yet".

An interview was conducted on 3/19/15 at 12:45 PM with EI # 10, Nurse Manager. During the interview with the surveyors EI # 10 was asked how often are care team meetings conducted. EI # 10 stated that since her hire date she has only attended one care team meeting.

An interview conducted on 3/19/15 at 2:00 PM with EI # 9, Program Director.

During the interview with the surveyors EI # 9 was asked how often care team meetings were conducted. EI # 9 stated there was one this AM (3/19/15) and that a care team meeting was held one time last week.

This condition level deficiency is cited based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards.

This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

Refer to A144 and A701 for findings.

Based on review of the Safety Management Plan, Hazard Risk Analysis, Risk Assessment of Suicide in Psych areas, Patient and Staff Safety Review, Risk Assessment of Psychiatric Unit, Pro-Active Risk Assessment Form, adverse event Debriefing, Safety Issues & Concerns, Debrief Analysis and Action Plan, Equipment Management Program Service Report, Survey Follow-up, medical records, observations and interviews, it was determined the facility failed to ensure:

1. The ceiling in the Psych Intake area for the Emergency Department (ED) was maintained in a manner to provide a safe environment for patients who are at risk for self inflicted injury.

2. The Inpatient Psychiatric Units were maintained to prevent patient elopements and a safe environment to prevent a patient from using light weight furniture in the patient room to barricade him/herself in the room.

3. The Inpatient Psychiatric Units were maintained with tamper proof sprinkler heads, the bath tubs in patient rooms were not operational, hand rails were enclosed and patient beds were equipped with non-removable head and foot boards.

This deficient practice affected 3 of 14 patient records reviewed, including Patient Identifier (PI) # 1, 11 and 12 and had the potential to negatively affect all patients and patient care areas located within this facility.

Findings include:

Refer to A144 for findings.