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Based on observation, document review, and staff interview, it was determined that the hospital's governing body failed to ensure the hospital met all Federal regulations and assumed full responsibility for determining, implementing, and monitoring policies governing the hospital's total operation. The governing body failed to provide a ligature risk free environment and provide for care in a safe setting (refer to A-0115 and A-0144). The governing body failed to develop an ongoing program that shows measurable improvement in indicators for which there is evidence that will improve health outcomes and must measure analyze and track quality indicators that identify improvement projects for processes of care, hospital service and operations (refer to A-0273); failed to use data collection to identify opportunities for improvement and changes that will lead to improvement and must set priorities for its performance improvement activities that focus on problem prone areas (refer to A-0283); failed to include an ongoing program that shows measurable improvement in indicators for which there is evidence it will identify and reduce medical errors, measure and analyze and track adverse events in the pharmacy and failed to implement preventive actions and mechanisms that include feedback and learning throughout the hospital (refer to A-0286); failed to ensure all hospital departments and services participate in the QAPI (Quality Assurance and Performance Improvement) program and maintain and demonstrate evidence (refer to A-0308); and the hospital's governing body failed to ensure that an ongoing program for ongoing quality improvement and patient safety included the reduction of medical errors and failed to ensure the hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care, patient safety and all improvement actions are evaluated (refer to A-0309).The governing body failed to ensure the hospital planned appropriately and provided staff in adequate numbers, according to the unit's patient census, to ensure nursing staff responded to each individual patient's nursing needs in a safe and effective manner around the clock; (refer to A-0392). provide ongoing nursing assessments when a patient experiences changes in physical condition; complete ongoing assessments of patient responses to interventions; and notify physician of changes in patient's condition; (refer to A-0395).The governing body failed to ensure nursing staff followed their policy to update and keep a current nursing care plan; (refer to A-0396). The governing body failed to provide a designated professional responsible for maintaining the medical records (refer to A-0432).The governing body failed to develop and maintain an environment to ensure the safety and well-being for special needs of patients admitted to the psychiatric hospital (refer to A-0701). The governing body failed to ensure hospital staff maintain facility supplies and equipment to ensure safety and quality (refer to A-0724). The governing body failed to develop an active infection control system (refer to A-0749). The governing body failed to ensure the hospital establish in writing discharge planning policies and procedures planning (refer to A-0799, A-0800, A-0806, A-0807, A-0810, A-0811, A-0812, A-0818, A-0819, A-0820, A-0821, and A-0823). The governing body failed to ensure staff discharge patients when they transferred to another hospital for further care and/or treatment (refer to A-0837). The governing body failed to reassess its discharging process on an on-going basis. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs (refer to A-843).

Based on observation, document review, and staff interview the hospital failed to provide care in a safe setting to patients admitted to the hospital for 2 of 2 suicidal patients and 29 of 29 assaultive/violent patients in the MAPS A1 unit, 14 of 14 suicidal patients and 12 of 12 assaultive/violent patients in the MAPS A2 unit, 1 of 1 suicidal and 20 of 20 assaultive/violent patients in CCP unit B1, 3 of 3 suicidal patients and 25 of 25 assaultive/violent patients in the SSP unit B2, 24 of 24 suicidal patients and 19 of 19 assaultive/violent patients in the PLS unit C1, 6 of 6 suicidal patients and 15 of 15 assaultive/violent patients in the HOPE unit C2, and 17 of 17 suicidal patients and 5 of 5 assaultive/violent patients in the CSP unit EB by failing to :
- Identify potential risks and conduct surveillance in the physical environment according to the " Safety Management Plan " Policy;
- Provide non-suicide resistive shower and tub water control knobs, non-exposed plumbing on sinks and commodes, and non-hinged commode seats. The configuration of the water control knobs, exposed plumbing pipes, and hinged commode seats created a looping hazard (material or a device could be looped around the knobs or plumbing to be used for choking or strangulation) in all 30 bathrooms/shower rooms in seven of seven nursing units throughout the facility;
- Secure heavy furniture which could provide dangerous projectiles or could easily be maneuvered and positioned under a protruding device as potential for hanging;
- Remove metal closet doors with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard in all 138 patient rooms;
- Provide door handles that prevent an anchor point. The door handles created a potential ligature attachment point affecting all patients admitted to the hospital at risk for suicide;
- Secure pictures to the wall using tamper resistant screws or anchors. The picture frames have the potential to be used as a weapon on others affecting all patients admitted to the hospital at risk for harming themselves or others;
- Secure heating/cooling vents to the ceiling and air exchange vents to the wall with tamper resistant screws or anchors creating an anchor for hanging or used as a weapon affecting 16 hallways, 138 patient rooms, seven day halls, 30 bathrooms/shower rooms throughout the facility;
- Provide a non-tamper proof ceiling. The suspended ceiling with removable tiles expose pipes and wiring above the tiles that have the potential to provide a hanging, choking, or strangulation hazard in 132 patient rooms, 16 hallways, 4 comfort rooms, and seven day halls throughout the facility;
- Remove, replace, or cover electrical outlets. The electrical outlets could be accessed with the potential to create a fire or electrical shock in 138 patient rooms, 30 bathrooms/shower rooms, 16 hallways, 4 comfort rooms, and 7 day halls throughout the facility;
- Secure ceiling mounted florescent light fixtures. The light fixtures have the potential to provide an anchor for hanging in 138 patient rooms, 30 bathrooms/shower rooms, 16 hallways, 4 comfort rooms, and 7 day halls throughout the facility;
- Remove hospital gowns with string closers and fitted sheets with elastic from patient use. The strings and elastic have the potential to provide a hanging, choking, or strangulation risk for all patients at risk for suicide in seven of seven nursing units throughout the facility;
- Provide a barrier between the Mental Health Technician (MHT) station and patients in the day hall. Patients could reach the telephone and computer keyboard and cord to use for hanging, choking, or strangulation or as a weapon on three of seven patient units;
- Secure laundry soap in patient ' s laundry room in two of seven laundry rooms. Laundry soap, when ingested, could be harmful;
- Provide a patient lift for patients exceeding four hundred pounds. The lift had the potential for a fall hazard for one patient over four hundred pounds.

Refer to A-0144

- The hospital admits patients with diagnosis of schizophrenia (mental disorder that makes it hard to: tell the difference between what is real and not real; think clearly; have normal emotional responses; act normally in social situations, psychotic disorders (loss of contact with reality that usually includes: false beliefs about what is taking place or who one is (delusions) ; seeing or hearing things that aren't there (hallucinations)), depressive disorders, bipolar disorders (condition in which a person has periods of depression and periods of being extremely happy or being cross or irritable), anxiety disorders, impulse-control disorders (characterized by failure to resist a temptation, urge or impulse that may harm oneself or others), and suicidal or homicidal thoughts.

These deficient practices presented an immediate threat to the health and safety of the patients. The hospital administration was notified of the Immediate Jeopardy (IJ) on 1/14/15 at 3:35 pm. The IJ was not removed on exit 1/23/15.


The cumulative effect of the systematic failure to provide for the safety of patients resulted in the potential for harm to all patients admitted to the hospital at risk for suicide or harm to others.

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospitals Executive Compliance Committee and Performance improvement Committee (PI) failed to develop an ongoing program that shows measurable improvement in indicators for which there is evidence that will improve health outcomes and must measure analyze and track quality indicators that identify improvement projects for processes of care, hospital service and operations (refer to A-0273); failed to use data collection to identify opportunities for improvement and changes that will lead to improvement and must set priorities for its performance improvement activities that focus on problem prone areas (refer to A-0283); failed to include an ongoing program that shows measurable improvement in indicators for which there is evidence it will identify and reduce medical errors, measure and analyze and track adverse events in the pharmacy and failed to implement preventive actions and mechanisms that include feedback and learning throughout the hospital (refer to A-0286); failed to ensure all hospital departments and services participate in the QAPI (Quality Assurance and Performance Improvement) program and maintain and demonstrate evidence (refer to A-0308); and the hospital's governing body failed to ensure that an ongoing program for ongoing quality improvement and patient safety included the reduction of medical errors and failed to ensure the hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care, patient safety and all improvement actions are evaluated (refer to A-0309).

The cumulative effect of the systemic failure to identify improvement projects, to develop programs that focus on problem prone areas, to track medical errors, to ensure all hospital departments and services participate in the QAPI program, and the hospital's governing body's failure to ensure comprehensive and ongoing QAPI program that focused on quality of care and patient safety resulted in the hospital's inability to provide care in a safe effective manner.

Based on medical record review, document review, and staff interview the hospital's nursing staff failed to: follow the policy for supervision and evaluation of care for each patient; provide ongoing nursing assessments when a patient experiences changes in physical condition; complete ongoing assessments of patient responses to interventions; and notify physician of changes in patient's condition; (refer to A-0395). The hospital failed to ensure nursing staff followed their policy to update and keep a current nursing care plan; (refer to A-0396). The failure of nursing service to ensure they supervised and re-evaluated patient ' s current physical condition and update the current nursing care plan resulted in an Immediate Jeopardy identified by the Centers for Medicare/Medicaid Services on 1/23/15 at 11:30am and not removed on exit 1/23/15.

The cumulative effect of the systemic failure to: supervise and evaluate the care for each patient; provide ongoing nursing assessments when patients experience a change in condition; complete ongoing assessments of patient responses to interventions; notify the physician of changes in the patient ' s condition; and keep a current nursing care plan after a patient ' s physical condition changes resulted in a patient ' s death and placed all patients admitted to the hospital at risk.

Based on observation, document review, and staff interview the hospital failed to develop and maintain an environment to ensure the safety and well-being for special needs of patients admitted to the psychiatric hospital (refer to A-0701) and failed to maintain facility supplies and equipment to ensure safety and quality (refer to A-0724).

The cumulative effect of the systematic failure to develop and maintain an environment to ensure the safety and well-being for special needs of patients admitted to the psychiatric hospital and maintain facility supplies and equipment resulted in the hospital's inability to provide care in a safe and effective manner.

Based on staff interview, the hospital failed to develop in writing specific discharge planning policies and procedures (refer to A-0799) and the hospital failed to discharge patients when they transferred the patient to another hospital for further care and/or treatment (refer to A-0837).


