HospitalInspections.org

Based on observation and interviews, the hospital failed to ensure patients requiring acute inpatient psychiatric care, who have been admitted for being a danger to self and others, received care in a safe setting. This deficient practice was evidenced by failure to ensure the physical environment was maintained in a manner to assure an acceptable level of safety for patients by:
1) having exposed power cords to the TV and water cooler in the day room;
2) having ligature risks for the bathroom toilets in 13 of 13 patient rooms and seclusion ante room; and
3) having accessible screws that were non-tamper proof.

Findings

1) Having exposed power cords to the TV and water cooler in the day room.

On 09/29/21 at 1:30 p.m., observation revealed a patient in the day room with no staff present. Further observations revealed an exposed power cord to the TV.

Observation on 09/30/2021 at 12:11 p.m. of the day room revealed exposed power cords to the TV and water cooler.

In an interview on 09/30/2021 at 12:11 p.m. S2DON confirmed the power cords to the TV and water cooler in the day room were exposed and were potential ligature risks.

2) Having ligature risks for the bathroom toilets in 13 of 13 patient rooms and seclusion ante room

Observation of the bathrooms in 13 of 13 patient rooms and the seclusion ante room on 09/28/2021 at 10:06 a.m. revealed each toilet had a toilet seat that was capable of being raised creating a potential ligature risk to patients at the base and hinges.

In an interview on 09/30/2021 at 12:04 p.m., S7VPOperations verified each toilet in 13 of 13 patient rooms and seclusion ante room had a toilet seat that was capable of being raised creating a potential ligature risk to patients.

3) Having accessible screws that were non-tamper proof.

On 09/28/2021 at 10:10 a.m., a tour of the hospital with S3Activity Director revealed non-tamper proof screws in the following areas:

Patient room a, which was not locked, on the bathroom mirror, toilet basin cover, the metal faceplate on the right wall in the bathroom, on the room door hinge, door catch and latch plates.

Patient room b, which was not locked, on the door hinge, door catch plate and latch plate.

Patient room c, which was not locked, on the door hinge, latch plate and latch catch plate.

Patient room d, which was not locked, on the door hinge, latch plate, latch catch plate and metal plate above the head of the bed.

In an interview on 09/28/2021 at 10:10 a.m., S3Activity Director verified the above information.



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Based on observation and interview, the hospital failed to ensure the environment was maintained in such a manner to assure the safety and well-being of the patients. This deficient practice is evidenced by:

1) Failing to ensure the hospital was cleaned to maintain the well-being of the patients.
2) Failing to ensure water spots on ceiling tiles were remediated.

Findings:

1) Failing to ensure the hospital was cleaned to maintain the well-being of the patients.

A review of the housekeeper's daily, weekly and monthly cleaning list revealed in part: hallways- sweep and mop, entire hallway and wipe down handrails.

An observation of the hallway handrail revealed a thick layer of dust and smoked cigarette butts between the handrails and walls.

In an interview on 09/29/2021 at 9:00 a.m., S6MHT confirmed the dust and cigarette butts between the handrails and walls.

In an interview on 09/29/2021 at 9:05 a.m., S5Housekeeper stated she is one of the housekeepers responsible for cleaning the handrails. She stated she has a daily, weekly and monthly list of areas to be cleaned. She also verified the dust between the handrails and walls.


2) Failing to ensure water spots on ceiling tiles were remediated.

An observation of the medication room on 09/29/2021 at 8:20 a.m. revealed water stains on the ceiling near the vent.
Further observation revealed water stains within the nursing station, the day room and hallway near the entry on to the patient unit.

In an interview on 09/29/2021 at 8:20 a.m., S4LPN verified the water stains in the medication room. He further stated the water stains have occurred repeatedly since his employment of about 6 years.

In an interview on 09/29/2021 at 8:50 a.m. S6MHT verified the water stain on the ceiling in the nurses station day room and hallway near the entry on to the patient unit.

Based on observations and interviews the hospital failed to develop and implement an effective system in controlling infections and communicable diseases of patients as evidenced by failing to ensure washed andd cleaned donated patient clothing was stored in a sanitary environment.

Findings:

An observation of the staff bathroom on the hallway near the nurse's station revealed clothing being stored in the bathroom. Clothes were noted to be folded and hanging.

In an interview on 09/29/2021 at 8:55 a.m., S6MHT stated that donated clothes are received and washed by the staff. After washing, the clothes are stored in the bathroom until needed by patients. She stated if a patient needs clothes, the staff would provide them to the patient without washing them after being stored in the bathroom.