HospitalInspections.org

Based on observation, interview, record review and policy review, the hospital failed to recognize and remove ligature (anything which could be used for the purpose of hanging or strangulation) risks located on the Behavioral Health Unit (BHU) for one current patient (#12) of one current patient reviewed that was admitted with suicidal ideations (SI, thoughts of causing one's own death). This failure had the potential to affect each patient admitted to the BHU with SI. The hospital census was 31 that included a census of eight on the BHU.

Findings included:

Review of the hospital's policy titled, "Suicide Assessment and Prevention," revised 04/2019, showed the following:
- Patients at risk for suicide, require intensive support, close observation, frequent re-assessment and application of protective measures for their emotional and physical well-being at all times.
- Additional safety interventions were implemented for patients on suicide precautions.
- These interventions include remove all potential ligatures (shoelaces, belts, cords) from the environment.
- It was the responsibility of all staff to maintain a safe and therapeutic environment for all patients at all times.

Review of the hospital's undated policy titled, "Medical Beds on the Psychiatric Unit," showed that the purpose of the policy was to ensure any safety risks posed by medical beds were assessed and appropriate mitigation (reduce the risk of harm) strategies were identified and implemented. Mitigation strategies and safety precautions that apply to the use of all medical beds included all patients will be assessed each shift for self-harm and any change in status reported to the physician and all nursing staff will be educated on environmental safety and ligature risks posed by the medical beds on the unit.

Review of Patient #12's medical record showed that he was an 82 year old male admitted to the BHU on 05/15/21 for SI.

Observation on 05/18/21 at 9:30 AM and 12:41 PM on the BHU, showed that all 10 patient beds had one unsecured black electrical cord attached to them that measured between 37 to 51 inches in length and were easily unplugged.

During an interview on 05/19/21 at 1:30 PM, Staff H, BHU Nurse Manager, stated that all patients on the BHU were not allowed to have items that could become ligature risks such as phone cords, shoe strings, belts and pants with strings. Bed cords that were not secured could be used as a ligature. She was unaware that the bed cords on the BHU were not secured.

Based on interview, record review and policy review, the hospital failed to ensure that staff were trained in first aid (the first and immediate assistance given to any person suffering from either a minor or serious illness or injury) related to restraints (application of mechanical restraining devices or manual restraints which are used to limit the physical mobility of a patient), for two staff (D and L) personnel files of three staff personnel files reviewed. This failure had the potential to result in serious injury or death to patients who required restraints in the hospital. The hospital census was 31.

Findings included:

Review of the hospital's policy titled, "Department of Nursing, Restraints," revised 01/15/13 showed that restraint application was performed by direct patient care staff that was qualified, had completed the competency based education program and that the annual education at the nursing skills validation would include restraint training and first aid training.

Review of the undated, hospital provided document titled, "Patient Safety/Restraint Annual Education," showed no first aid training.

Review of the hospital's restraint log showed a total of 31 patients required restraints for the previous six months.

Review of two staff personnel records for Staff D and Staff L showed no restraint first aid training.

During an interview on 05/18/21 at 1:48 PM, Staff E, Registered Nurse (RN), Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Manager and Staff Educator stated that she trained staff for restraint training. She stated that first aid was not incuded in this training.