Findings include:


- The hospital failed to provide discharge planning policies and procedures as requested on entrance. The hospital lacked a policy/procedure regarding identification of patients in need of discharge planning. The hospital lacked a policy/procedure regarding discharge planning evaluations. The hospital lacked a policy/procedure that specifies who can develop a discharge evaluation.The hospital lacked a policy/procedure that specifies that the discharge evaluation is completed in a timely manner, to avoid unnecessary delays in discharge. The hospital lacked a policy/procedure that specifies the hospital discusses the results of the discharge evaluation with the patient or their representative.The hospital lacked a policy/procedure that specifies the hospital must include the discharge planning evaluation in the patient's medical record for use in establishing an appropriate discharge plan.The hospital lacked a policy/procedure that specifies that a registered nurse, social worker, or other appropriately qualified personnel must develop, or supervise the development of, a discharge plan. The hospital lacked a policy/procedure that specifies in the absence of a finding by the hospital that a patient needs a discharge plan; the patient's physician may request a discharge plan.The hospital lacked a policy/procedure that specifies the hospital must arrange for the initial implementation of the patient's discharge plan. The hospital as needed will counsel the patient and family members or interested person to prepare them for post-hospital care.The hospital lacked a policy/procedure that specifies the hospital mst reassess the patient's discharge plan if there are factors that may affect continuing care needs or the appropriateness of the discharge plan.The hospital lacked a policy/procedure that specifies the hospital must include in the discharge plan a list of home health agencies or skilled nursing facilities that are participating in the Medicare program. The reassessment must include a review of discharge plans to ensure that they are responsive to discharge needs.


- Licensed Social Worker staff S, interviewed on 1/13/15 explained the hospital does not have "formal" policies and procedures for discharge planning.


The cumulative effect of the systematic failure to ensure the facility met the requirements to have written discharge planning policies and procedures and discharge patients when they transferred to another hospital for further care and/or treatment and had the potential to put all patients in need of discharge planning at risk for inadequate services and care after hospitalization.

Based on observation, interview and record review the facility failed to provide care in a safe setting to patients admitted to the psychiatric hospital for 2 of 2 suicidal and 29 of 29 assaultive/violent patients in the MAPS unit A1, 14 of 14 suicidal and 12 of 12 assaultive/violent patients in the MAPS unit A2, 1 of 1 suicidal and 20 of 20 assaultive/violent patients in CCP unit B1, 3 of 3 suicidal and 25 of 25 assaultive/violent patients in the SSP unit B2, 24 of 24 suicidal and 19 of 19 assaultive/violent patients in the PLS unit C1, 6 of 6 suicidal patients and 15 of 15 assaultive/violent patients in the HOPE unit C2, and 17 of 17 suicidal patients and 5 of 5 assaultive/violent patients in the CSP unit EB.

The hospital census was 181. The hospital had 67 current patients assessed as a suicidal risk and 125 current patients assessed as assaultive/violent risk.

Findings include:

- The hospital ' s form " Nursing Needs Assessment " states (in part): The data from this form will assist in evaluating the adequacy of 24-hr nursing personnel staffing, based on the identified care needs and acuity level of the patients ... This form shall be completed for each identified ward of the hospital by a registered profession nurse who has clinical knowledge of the patients ...Data should reflect the patients ' current needs/behaviors. V. Psychiatric Nursing Care Problems 1. Assaultive/violent: Number of patients who are: 1. Potentially assaultive (has occasionally demonstrated during hospitalization 2. Actively assaultive (has evidence physically/verbally within last 48 hrs. 2. Suicidal: Number of patient who are ...1. Low risk suicidal (requires some protection against impulses 2. Intermediate risk suicidal (high potential for self-injury; requires close observation) 3. Acute risk suicidal (in immediate danger of suicide) VII. Observations/Supervision: Number of patients who are on: 1. 1:1 supervision 2. Under constant/line-of-sight supervision 3. Every 15-30 minute supervision checks 4. Every 3-4 hour supervision checks.

- Risk Manager Staff B interviewed on 1/12/15 at 2:20 pm indicated that the " Nursing Needs Assessment " form is completed daily by a nurse on each unit to help determine their staffing needs.

The hospital ' s policy titled " Therapeutic Observational Status " dated 12/10/14 provided the following guidance (in part): The purpose of Therapeutic Observational Status is to maintain the safety of the patient and others. ...At admission and ongoing throughout hospitalization, patients are assessed for the level of risk of danger to self or others. Therapeutic Observational Status Categories: Red: 1. Unit Observation with 1:1 (Red High Alert) a. 1:1 requires a specific assigned clinical staff member to have constant 1:1 supervision of the patient. 2. Unit Observation (Red-High Alert) 15 minute Check b. The R.N. assigns staff to complete the Timed Check Sheet ...by entering the time of the check, initials, and appropriate codes at frequent, irregular intervals at least every fifteen minutes. 3. Unit Observation (Orange-Moderate Alert) a. Patients ...must remain on the unit with hourly checks being completed by Nursing Staff. 4. Escorted Observation Status (Moderate Alert) Yellow 2. A patient is accompanied by staff any time he/she leaves the building. 5. Standard Observation (Green) 1. A patient may leave the unit unescorted for up to 60 minutes during " Free Time " and must stay within the approved hospital boundaries.

The hospital ' s " Patient Handbook " dated December 2014 states " Patients or their legal guardians have the following rights: To receive care in a safe setting " .

- The hospital ' s policy " Safety Management Plan " dated 7/23/12 reviewed on 1/22/15 at 3:00 pm directed, " ...The Environment of Care Committee (EOCC) conducts quarterly rounds of buildings, grounds, equipment, and occupants to: c. Identify safety risks d. Conduct hazard surveillance. C. Safety Planning 1. The EOCC participates in performance improvement activities...monitoring performance regarding actual or potential risks ...Safety and Hazard Assessment, Identification of Processes, identify opportunities for improvement in order to ...establish and maintain a physical environment free of hazards ... " H. Environment 5. Facilities and grounds are maintained through collaborative efforts of Facility Services and program staff in order to create an environment that is comfortable, safe, clean and attractive. 6. Furnishings and equipment provided are safe and in good repair ...8. The EOCC reviews safety concerns submitted by employees, patient, visitors or other hospital committees/teams. The Director of Operations or designee, with the assistance of members of the EOCC, a. Directs ongoing performance improvement activities related to the environment of care; b. Directs the integration of environment of care monitoring and response activities into the hospital wide patient safety program; c. Reviews summaries of deficiencies, problems, failures and/or user errors related to managing, i. Safety; ii. Security; v. Fire Safety.

Staff BB, Assistant Superintendent, interviewed on 1/22/14 at 2:00 pm was unable to provide documentation of any findings from the EOCC addressing safety issues or any potential or actual risks or hazards identified in the physical environment of the hospital.

Managing and Preventing Symptoms (MAPS) unit (Individuals who are unable to manage behaviors and care for their well being due to an acute impairment in the ability to perceive reality) A1 building observed on 1/12/15 between 2:00 pm and 4:30 pm and 1/20/15 between 3:15 pm to 4:20 pm showed the following:

- The MAPS unit A1 had a total of 30 beds with 29 current patients (2 patients at risk for suicide (2 intermediate risk suicidal) and 29 Assaultive/violent patients (27 potentially assaultive/violent and 2 actively assaultive/violent). Therapeutic Observational Status for the 29 patients revealed: Red (15 minute) - 2 patients; Orange - 11 patients; Yellow - 16 patients.

- Hallway A and hallway B revealed a total of 19 patient rooms including eight private and 11 semi-private rooms. All 19 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 2 of 2 patients on the unit assessed as a suicide risk. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provide a hanging, choking, or strangulation for 2 of 2 patients on the unit assessed as a suicide risk. All 19 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. All 19 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. All 19 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 19 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 19 patient rooms had one metal ceiling heating/cooling vent easily removed and one metal air exchange vent secured to the wall with non-tamper proof screws potentially creating an anchor for hanging or use as a weapon. All 19 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic has the potential to provide a hanging, choking, or strangulation risk for 2 of 2 patients on the unit assessed as a suicide risk.

- Observation of room 143 revealed a displaced ceiling tile and room 144 revealed a missing ceiling tile. Above the ceiling tiles are plumbing and electrical wiring. Access to the plumbing pipes and electrical wiring has the potential to provide a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The shower room on hallway B revealed a metal vent with missing screws and room 143 revealed a displaced vent. The metal vent could easily be removed and create an anchor for hanging or be used as a weapon.

- The Day Hall (the units living and dining area) revealed a suspended ceiling with approximately 20-inch by 20-inch ceiling tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The Day Hall contained two water fountains attached to the wall that could be pulled off of the wall and used for a weapon. Two telephones for patient use located beside the nurses station had a 29 inch cord providing a potential hazard for hanging, choking, or strangulation affecting 2 of 2 patients on the unit assessed as a suicide risk. The Day Hall had eight electrical outlets easily accessible with the potential to create a fire or electrical shock. The Day Hall had ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The day hall had eight metal ceiling vents easily removed creating an anchor for hanging or use as a weapon. One wall had four cabinets with C handles with the potential hazard for hanging, choking, or strangulation for 2 of 2 patients on the unit assessed as a suicide risk. The Mental Health Technician (MHT) station (desk area) in the day hall failed to have an adequate barrier enclosing the area from patients. The MHT station measured 42 ½ inches tall and had a 12 ¾ inch wide counter. Patients could easily reach the telephone and the telephone cord could be used as a strangulation device as well as the computer keyboard and cord to be used as a weapon.

- MHT staff O interviewed on 1/13/15 at 2:00 pm indicated patients can and have reached over the MHT station to obtain the phone and keyboard.

- The patient bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal vent in the ceiling tiles and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or use as a weapon. The bathroom had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The shower room on hallway A had a bathtub with a water temperature dial with a 3 inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The plumbing is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The shower room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The shower room had one metal vent in the ceiling tiles easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. Hallway A had four electrical outlets easily accessible with the potential to create a fire or electrical shock.


- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock or electrical shock. The comfort room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The comfort room had one eraser board and five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. Three sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had one metal vent with non-tamper proof screws and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathrooms had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic inserts covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway B had a bathtub with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. The shower room had one sink with a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had one metal vent in the ceiling tiles easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets with the potential to create a fire or electrical shock. The shower room had three ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway B revealed six ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway B has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as suicidal risk. Hallway B had four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Managing and Preventing Symptoms (MAPS) unit A1 building observed on 1/13/15 at 2:00 pm revealed a patient in the day hall wearing a hospital gown with strings for securing the gown. Mental Health Technician (MHT) staff D interviewed on 1/13/15 at 2:00 pm revealed patients wear hospital gowns when doing laundry and some wear them at night. Staff D acknowledged the use of hospital gowns with strings and the fitted bed sheets with elastic edging had the potential to be used by patients as a means of hanging or strangulation. Staff D acknowledged that all patients on the unit can request gowns or sheets from staff members regardless of whether they are a suicidal risk or at risk to harm others.

Managing and Preventing Symptoms (MAPS) unit (Individuals who are unable to manage behaviors and care for their well-being due to an acute impairment in the ability to perceived reality) A2 building observed on 1/13/15 between 11:20 am to 12:30 pm and 1/20/15 between 4:20 pm and 5:15 pm showed the following:

- The MAPS unit A2 had a total of 30 beds with 24 current patients (14 patients at risk for suicide (9 low risk suicidal; 4 intermediate risk suicidal; 1 acute risk suicidal risk) and 12 Assaultive/violent patients (11 potentially assaultive/violent; 1 actively assaultive/violent). Therapeutic Observational Status for the 24 patients revealed: Red (1:1) - 1 patient; Red (15 minute) - 4 patients; Orange - 9 patients; and Yellow-10 patients.

- Hallway A and hallway B revealed a total of 18 patient rooms including six private and 12 semi-private rooms. All 18 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 14 of 14 patients assessed at risk for suicide on the unit. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 18 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 18 patient rooms had one metal ceiling vent easily removed and one metal vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. All 18 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic on the fitted sheets provide a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit.


- The Day Hall (the units living and dining area) revealed a suspended ceiling with approximately 20-inch by 20-inch ceiling tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The Day Hall contained two water fountains attached to the wall that could be pulled off of the wall and used for a weapon. Two telephones for patient use located beside the nurses station had a 29 inch cord providing a potential hazard for hanging, choking, or strangulation affecting 14 of 14 patients assessed at risk for suicide on the unit. The Day Hall had eight electrical outlets easily accessible with the potential to create a fire or electrical shock. The Day Hall had 17 ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The day hall had six cabinet doors with C handles with the potential hazard for hanging, choking, or strangulation. The Mental Health Technician (MHT) station (desk area) in the day hall failed to have an adequate barrier enclosing the area from patients. The MHT station measured 42 ½ inches tall and had a 12 ¾ inch wide counter. Patients could easily reach the telephone and the telephone cord which could be used as a strangulation device as well as the computer keyboard and cord for use as a weapon.

- The patient bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The bathroom had one metal vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathroom had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway A had a bathtub and shower stall with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with hinged seat and exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The toilet seat and exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The shower room had two ceiling mounted florescent light fixtures with a plastic insert easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. Hallway A had five electrical outlets easily accessible with the potential to create a fire or electrical shock.


- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock. The comfort room had five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. Three sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients on the unit assessed as a suicide risk. The bathroom had one metal ceiling vent easily removed from the tiles and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathrooms had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic inserts covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway B had a bathtub with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with a hinged seat and exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 7 inches from the wall. The shower room had one sink with a 10-inch protruding water faucet. The toilet seat and exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The bathroom had one metal vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets with the potential to create a fire or electrical shock. The shower room had three ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway B revealed six ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients on the unit assessed as a suicide risk. Hallway B had four electrical outlets easily accessible with the potential to create a fire or electrical shock. Hallway B had three pictures attached to the wall with non-tamper proof screw.

Continuing Care (CCP) unit (Individuals whose psychiatric symptoms have contributed to their involvement with the courts; and individuals who are referred by law enforcement for Detox, care and treatment (DCT)) B1 building observed on 1/12/15 between 2:00 pm and 4:30 pm showed the following:

- The CCP unit B1 had a total of 30 beds with 28 current patients - (1 patient assessed as risk for suicide (1 low risk suicidal) and 20 patients assessed as risk for assaultive/violent (16 potentially assaultive/violent and 4 actively assaultive/violent). Therapeutic Observational Status for the 28 patients revealed: Red (15 minute) - 3 patients; Orange - 12 patients; Yellow - 8 patients and Green - 5 patients.

- Hallway A and hallway B revealed a total of 18 patient rooms including seven private and 11 semi-private rooms. All 18 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 1 of 1 patient on the unit. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provides a hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 18 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 18 patient rooms had one metal ceiling vent easily removed and one metal vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. All 18 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic on the fitted sheets provide a hanging, choking, or strangulation hazard for 1 of 1 patient assessed at risk for suicide on the unit.

- The bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 1 of 1 suicidal patients on the unit. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal ceiling vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathroom had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The shower room on hallway A had a bathtub with a water temperature dial with a 3 inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. The shower room two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal ceiling vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. Hallway A had four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock. The comfort room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The comfort room had one eraser board and five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The pipi

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospitals Executive Compliance Committee and Performance Improvement Committee (PIC) failed to develop an ongoing program that shows measurable improvement in indicators for which there is evidence that will improve health outcomes and must measure analyze and track quality indicators that identify improvement projects for processes of care, hospital service and operations. Failure to incorporate previously identified quality indicators and measure, analyze, and track high risk and problem prone areas including nursing assessments and services, infection control, pharmacy, and ligature risks has the potential to affect health outcomes, patient safety, and quality of care for all patients admitted to the hospital.

Findings include:

- Policy titled "Performance Improvement Plan (PI-1.0)" dated 7/30/12 reviewed on 1/27/15 at 12:20 pm directed staff," ...performance improvement activities help us identify and implement opportunities ..."

- The hospitals policy "Safety Management Plan" reviewed on 1/22/15 at 3:00 pm directed, "...The Environment of Care Committee participates in performance improvement activities...monitoring performance regarding actual or potential risks ...Safety and Hazard Assessment, Identification of Processes, of this procedure outlines processes used to identify opportunities for improvement in order to ...establish and maintain a physical environment free of hazards ..."

- Review of the statement of deficiency for two surveys by CMS State Agency on 10/30/14 and Joint Commission survey on 12/23/14 identified the hospital's high risk, problem prone processes that resulted in three immediate jeopardy's (IJ's). The 10/30/14 survey resulted in two IJ's involving nursing services and pharmacy. The nursing IJ identified the nursing staff lacked appropriate physical assessments for medical interventions that resulted in harm to a patient. The pharmacy IJ identified the pharmacy failed to identify patients on high-risk medications and failed to obtain medication clarifications in a timely matter that resulted in harm to a patient. The Joint Commission survey on 12/23/14 resulted in a physical environment IJ due to ligature risks, (anchor points that included: beds, cords that had length enough to secure them to the frame of the bed, bathrooms and fixtures with anchor points, and oxygen tubing and power cords that can be used for strangulation/hanging). The survey on 10/30/14 identified problems with the condition of participation for infection control including hand hygiene, laundry handling, cleaning, and point of care testing.

- The Performance Improvement Committee (PIC) minutes reviewed on 1/28/15 at 1:50 pm revealed minutes for meetings held on 10/17/14 and 11/6/14 and lacked minutes for December or January. The minutes revealed the hospital PIC lacked quality data or discussion of indicators relating to nursing assessments, pharmacy, infection control, or patient safety related to ligature risks and the committee failed to meet after the facility had knowledge of issues affecting patient outcomes.

- The PIC's project data reviewed on 1/22/15 at 2:00 pm with administrative staff BB revealed "Quality Indicator Tracer" and "Patient Safety Tracers" and lacked evidence the hospital incorporated data collection on physical nursing assessments, infection control, pharmacy, and ligature risks.

- Performance Improvement program review on 1/22/15 between 2:00 pm to 3:00 pm revealed the PIC lacked evidence of data collection from nursing services, environmental assessments and failed to measure, analyze, and track data from the pharmacy and therapeutics committee.

Administrative staff BB interviewed on 1/22/15 between 2:00 and 3:00 pm verified the hospital lacked evidence of data collection and analysis for nursing assessments, pharmacy services, and environmental assessments recently identified as high risk and problem processes.

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospital's Director of Performance Improvement (PI) failed to use data collection to identify opportunities for improvement and changes that will lead to improvement and set priorities for its performance improvement activities that focus on problem prone areas that affected health outcomes, patient safety and quality of care.

Findings include:

- Policy titled "Performance Improvement Plan (PI-1.0)" dated 7/30/12 reviewed on 1/27/15 at 12:20 pm revealed the Director of Performance Improvement (PI) is available to provide consultation in data issues sources, collection, verification, interpretation, presentation and report writing. The Director of PI assures monthly reporting to the PI council and assures projects are on track. "High risk, high volume, and problem prone processes are considered when determining improvement priorities." The Performance Improvement Council "Assesses the status and performance improvement projects through timely reports", and "Monitors implementation of action plans from Failure Modes and Effects analysis."

- The Performance Improvement Committee's project data reviewed on 1/22/15 at 2:00 pm with administrative staff BB revealed "Quality Indicator Tracer" and "Patient Safety Tracers" and lacked data and project improvement activities for nursing assessments, pharmacy services, and environmental assessments recently identiied as high risk, problem prone processes.

Administrative staff BB interviewed on 1/22/15 between 2:00 and 3:00 pm verified the hospital lacked evidence of data collection and analysis for nursing assessments, pharmacy services, and environmental assessments recently identified as high risk and problem processes.

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospital's Executive Compliance Committee and Performance improvement Committee (PI) failed to include an ongoing program that shows measurable improvement in indicators for which there is evidence it will identify and reduce medical errors, measure and analyze and track adverse events in the pharmacy and failed to implement preventive actions and mechanisms that include feedback and learning throughout the hospital.. Failure to measure, analyze, and track high risk and problem prone areas has the potential to affect health outcomes, patient safety, and quality of care for all patients admitted to the hospital.

Findings include:

- Policy titled "Performance Improvement Plan (PI-1.0)" dated 7/30/12 reviewed on 1/27/15 at 12:20 pm revealed the Director of Performance Improvement (PI) is available to provide consultation in data issues sources, collection, verification, interpretation, presentation and report writing. The Director of PI assures monthly reporting to the PI council and assures projects are on track. "High risk, high volume, and problem prone processes are considered when determining improvement priorities." The Performance Improvement Council "Assesses the status and performance improvement projects through timely reports", and "Monitors implementation of action plans from Failure Modes and Effects analysis."

- Pharmacy Director staff QQ Interviewed on 1/14/15 at 1:50 pm revealed the pharmacy is currently monitoring the types and amounts of medication clarification needed, medication errors, monitoring high-risk medications, and medications requiring laboratory monitoring for patient safety. Staff QQ revealed they report to the Pharmacy and Therapeutics committee and Risk management.

- The Performance Improvement Committee minutes reviewed on 1/28/15 at 1:50 pm revealed the committee met on 10/17/14 and 11/6/14. The hospital lacked evidence of meeting minutes from the PI committee for December and January. The meeting minutes dated 11/6/14 failed to include data or discussion related to the identified problem prone areas in nursing assessments, pharmacy services, found.

Administrative staff BB, Performance Improvement Committee designee, interviewed on 1/22/15 in their office between 2:00 and 3:00 pm verified the hospital ' s PI Committee is scheduled to meet on a monthly basis. Staff BB lacked evidence of data and analysis collection concerning problems identified during the 10/30/14 survey for pharmacy services. Staff BB confirmed the committee failed to meet because the staff in charge of keeping the data for the performance improvement committee left their employment at the hospital in October.

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospital's governing body failed to ensure all hospital departments and services participate in the QAPI (Quality Assurance and Performance Improvement) program and maintain and demonstrate evidence of its QAPI program. The failure to ensure all hospital services maintain and demonstrate evidence of participation in the QAPI program placed all patients admitted to the hospital as risk for harm.

Findings include:

- The Performance Improvement Committee data, analyis and meeting minutes reviewed on 1/28/15 at 1:50 pm lacked evidence of data and analysis from the hospital departments of laundry, dietary and laboratory. The minutes for 10/17/14 and 11/6/14 failed to include data or discussion relating to laundry, dietary, and laboratory. The committee lacked evidence of data collection and meeting minutes in December.

- Laundry staff HH interviewed on 1/13/15 at 8:10 am indicated the laundry does not have a QAPI project.

- Dietary staff OO interviewed on 1/13/15 at 11:30 am indicated they lack a QAPI project and do not send reports to QAPI.

- Laboratory Director staff PP interviewed on 1/13/15 at 9:30 am indicated they have not reported data to QAPI.

The plan failed to include all departments in their QAPI program.

Based on the Performance Improvement Committee plan review, meeting minutes, and staff interview the hospital's governing body failed to ensure that an ongoing program for ongoing quality improvement and patient safety included the reduction of medical errors and failed to ensure the hospital wide quality assessment and performance improvement efforts addressed priorities for improved quality of care, patient safety and all improvement actions are evaluated. Failure to develop and maintain an ongoing program for quality improvement and patient safety, identify and address priortities for improved quality of care and patient safety previously identified has the potential to affect health outcomes, patient safety, and quality of care for all patients admitted to the hospital.

- Policy titled "Performance Improvement Plan (PI-1.0)" dated 7/30/12 reviewed on 1/27/15 at 12:20 pm revealed the Director of Performance Improvement (PI) is available to provide consultation in data issues sources, collection, verification, interpretation, presentation and report writing. The Director of PI assures monthly reporting to the PI council and assures projects are on track. "High risk, high volume, and problem prone processes are considered when determining improvement priorities. "The Performance Improvement Council "Assesses the status and performance improvement projects through timely reports", and "Monitors implementation of action plans from Failure Modes and Effects analysis."

- The Performance Improvement Committee's project data reviewed on 1/22/15 at 2:00 pm with administrative staff BB provided "Quality Indicator Tracer" and "Patient Safety Tracers" that lacked data and project improvement activities for previously identified problem prone process of nursing services, pharmacy services, and and patient safety.

Administrative staff BB interviewed on 1/22/15 between 2:00 and 3:00 pm verified the hospital lacked evidence of data and analysis collection for nursing services, pharmacy services, and data from patient safety ligature risk assessments identified as high risk and problem processes.

Based on observation, policy review and interviews the hospital failed to plan appropriately and provide staff in adequate numbers, according to the unit's patient census, to ensure nursing staff responded to each individual patient's nursing needs in a safe and effective manner around the clock for one of 32 patient's sampled (Patient #1) and 2 of 7 nursing units (PLS/C1 and HPE/C2). This deficient practice resulted in the death of patient #1 and had the potential to cause harm to all patients due to inadequate staffing for the patient acuity and census on the psychiatric unit.

Findings:

- The hospital's policy titled " Nursing Services (LD-3.21) dated 8/13/12" reviewed on 1/29/15 at 9:45 am directed" ...Staffing is reviewed on an ongoing basis to ensure appropriate staff mix and number." and "... nursing staff will be evaluated and adjusted by the nursing supervisor or designee ...A core number of staff per skill level has been determined per unit, per shift as outlined below as related to acuity ...Hope (C2) unit/Positive Living Skills (C1) unit (PLS), CAPACITY & OVERFLOW, 30 plus three."

- Review of "Core Staffing" on 1/21/15 listed the PLS/C1and Hope/C2 unit nurse staffing requirements as the following:
* Day, (AM) shift= 5 staff that includes one registered Nurse (RN), one Licensed Practical Nurse/Licensed Mental Health Technician (LPN/LMHT), and three (Mental Health Technicians/ Mental Health Technician Trainee)MHT/MHTT:
* Afternoon/evening (PM) shift=5 staff (one RN, one LPN, and three MHT/MHTT):
* and night shift=4 staff (one RN and three MHT/MHTT).

- Review of the hospital's "Staffing Schedule" on 1/21/15 listed patient census on PLS/C1 unit:
* 12/4/14 patient census as 31,
* 12//5/14 patient census as 31,
* 12/6/14 patient census as 32,
* 12/7/14 patient census as 32,
* 12/8/14 patient census as 30,
* 12/9/14 patient census as 29,
* and 12/10/14 patient census as 28.

- Patient #1's medical record review on 1/13/15 revealed an admission date of 11/9/14 to the PLS unit (identified as a 30 bed unit) with an Axis I diagnosis of major depressive disorder (MDD), moderate, recurrent, and an Axis III diagnosis of hypertension (HTN). Weekly nursing assessment dated 12/4/14 documented patient #1's "Elimination" assessment as, "no reported problems". The assessment lacked yes; no; or descriptive responses to the following items on the physical assessment: Bowels sounds present X 4 quadrants; Abdomen-hard, distended, pain; Nausea/vomiting/heartburn; Constipation/diarrhea; difficulty chewing or swallowing; and date of last bowel movement.

Supervisor registered nursing staff H on 12/6/16 at 8:00am documented they notified the physician and received a one-time order for "Mag Citrate (a laxative) " and "docusate sodium (a laxative).

Medical record review lacked any nursing documentation of follow up nursing assessment of the patient's gastrointestinal system including bowel sounds, patient complaints of constipation, pain or distention, or bowel movements on 12/7/14, 12/8/14, and 12/9/14. Nursing staff J, on 12/10/14 at 7:58 pm documented they received a physician telephone order for Mag Citrate for constipation. Nursing staff J obtained a physician's order for Milk of Magnesia (a laxative) for constipation on 12/10/14 at 11:20 pm. The medical record lacked evidence of a complete gastrointestinal assessments that included listening to the bowel sounds of the abdomen, observation/feeling the abdomen, documenting bowel movements and vital signs including the patient's temperature prior to calling medical staff for the patient's continued complaint of constipation. The medical record lacked evidence of nursing's gastrointestinal assessment after the administration of the Milk of Magnesia medication that included bowel sounds, observation/feeling the abdomen, a bowel movement, and vital signs or notified the physician regarding the patient's response to the interventions.

Supervisory nursing staff H documented on 12/11/14 at 12:06 pm in patient #1's medical record that the patient was "unable to respond to her, eyes rolling back into head, abdomen was extremely distended and hard." Nursing staff documented they notified the medical staff and the physician ordered patient #1 transferred by ambulance to hospital B emergency department (ED) at 11:50 am for possible bowel impaction. The patient expired at hospital B at 2:40 pm, two hours and fifty minutes later and the patient's cause of death was ileus (the absence of movement in the intestine) with sepsis (infection).

Review of the "Nurse Staffing Schedule" from 12/4/14 to 12/10/14 revealed the following:
1) On 12/4/14 evening shift, a MHT from the day shift worked over until 4:30pm on the evening shift until 11:pm.
2) On 12/6/14 evening shift, a MHT from Hope-C2 was pulled to worked the PLS/C1 unit
3) On 12/7/14 evening shift, a C-1 day shift RN, volunteered to work a double shift until 11:00pm and an evening shift RN from C2 was pulled to work the C1 unit until 11:00pm.
4) On 12/10/14 a morning/day shift (AM) MHT from the Managing and Preventing Symptoms (MAPS) A-I unit worked C-1 to provide patient care.

Nursing supervisor staff H interviewed on 1/13/15 at 1:30 pm reported they were on duty 12/6/14 when patient #1 complained of constipation. Staff H verified they failed to document a complete nursing gastrointestinal assessment that included the bowel sounds, observation/feeling the abdomen, patient bowel movements, vital signs, failed to complete written progress notes for the newly ordered mag citrate and docusate sodium laxative and a nursing assessment with results of the laxative medication. Staff H confirmed the medical record lacked evidence of a nursing assessment of the patient's abdomen and elimination status including bowel sounds, observation/feeling the abdomen, bowel movements, or vital signs between the dates of 12/6/14 to 12/10/14 when nursing staff obtained another order for Mag citrate due to patient #1's continued complaint of constipation. Staff H shared the high census of patients on the unit and patient's medical needs contributed to nursing's failure to document assessments and follow up assessments in the medical record.

Nursing staff J interviewed on 1/13/15 at 3:30 pm shared they worked a double shift the evening of 12/10/14 and the night shift into the morning of 12/11/14. Staff J acknowledged at shift report (day to evening shift) nursing had failed to communicate to them patient #1's complaints of constipation. Staff J verified the high census on the unit contributed to failing to communicate the patient's medical concern related to the constipation and the lack of time to document nursing assessments in patient #1's medical record.

Administrative staff B interviewed by phone on 1/27/15 verified the nursing department follows the "Core Staffing" grid to staff the units shifts. Staff B revealed the PLS-C1 unit opened 4/14 with a 30 bed capacity. Staff B shared the nursing staffing documents from 12/4/14 to 1/19/15 lists each nursing unit census as of midnight on the date documented and shared the MHT assigned to complete "ligature rounds" are not counted as a nursing care staff member for the shift.

Review of " Core Staffing " listed the PLS/C1and Hope/C2 unit nurse staffing requirements as the following:
* Day, (AM) shift= 5 staff that includes one registered Nurse (RN), one Licensed Practical Nurse/Licensed Mental Health Technician (LPN/LMHT), and three (Mental Health Technicians/ Mental Health Technician Trainee)MHT/MHTT:
* Afternoon/evening (PM) shift=5 staff (one RN, one LPN, and three MHT/MHTT):
* and night shift=4 staff (one RN and three MHT/MHTT).
The one MHT assigned to ligature rounds is not to be included in their count for meeting their "core" staffing requirement.

- Observation on 1/21/15 at 8:45 am revealed unit HPE C-2 lacked hospital staff in the dayroom between 8:55 am and 9:05 am and again from 9:06 am to 9:14 am.

MHT staff GG interviewed on 1/21/14 at 9:15 am acknowledged they do not have enough staff on the unit right now. Staff GG revealed one MHT with a patient in the seclusion room, one MHT currently assigned to ligature risk rounds, and one MHT with a patient in physical therapy. Staff GG reported being the only MHT available on the unit at this time.

Based on record review, document review and staff interview, the hospital failed to: ensure nursing staff supervised and evaluated the care provided for each patient; provide ongoing nursing assessments when patients experience a change in condition; complete ongoing assessments of patient responses to interventions; notify the physician of changes in the patient ' s condition for one of 32 sampled patients (Patient #1) who reported physical complaints.

The failure to ensure nursing services supervised and completed an evaluation and assessment, re-assessed and notified the physician of the results of the ordered interventions, and to notify the physician of changes in the patient ' s condition places all patients admitted to the hospital with medical issues or who develop a medical issues/physical changes during their admission at risk for harm or death.

Findings included:

- Policy titled " Nursing Services (LD-3.21), Organization Procedures Manual, effective date August 13, 2012 " reviewed on 1/15/15 stated the " Nursing Services mission is through utilization of best practices in the delivery of standards of nursing care and collaboration with individuals, families and the community. " The nursing policy directed nursing staff to care for the patient from admission through discharge with the nursing process of data collection, assessment, planning, interventions and ongoing evaluation. The policy directed nursing to complete an initial assessment and nursing care plan at the time of admission and continue to develop and modify the care plan as needed throughout the patient ' s admission. The policy listed the Program Nurse Manager as the responsible member for the supervision of direct and indirect patient care of the nursing units/shifts. The nurse manager ' s responsibility includes safe, adequate, 24 hour nursing coverage of nursing units and the implementation of standards of nursing practice. The Nurse Senior (R.N. senior) is responsible for providing direction and monitoring of assessment skills of unit nursing staff so all aspects of patient care based on sound nursing practice and treatment.

- Policy titled, " Assessment (PC-2.0), Effective Date: November 24, 2014, " reviewed on 1/15/15 stated that initial and ongoing assessments are crucial to determine the appropriate care, treatment and services needed to meet the patients individualized needs that may change during the course of hospitalization. Under, " G, 4. RN/LPN will conduct a. A weekly reassessment of the patients physical ...condition and will document on the Nurses Assessment/Progress Note and Nursing Physical Reassessment. b. A Nursing Physical Reassessment any time there is a Change in Condition. " ... A Change in Condition is a clinical important deviation from a patient ' s baseline in physical, cognitive, behavioral, or functional domains. " Clinically important " means a deviation that, without intervention, may result in complications or death. "

- The " Davis Drug Guide for Nurses, 2014 " reviewed on 1/27/15 listed " Magnesium Laxatives magnesium citrate " as a laxative, with a time/action of within three to six hours. The drug guide directed nursing staff for the following; " Nursing Implication- Assessment; Assess patient for abdominal distention, presence of bowel sounds and usual pattern of bowel function. Assess color, consistency, and amount of stool produced ... Follow all oral laxative doses with a full glass of liquid to prevent dehydration and for faster effect. Do not administer at bedtime or late in the day. "

- Patient #1 ' s medical record review on 1/13/15 revealed an admission date of 11/9/14 with an Axis I diagnosis of major depressive disorder (MDD), moderate, recurrent, and an Axis III diagnosis of hypertension (HTN). Patient #1 reason for admission listed; suicidal ideation, hitting their head, and wanting to jump out of a moving vehicle. The plan included a medication treatment of Trazodone (used for the treatment of anxiety and insomnia) 150mg every evening at bedtime and Zyprexa (used for treatment of psychosis (loss of contact with reality that usually includes: false beliefs about what is taking place or who one is (delusions) ; seeing or hearing things that aren't there (hallucinations)) and bi-polar (condition in which a person has periods of depression and periods of being extremely happy or being cross or irritable) 10mg two times a day. The physician ' s admission physical examination recorded the vital signs blood pressure of 125/86, pulse 93, documented the abdomen as non-distended and the patient denied problems with appetite or elimination. Nursing assessment on 11/9/14 indicated patient ' s appetite and diet adequate and no complaints of problems noted regarding elimination status. Weekly nursing assessment dated 11/16/14 documented patient #1 ' s " Elimination " assessment as " no known issues. " The medical record lacked evidence of a weekly nursing assessment for patient #1 on 11/23/14. A nursing assessment completed on 11/27/14 (four days late) documented an assessment of the gastrointestinal system and listed date of last bowel movement as 11/25/14. Weekly nursing assessment dated 12/4/14 documented patient #1 ' s " Elimination " assessment as, " no reported problems " . The assessment lacked yes; no; or descriptive responses to the following items on the physical assessment: Bowels sounds present X 4 quadrants; Abdomen-hard, distended, pain; Nausea/vomiting/heartburn; Constipation/diarrhea; difficulty chewing or swallowing; and date of last bowel movement.

Supervisor registered nursing staff H on 12/6/16 at 8:00am documented they received a physician telephone order from medical staff I for "Mag Citrate (a laxative), 296 milliliter (ml) by mouth (PO) a one-time order (stat) immediately for constipation," and "docusate sodium (a laxative), 100 milligram (mg), by mouth (PO) two times a day (BID) for constipation. RN staff H signed the physician order. The medical record lacked evidence of a nursing gastrointestinal assessment or progress note that included listening to the patient ' s bowel sounds, observation/feeling the abdomen, date of last bowel movement, patient complaint of constipation, vital signs including a temperature; and the reason for the physician ordering constipation medications. The medical record lacked documentation of a follow up nursing evaluation/assessment of the patient ' s abdomen, the results of the patient ' s response to the laxative (bowel movement or lack of) and any notification to the physician concerning the lack of results for the prescribed medication.

Patient #1 ' s medical record indicated they received the laxative Mag Citrate on 12/6/2014 at 10:16 am and the stool softener Colace twice a day on 12/7/14, 12/8/14, and 12/9/14. The medical record lacked documentation of any follow up nursing assessment of the patient ' s gastrointestinal system including bowel sounds, patient complaints of constipation, pain or distention, or bowel movements on 12/7/14, 12/8/14, and 12/9/14.

On 12/10/14 at 11:10 am the IDT (interdisciplinary team) including the psychiatrist, registered nurse and social worker met. Patient #1 reported they had a bowel movement after given some medication but felt they were blocking up again and the bowels were not working well. The nursing staff failed to create a care plan regarding the patient ' s constipation after the IDT meeting.

Nursing staff J, on 12/10/14 at 7:58 pm (about 9 hours after the IDT meeting), documented they received a physician telephone order from medical staff L for Mag Citrate 296ml solution, PO (oral), Stat(immediately) for constipation. Licensed Practical Nurse staff K, on 12/10/14 at 9:30 pm, documented the patient received " MAG citrate for constipation at 8:26 pm with the patient still voicing complaints, no results yet. " Nursing staff J, on 12/10/14 at 10:22 pm, documented the patient reported that he could not pass his stool. The patient had not had a bowel movement at 9:30 pm, the nurse notified the physician and no new orders were received. The medical record lacked evidence of a complete gastrointestinal assessments that included listening to the bowel sounds of the abdomen, observation/feeling the abdomen, documenting bowel movements and vital signs including the patient ' s temperature prior to calling medical staff L for the patient ' s continued complaint of constipation. The medical record lacked evidence of nursing ' s gastrointestinal assessment after the administration of the mag citrate medication that included bowel sounds, observation/feeling the abdomen, a bowel movement, and vital signs.

Nursing staff J obtained a physician ' s order for Milk of Magnesia (a laxative) 30 ml po (oral) for constipation on 12/10/14 at 11:20 pm. The medical record lacked documentation that nursing performed any additional gastrointestinal assessments or notified the physician regarding the patient ' s response to the intervention.

The medical record lacked evidence of any nursing progress notes regarding constipation between 12/10/14 10:22 pm and 12/11/14 12:06 pm.

Supervisory nursing staff H documented in a progress note dated/timed 12/11/14 at 12:06 pm patient #1 was " unable to respond to her, eyes rolling back into head, abdomen was extremely distended and hard. Mouth had dried brown mucous around edges and their breath smelled of feces. Bowel sounds were hypoactive (decreased or absent bowel sounds often indicating constipation). Vital signs were B/P - 95/58 (normal blood pressure is 120/80), pulse 72, respirations 16, and they were unable to obtain a temperature. " Nursing staff documented in the medical record that they notified the medical staff and the physician ordered patient #1 transferred by ambulance to hospital B emergency department (ED) for possible bowel impaction. The ambulance arrived to transfer the patient at 11:45 am and left at 11:50 am. The patient expired at hospital B at 2:40 pm, two hours and fifty minutes later and the patient ' s cause of death was ileus (the absence of movement in the intestine) with sepsis (infection).

Nursing supervisor staff H interviewed on 1/13/15 at 1:30 pm reported they were on duty 12/6/14 when patient #1 complained of constipation and they called the physician to receive an order for the Mag citrate and docusate sodium. Staff H verified they failed to document a complete nursing gastrointestinal assessment that included the bowel sounds, observation/feeling the abdomen, patient bowel movements, vital signs, failed to complete written progress notes for the newly ordered mag citrate and docusate sodium laxative and a nursing assessment with results of the laxative medication. Staff H confirmed the medical record lacked evidence of a nursing assessment of the patient ' s abdomen and elimination status including bowel sounds, observation/feeling the abdomen, bowel movements, or vital signs between the dates of 12/6/14 to 12/10/14 when nursing staff obtained another order for Mag citrate due to patient #1 ' s continued complaint of constipation.

Nursing staff J interviewed on 1/13/15 at 3:30 pm shared they worked a double shift the evening of 12/10/14 and the night shift into the morning of 12/11/14. Staff J acknowledged at shift report (day to evening shift) nursing had failed to communicate to them patient #1 ' s complaints of constipation. Staff J verified the medical record lacked evidence of a complete gastrointestinal assessment with bowel sounds, observing/feeling of the abdomen, bowel movements, and vital signs.

Administrative nursing director staff UU interview on 1/23/15 revealed the expectation for nursing regarding a patient with constipation would include an assessment of the gastrointestinal system including observation, listening, feeling, vital signs, documentation of bowel habits, response to a laxative medication and notification to the physician of continued patient complaints.

Medical staff M interviewed on 1/13/15 at 2:35pm acknowledged the expectation of nursing staff would be to report their observations, the lack of bowel movements, an abdominal assessment and vital signs to the IDT team or the on call medical staff.

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Based on record review, document review and staff interview, the hospital failed to ensure nursing staff updated the patient ' s care plan as part of the interdisciplinary care plan for one of 32 patients (Patient #1). The failure to ensure nursing services updated the care plan, including the update as part of the interdisciplinary (IDT) care plan, resulted in nursing staff failing to perform ongoing assessments of the patient ' s medical issues. This failure placed all patients admitted to the hospital who experienced a change in physical condition during their admission at risk for harm.

Findings include:

- The policy titled " Nur-1.0 Nursing Process Procedure, Effective date: November 24, 2014, " under, " II. " directed nursing staff under " 8. The Treatment Plan which incorporates the Initial Nursing Care Plan (electronic) ...VIII. Initial Nursing Care Plan (electronic) ... B. The Initial Nursing Care Plan will be evaluated at least weekly and involves: 1. Resolving the goal if met or transferring it to the Treatment Plan if expected to continue beyond 30 days. 2. Documents reason for the change. IX. Treatment Plan (electronic) The Treatment Plan shall be reviewed and revised as needed in accordance with the patient ' s condition. The RN is responsible to write the Treatment Plan regarding medical issues. "

- Patient #1 ' s medical record review on 1/13/15 revealed an admission date of 11/9/14 with an Axis I diagnosis of major depressive disorder (MDD), moderate, recurrent, and an Axis III diagnosis of hypertension (HTN). The physician ' s recorded admission physical examination failed to identify concerns with appetite or elimination. The physician ordered Lisinopril to treat the patient ' s hypertension and ordered the DASH diet (The DASH diet eating plan has been proven to lower blood pressure in studies sponsored by the National Institutes of Health (Dietary Approaches to Stop Hypertension). The IDT (Interdisciplinary Team) including the physician, psychiatrist, registered nurse and social worker met on 11/13/2014, 11/20/14 (psychiatrist failed to attend), and 11/25/14. The medical record review revealed the IDT did not meet again to discuss patient #1 complaints of constipation on 12/6/14 and their lack of bowel movements until 12/10/14 (two weeks later) to prevent a bowel impaction.

RN staff H on 12/6/16 at 8:00 am documented they received a physician telephone order from medical staff I for " magnesium citrate (a laxative), 296 milliliter (ml) orally, to be administered one time for constipation," and "docusate sodium (a laxative), 100 milligram (mg), orally, two times a day for constipation. " The medical record lacked evidence nursing staff updated the nursing care plan or the treatment plan when the patient began receiving medications for constipation.

On 12/10/14 at 11:10 am (two weeks after the last IDT meeting), the IDT including the psychiatrist, registered nurse and social worker met. Patient #1 reported they had a bowel movement after given some medication but felt they were blocking up again and the bowels were not working well. The IDT documented under " Summary of any Assessments Since Last Note; No new Medication " and under " Changes in observational status/Treatment Plan with Rationale; No change. " Nursing staff failed to update the Treatment Plan/care plan to include the change in the patient ' s physical status regarding continued constipation and the physician ordered medications including magnesium and docusate sodium laxative.

The patient expired at hospital B on 12/11/14 at 2:40 pm with a diagnosis of ileus (the absence of movement in the intestine) with sepsis (potentially life-threatening bacterial infection in the bloodstream or body).

Nursing supervisor H interviewed on 1/13/15 at 1:30 pm reported they were on duty 12/6/14 when patient #1 complained of constipation and they called the physician to receive an order for the magnesium citrate and docusate sodium. Staff H verified they failed to create a care plan and document a complete nursing assessment related to constipation. Nursing supervisor H also verified they failed to update the patient ' s care plan/treatment plan and IDT ' s meeting notes on 12/10/14 regarding patient #1 ' s continued complaints of constipation and the medication interventions implemented for constipation a few days prior. Staff H confirmed the nursing expectation is to document all assessments and medical interventions and update the nursing/IDT care plan when the change in the patient ' s physical condition occurs.

Based on interview the hospital failed to provide a medical record service with a designated professional responsible for maintaining the medical records. This deficient practice has the potential to affect the completion, filing, and retrieval of records.

Findings include:

- The Kansas State regulation KAR 28-34-9a (b)(1)reviewed on 1/27/15 at 10:00 am revealed " The medical records service shall be under the direction of a person who is a registered record health information administrator or a registered health information technicianas certified by the American Health Information Management Association, or who meets the educational or training requirements for such certification. "

- The Kansas State regulations KAR 28-34-9(b)(2) If the employment of a full-time registered health information administrator or registered health information technician is impossible, the hospital shall employ a registered records administrator or an accredited records technician on a part-time consultant basis. The consultant shall organize the department, train full-time personnel, and make periodic visits to evaluate the records. There shall be a written contract between the hospital and the consultant that specifies the consultant's duties and responsibilities.

- The hospital failed to have a policy requiring a Registered Health Information Technician (RHIT) to be the Medical Records Director.

Based on observation, interview and record review the facility failed to develop and maintain an environment to ensure the safety and well-being for special needs of patients admitted to the psychiatric hospital by failing to:
- Identify potential risks and conduct surveillance in the physical environment according to the "Safety Management Plan" Policy;
- Provide non-suicide resistive shower and tub water control knobs, non-exposed plumbing on sinks and commodes, and non-hinged commode seats. The configuration of the water control knobs, exposed plumbing pipes, and hinged commode seats created a looping hazard (material or a device could be looped around the knobs or plumbing to be used for choking or strangulation) in all 30 bathrooms/shower rooms in seven of seven nursing units throughout the facility;
- Secure heavy furniture which could provide dangerous projectiles or could easily be maneuvered and positioned under a protruding device as potential for hanging in all 138 patient rooms;
- Remove metal closet doors with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard in all 138 patient rooms;
- Provide door handles that prevent an anchor point. The door handles created a potential ligature attachment point affecting all patients admitted to the hospital at risk for suicide;
- Secure pictures to the wall using tamper resistant screws or anchors. The picture frames have the potential to be used as a weapon on others affecting all patients admitted to the hospital at risk for harming themselves or others;
- Secure heating/cooling vents to the ceiling and air exchange vents to the wall with tamper resistant screws or anchors creating an anchor for hanging or used as a weapon affecting 16 hallways, 138 patient rooms, seven day halls, 30 bathrooms/shower rooms throughout the facility;
- Provide a non-tamper proof ceiling. The suspended ceiling with removable tiles expose pipes and wiring above the tiles that have the potential to provide a hanging, choking, or strangulation hazard in 132 patient rooms, 16 hallways, 4 comfort rooms, and seven day halls throughout the facility;
- Remove, replace, or cover electrical outlets. The electrical outlets could be accessed with the potential to create a fire or electrical shock in 138 patient rooms, 30 bathrooms/shower rooms, 16 hallways, 4 comfort rooms, and 7 day halls throughout the facility;
- Secure ceiling mounted florescent light fixtures. The light fixtures have the potential to provide an anchor for hanging in 138 patient rooms, 30 bathrooms/shower rooms, 16 hallways, 4 comfort rooms, and 7 day halls throughout the facility;
- Remove hospital gowns with string closers and fitted sheets with elastic from patient use. The strings and elastic have the potential to provide a hanging, choking, or strangulation risk for all patients at risk for suicide in seven of seven nursing units throughout the facility;
- Provide a barrier between the Mental Health Technician (MHT) station and patients in the day hall. Patients could reach the telephone and computer keyboard and cord to use for hanging, choking, or strangulation or as a weapon on three of seven patient units;
- Secure laundry soap in patient's laundry room in two of seven laundry rooms. Laundry soap, when ingested, could be harmful;
- Provide a patient lift for patients exceeding four hundred pounds. The lift had the potential for a fall hazard for one patient over four hundred pounds.

Findings Include:

- The hospital's policy "Safety Management Plan" dated 7/23/12 reviewed on 1/22/15 at 3:00 pm directed, "...The Environment of Care Committee (EOCC) conducts quarterly rounds of buildings, grounds, equipment, and occupants to: c. Identify safety risks d. Conduct hazard surveillance. C. Safety Planning 1. The EOCC participates in performance improvement activities...monitoring performance regarding actual or potential risks ...Safety and Hazard Assessment, Identification of Processes, identify opportunities for improvement in order to ...establish and maintain a physical environment free of hazards ..." H. Environment 5. Facilities and grounds are maintained through collaborative efforts of Facility Services and program staff in order to create an environment that is comfortable, safe, clean and attractive. 6. Furnishings and equipment provided are safe and in good repair ...8. The EOCC reviews safety concerns submitted by employees, patient, visitors or other hospital committees/teams. The Director of Operations or designee, with the assistance of members of the EOCC, a. Directs ongoing performance improvement activities related to the environment of care; b. Directs the integration of environment of care monitoring and response activities into the hospital wide patient safety program; c. Reviews summaries of deficiencies, problems, failures and/or user errors related to managing, i. Safety; ii. Security; v. Fire Safety.

Staff BB, Assistant Superintendent, interviewed on 1/22/14 at 2:00 pm was unable to provide documentation of any findings from the EOCC addressing safety issues or any potential or actual risks or hazards identified in the physical environment of the hospital.

Managing and Preventing Symptoms (MAPS) unit (Individuals who are unable to manage behaviors and care for their wellbeing due to an acute impairment in the ability to perceive reality) A1 building observed on 1/12/15 between 2:00 pm and 4:30 pm and 1/20/15 between 3:15 pm to 4:20 pm showed the following:

- The MAPS unit A1 had a total of 30 beds with 29 current patients (2 patients at risk for suicide (2 intermediate risk suicidal) and 29 Assaultive/violent patients (27 potentially assaultive/violent and 2 actively assaultive/violent). Therapeutic Observational Status for the 29 patients revealed: Red (15 minute) - 2 patients; Orange - 11 patients; Yellow - 16 patients.

- Hallway A and hallway B revealed a total of 19 patient rooms including eight private and 11 semi-private rooms. All 19 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 2 of 2 patients on the unit assessed as a suicide risk. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provide a hanging, choking, or strangulation for 2 of 2 patients on the unit assessed as a suicide risk. All 19 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. All 19 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. All 19 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 19 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 19 patient rooms had one metal ceiling heating/cooling vent easily removed and one metal air exchange vent secured to the wall with non-tamper proof screws potentially creating an anchor for hanging or use as a weapon. All 19 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic has the potential to provide a hanging, choking, or strangulation risk for 2 of 2 patients on the unit assessed as a suicide risk.

- Observation of room 143 revealed a displaced ceiling tile and room 144 revealed a missing ceiling tile. Above the ceiling tiles are plumbing and electrical wiring. Access to the plumbing pipes and electrical wiring has the potential to provide a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The shower room on hallway B revealed a metal vent with missing screws and room 143 revealed a displaced vent. The metal vent could easily be removed and create an anchor for hanging or be used as a weapon.

- The Day Hall (the units living and dining area) revealed a suspended ceiling with approximately 20-inch by 20-inch ceiling tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The Day Hall contained two water fountains attached to the wall that could be pulled off of the wall and used for a weapon. Two telephones for patient use located beside the nurses station had a 29 inch cord providing a potential hazard for hanging, choking, or strangulation affecting 2 of 2 patients on the unit assessed as a suicide risk. The Day Hall had eight electrical outlets easily accessible with the potential to create a fire or electrical shock. The Day Hall had ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The day hall had eight metal ceiling vents easily removed creating an anchor for hanging or use as a weapon. One wall had four cabinets with C handles with the potential hazard for hanging, choking, or strangulation for 2 of 2 patients on the unit assessed as a suicide risk. The Mental Health Technician (MHT) station (desk area) in the day hall failed to have an adequate barrier enclosing the area from patients. The MHT station measured 42 ½ inches tall and had a 12 ¾ inch wide counter. Patients could easily reach the telephone and the telephone cord could be used as a strangulation device as well as the computer keyboard and cord to be used as a weapon.

- MHT staff O interviewed on 1/13/15 at 2:00 pm indicated patients can and have reached over the MHT station to obtain the phone and keyboard.

- The patient bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal vent in the ceiling tiles and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or use as a weapon. The bathroom had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The shower room on hallway A had a bathtub with a water temperature dial with a 3 inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The plumbing is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The shower room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The shower room had one metal vent in the ceiling tiles easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. Hallway A had four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock or electrical shock. The comfort room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The comfort room had one eraser board and five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. Three sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had one metal vent with non-tamper proof screws and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathrooms had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic inserts covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway B had a bathtub with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. The shower room had one sink with a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as a suicide risk. The bathroom had one metal vent in the ceiling tiles easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets with the potential to create a fire or electrical shock. The shower room had three ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway B revealed six ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway B has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 2 of 2 patients on the unit assessed as suicidal risk. Hallway B had four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Managing and Preventing Symptoms (MAPS) unit A1 building observed on 1/13/15 at 2:00 pm revealed a patient in the day hall wearing a hospital gown with strings for securing the gown. Mental Health Technician (MHT) staff D interviewed on 1/13/15 at 2:00 pm revealed patients wear hospital gowns when doing laundry and some wear them at night. Staff D acknowledged the use of hospital gowns with strings and the fitted bed sheets with elastic edging had the potential to be used by patients as a means of hanging or strangulation. Staff D acknowledged that all patients on the unit can request gowns or sheets from staff members regardless of whether they are a suicidal risk or at risk to harm others.

Managing and Preventing Symptoms (MAPS) unit (Individuals who are unable to manage behaviors and care for their well-being due to an acute impairment in the ability to perceived reality) A2 building observed on 1/13/15 between 11:20 am to 12:30 pm and 1/20/15 between 4:20 pm and 5:15 pm showed the following:

- The MAPS unit A2 had a total of 30 beds with 24 current patients (14 patients at risk for suicide (9 low risk suicidal; 4 intermediate risk suicidal; 1 acute risk suicidal risk) and 12 Assaultive/violent patients (11 potentially assaultive/violent; 1 actively assaultive/violent). Therapeutic Observational Status for the 24 patients revealed: Red (1:1) - 1 patient; Red (15 minute) - 4 patients; Orange - 9 patients; and Yellow-10 patients.

- Hallway A and hallway B revealed a total of 18 patient rooms including six private and 12 semi-private rooms. All 18 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 14 of 14 patients assessed at risk for suicide on the unit. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. All 18 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 18 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 18 patient rooms had one metal ceiling vent easily removed and one metal vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. All 18 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic on the fitted sheets provide a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit.

- The Day Hall (the units living and dining area) revealed a suspended ceiling with approximately 20-inch by 20-inch ceiling tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The Day Hall contained two water fountains attached to the wall that could be pulled off of the wall and used for a weapon. Two telephones for patient use located beside the nurses station had a 29 inch cord providing a potential hazard for hanging, choking, or strangulation affecting 14 of 14 patients assessed at risk for suicide on the unit. The Day Hall had eight electrical outlets easily accessible with the potential to create a fire or electrical shock. The Day Hall had 17 ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The day hall had six cabinet doors with C handles with the potential hazard for hanging, choking, or strangulation. The Mental Health Technician (MHT) station (desk area) in the day hall failed to have an adequate barrier enclosing the area from patients. The MHT station measured 42 ½ inches tall and had a 12 ¾ inch wide counter. Patients could easily reach the telephone and the telephone cord which could be used as a strangulation device as well as the computer keyboard and cord for use as a weapon.

- The patient bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The bathroom had one metal vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathroom had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway A had a bathtub and shower stall with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with hinged seat and exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The toilet seat and exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The shower room had two ceiling mounted florescent light fixtures with a plastic insert easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. Hallway A had five electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock. The comfort room had five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. Three sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients on the unit assessed as a suicide risk. The bathroom had one metal ceiling vent easily removed from the tiles and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathrooms had two electrical outlets easily accessible with the potential to create a fire or electrical shock. The bathroom had two ceiling mounted florescent light fixtures with a plastic inserts covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- The shower room on hallway B had a bathtub with a water temperature dial with a 3-inch protruding handle. The shower room had one commode with a hinged seat and exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 7 inches from the wall. The shower room had one sink with a 10-inch protruding water faucet. The toilet seat and exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 14 of 14 patients assessed at risk for suicide on the unit. The bathroom had one metal vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets with the potential to create a fire or electrical shock. The shower room had three ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging.

- Hallway B revealed six ceiling mounted florescent light fixtures with a plastic covering easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 14 of 14 patients on the unit assessed as a suicide risk. Hallway B had four electrical outlets easily accessible with the potential to create a fire or electrical shock. Hallway B had three pictures attached to the wall with non-tamper proof screw.

Continuing Care (CCP) unit (Individuals whose psychiatric symptoms have contributed to their involvement with the courts; and individuals who are referred by law enforcement for Detox, care and treatment (DCT)) B1 building observed on 1/12/15 between 2:00 pm and 4:30 pm showed the following:

- The CCP unit B1 had a total of 30 beds with 28 current patients - (1 patient assessed as risk for suicide (1 low risk suicidal) and 20 patients assessed as risk for assaultive/violent (16 potentially assaultive/violent and 4 actively assaultive/violent). Therapeutic Observational Status for the 28 patients revealed: Red (15 minute) - 3 patients; Orange - 12 patients; Yellow - 8 patients and Green - 5 patients.

- Hallway A and hallway B revealed a total of 18 patient rooms including seven private and 11 semi-private rooms. All 18 patient rooms have furniture including dressers with removable drawers and wooden beds with legs and flat metal springs with metal slats formed into a grid pattern to hold the mattress. The unsecured lightweight furniture in patient rooms moved easily with the potential for placement under a protruding device or propped up as a potential for hanging for 1 of 1 patient on the unit. All rooms have a 6 inch door handle that protrudes 3 ½ inch out from the door. The door handles potentially provides a hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 patient rooms have a metal closet with either a handle, latch hook, or a one-inch opening. The closet handles, latch hooks, or openings potentially provide a hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 rooms have a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 patient on the unit. All 18 patient rooms had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock. All 18 patient rooms had one or two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. All 18 patient rooms had one metal ceiling vent easily removed and one metal vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. All 18 patient rooms had a bed made with a fitted sheet with elastic edging. The elastic on the fitted sheets provide a hanging, choking, or strangulation hazard for 1 of 1 patient assessed at risk for suicide on the unit.

- The bathroom on hallway A had two commodes with a hinged seat and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. The bathroom had one urinal with exposed plumbing. Two sinks have a 10-inch protruding water faucet. The exposed plumbing and hinged toilet seat potentially provides a hanging, choking, or strangulation hazard for 1 of 1 suicidal patients on the unit. The bathroom had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal ceiling vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The bathroom had two to four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The shower room on hallway A had a bathtub with a water temperature dial with a 3 inch protruding handle. The shower room had one commode with exposed plumbing pipes on the toilet. The piping is 28 inches from the floor and 5 inches from the wall. One sink has a 10-inch protruding water faucet. The exposed plumbing potentially provides a hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. The shower room two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The bathroom had one metal ceiling vent easily removed and one vent secured to the wall with non-tamper proof screws creating an anchor for hanging or used as a weapon. The shower room had two electrical outlets easily accessible with the potential to create a fire or electrical shock.

- Hallway A revealed seven ceiling mounted florescent light fixtures with a plastic inserts easily removed. The light fixtures have the potential to provide an anchor for hanging. Hallway A has drop style ceiling with approximately 20 inch X 20 inch removable tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. Hallway A had four electrical outlets easily accessible with the potential to create a fire or electrical shock.

- The comfort room revealed a suspended ceiling with removable 12-inch tiles. Above the ceiling tiles are plumbing and electrical wiring. The exposed pipes and wiring above the ceiling tiles have the potential for hanging, choking, or strangulation hazard for 1 of 1 suicidal patient on the unit. The comfort room had four electrical outlets easily accessible with the potential to create a fire or electrical shock. The comfort room had two ceiling mounted florescent light fixtures with a plastic insert covering easily removed. The light fixtures have the potential to provide an anchor for hanging. The comfort room had one eraser board and five picture frames secured with non-tamper proof screws with the potential for removal and use as a weapon.

- The patient bathroom on hallway B had two commodes with hinged seats and exposed plumbing pipes on the toilets. The piping is 28 inches from the floor and 7 inches from the wall. Three sinks have a 10-inch protruding wate

Based on observations, policy review, and interview the hospital failed to maintain facility supplies and equipment to ensure safety and quality in one of two walk-in refrigerators, one of two walk-in freezers, one of eight treatment rooms, and one of one supply rooms.

Findings include:

-The hospital's policy "Establish Effective Recordkeeping Procedures" reviewed on 1/22/15 at 5:40pm directed, "...Effective food safety procedures can be critical in the event of an outbreak of foodborne illness ...Refrigerator and Freezer Temperature Log-Twice daily.

-Observation on 1/13/15 at 8:45am in the hospital ' s warehouse revealed a walk-in refrigerator with 60 cases of ½-pint containers of milk. The walk-in freezer had approximately nine pallets of frozen foods. The facility lacked documentation for monitoring the refrigerator and freezer to ensure food safety.

-Materials Management employee staff X interviewed on 1/13/15 at 8:45am indicated they did not document refrigerator or freezer temperatures daily. Staff X stated they were in and out of the refrigerator and freezer many times a day and would know if they were not working right.

- The Hospital's policies and procedure titled, "Sterile and Non-Sterile Items" reviewed on 1/22/15 at 10:00am directed, "...The date on a STERILE item that has the date and the words "exp" or "best if used by "...would be an expiration date ...ALL STERILE Supplies EXPIRE THREE YEARS AFTER THE RECEIVED DATE ...The only exception is if the manufacturer's expiration date comes prior to our date..."
- Treatment room in the East Biddle Annex observed on 1/13/15 at 10:00am revealed a room with one exam table, one cabinet with drawers beside the exam table, and one large built-in cabinet with multiple shelves. The hospital ' s physicians and a podiatrist who comes to the hospital once a month to see patients use the treatment room. Observation of the cabinets revealed the following:
One-250milliliter (ml) of Hydrogen Peroxide with an expiration date of 2/13.
One-box of 100 count plus one full glass container of sterile tongue depressors with an expiration date of 4/14/14.
One -box of 100 count sterile tongue depressors with an expiration date of 4/9/12.
One-box of 1000 count of sterile single tipped applicators with an expiration date of 6/2000.
Two-boxes plus ½ of a glass container of individual packets of sterile surgical lubricant with an expiration date of 4/12.
One-24 count package of "Ready Cleanse" cleansing wipes with an expiration date of 10/2011.
Eighteen-packages of sterile Kelly Forceps with an expiration date of 11/14/11.
One-package of a sterile dental instruments with an expiration date of 12/14/12.

- Satellite supply room observed on 1/13/15 at 11:05am revealed a room with multiple shelving units that store patient supply items including the following:

Thirteen-4ounce tubes of Nutrashield Skin Protection Cream with an expiration date of 8/20/14.

Licensed Practical Nurse (LPN), staff MM interviewed on 1/13/15 acknowledged the expired supplies. Staff MM was unaware that some of the supplies had expiration dates. Staff MM explained the Hospital's policy states that all sterile supplies contain a sticker with a date on it when they receive the supply and three years from that date the item expires. Staff MM indicated they were in charge of supplies and failed to remove outdated items.

Based on observation, policy review, and staff interview the hospital's infection control officer failed to develop and maintain an active infection control system ensuring hospital personnel followed basic infection control practices for five of six observed glucometer (blood sugar analyzer) tests, three of three observed handling of dirty laundry, one of two observed dressing changes (patient #31), two of two observed cleanings of a discharged patient's room, and cracked vinyl on wheelchairs, torn mattresses, rusted bed springs, and trash cans in five of seven units. This deficient practice places patients at risk for hospital-acquired infections.

Findings include:

- The Hospital's "Infection Prevention and Control Program" reviewed on 1/22/15 at 2:00 pm, directed, "...The Infection Control Officer is given the authority to institute any surveillance, prevention, and control measures to prevent or control the acquisition and transmission of infectious agents..."Infection Prevention Responsibility of Infection Prevention Committee", ...reviewing conclusions, recommendations and actions taken relating to the evaluation of healthcare associated incidence rates, epidemiological significant outbreaks, unusual pathogens and personnel infections...forwarding minutes to the Medical Staff and Nursing Administrative Committees ..."

-The Hospital's policy/procedure, "Hand Hygiene" reviewed on 1/22/15 at 2:00pm directed, "...Hand Antisepsis Using Alcohol-Based Hand Rubs, B. Indication for Use if Hands are Not Visibly Soiled 1. Before and after having direct contact with patients. Before preparing medications...After removing gloves...During medication pass, if the patient is touched or if an object is handled that the patient has touched..."

-Infection Control Officer staff CC interviewed on 1/22/15 at approximately 1:00pm verified they were responsible for the management of the infection control program. The infection control committee started reviewing policies and procedures and approves hospital wide cleaning products. Staff CC acknowledged they have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control for hand hygiene, handling of soiled linens and use of PPE (personal protective equipment) with between 70% to 80% compliance. Staff E acknowledged they failed to develop and implement a surveillance program for cleaning of patient rooms or the laundry handling.


-Observation on 1/13/15 at 7:55am in the laundry building of the hospital revealed a loading and unloading dock on the east side of the building.


Laundry staff HH interviewed on 1/13/15 at 8:10am indicated the truck picks up laundry from the units and deliver to the dock on the east side of the building. Staff HH acknowledged the soiled linen from the units has to pass the clean linen ready to be delivered to the unit and passes through the laundry room to the west side of the building. Staff HH acknowledged the potential risk for cross contamination when taking soiled linen by clean linens.


-Observations during the survey process revealed the following breaches in infection control practices for hand hygiene, disinfectant wet time per manufacturer's recommendation, and cleaning of a discharged patient room.

-The manufacturer's information sheet for "pH7Q Ultra" reviewed on 1/21/15 at 12:50pm directed, "...disinfection...let solution remain on surfaces for a minimum of 10 minutes..."

-The hospitals policy for "Patient Unit, Cleaning of" reviewed on 1/21/15 at 12:50pm directed, "...Clean and disinfect bed, bed drawers, dresser, and locker..."

-Mental Health Technician (MHT) staff D and Housekeeping staff DD observed on 1/14/15 between 10:35am to 11:15am cleaned room 146 on Managing and Preventing Symptoms (MAPS) A1 after a patient's dismissal. Staff D entered room 146 failed to perform hand hygiene, applied gloves, and removes trash and soiled linens from the room. Staff D removed their gloves and reapplied gloves without performing hand hygiene. Staff D sprayed the mattress with "pH7Q Ultra" disinfecting cleaner, wiped the mattress with a cloth. The mattress remained wet for five minutes not the required 10 minutes for disinfection. Staff D placed the "pH7Q Ultra" spray bottle on the floor.

Staff D obtained the "pH7Q Ultra" spray bottle from the floor, sprayed the dresser and dresser draws, wiped off the top of the dresser, and placed the contaminated "pH7Q Ultra" spray bottle that sat on the floor on top of the dresser.

Housekeeping staff DD, wearing gloves cleaned the closet, bed frame and cross bars, then laid the soiled cloth and "pH7Q Ultra" spray bottle on the dresser. The surfaces of the closet and bed remained wet between one to four minutes. The closet and bed frame failed to remain wet for the required 10 minutes for disinfection.

The head board, foot board, bed springs, and bed legs failed to be cleaned at all.

When staff D and staff DD removed their gloves they failed to perform hand hygiene. Failure to clean a discharged patient's room effectively and perform hand hygiene places all patients at risk for exposure to blood borne pathogens.

Staff D interviewed on 1/14/15 at 11:15am acknowledged they were unaware of the disinfection time for "pH7Q Ultra" and verified they placed the contaminated spray bottle on the dresser, they failed to perform hand hygiene between glove changes, and they failed to clean all of the bed parts.

- Housekeeping staff II observed on 1/15/15 between 10:10 am to 10:37 am cleaned room 264 on Crisis Stabilization Program (East Biddle) unit after a patient's dismissal. Staff II entered room 264, failed to perform hand hygiene, applied gloves, removed trash, removed soiled linen from the bed and placed it on the floor. Staff II sprayed the mattress, bed frame, foot board, and the head board, with " pH7Q Ultra" disinfecting cleaner, wiped the sprayed items with a dry cloth. The surfaces remained wet seven to eight minutes not the required 10 minutes for disinfection.
Housekeeping staff II sprayed the window sill, and vent with "pH7Q Ultra" and immediately wiped them with a dry cloth. The surfaces failed to remain wet for the required 10 minutes for disinfection.
Housekeeping staff II picked up the soiled linen and carried the linen against their body down the hall to the soiled utility room unlocked the door and placed the soiled linen in a linen hamper. Staff II went back to the room and sprayed the door and door frame with "pH7Q Ultra" using the same gloves. Staff II then removed the gloves stating, "one had a hole in it", applied clean gloves. Staff II failed to perform hand hygiene after removing the gloves. Failure to clean a discharged patient room effectively, perform hand hygiene, and dispose of soiled linen appropriately places all patients at risk for exposure to blood borne pathogens.

Staff II interviewed on 1/15/15 at 10:37am acknowledged they were aware of the disinfection time of the " pH7Q Ultra". Staff II acknowledged they were unaware the surfaces did not remain wet for the required 10 minutes, that the soiled loose linens should not be carried to the soiled utility.


-The Hospital's policy for glucose monitoring failed to direct staff on cleaning/disinfecting of the monitor.

-Licenses Practical Nurse (LPN) staff EE observed on 1/14/15 at 4:45pm, on Managing and Preventing Symptoms (MAPS) A2 unit performed a finger stick glucometer test on patient #33 in the treatment room. Staff EE wearing gloves performed a finger stick glucometer test. Staff EE removed their gloves and failed to performed hand hygiene. Staff EE replaced the glucometer in the case and failed to disinfect the glucometer after use on a patient. Staff E then went to medication room, obtained a medication for patient #33, and failed to perform hand hygiene. Failure to perform hand hygiene and clean the glucometer after each use places all patients at risk for exposure to blood borne pathogens.

-Registered Nurse (RN) staff FF observed on 1/14/15 at 5:10pm on Managing and Preventing Symptoms (MAPS) A2 unit performed a finger stick glucometer test on patient #14 in the treatment room. Staff FF wearing gloves performed a finger stick glucometer test, removed their gloves and performed hand hygiene. Staff FF replaced the glucometer in the case and failed to disinfect the glucometer after use on a patient. Failure to clean the glucometer after each use places all diabetic patients at risk for exposure to blood borne pathogens.

RN staff FF interviewed on 1/14/15 at 5:15pm acknowledged nursing staff should perform hand hygiene before and after treating patients and should disinfect equipment after use on patients.

-Registered Nurse (RN) staff Y observation on 1/14/15 at 9:55am on Plosive Living Skills (PLS) C2 unit performed a finger stick glucometer test on patient #33 in the treatment room. Staff Y, wearing gloves, performed a finger stick glucometer test, removed their gloves and performed hand hygiene. Staff Y replaced the glucometer in the case and failed to disinfect the glucometer after use on a patient. Failure to clean the glucometer after each use places all diabetic patients at risk for exposure to blood borne pathogens.

-RN staff Z interviewed on 1/12/15 at 2:30 pm revealed that glucometers require cleaning after each patient and checked every 24 hours.

- Registered Nurse staff KK observed on 1/14/15 at 4:50pm in the medication room passing medications to the patients. Staff KK drew up insulin into a syringe, applied one clean glove to one hand and gave the patient their insulin, and removed the glove and washed their hands. Staff KK failed to perform hand hygiene before applying the glove.

- Physical Therapist, staff KK observed on 1/13/15 at 9:40am in the physical therapy department performed wound care to a patient. Staff KK applied ointment to the patient's foot, removed gloves, applied clean gloves. Staff KK failed to perform hand hygiene before applying clean gloves. Staff KK, wearing gloves, dressed the wound area, removed one glove on right hand to tape the dressing, removed the glove from the left hand, picked up trash, and put slippers/shoes on the patient. Staff KK failed to perform hand hygiene after removing the gloves.

-Guidelines for Environmental Infection Control in Health-Care Facilities Recommendations of Center of Disease Control (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) Cleaning: remove all visible soil. Rust is visible therefore it cannot be cleaned.

-Managing and Preventing Symptoms (MAPS) A1 unit observed on 1/20/15 between 3:15pm and 4:20pm revealed rusted bed springs in rooms 143, 145, and 149. Rust is visible therefore it cannot be cleaned. Torn vinyl with foam exposed arm rests on a wheelchair in the day hall, and room 146. Torn mattresses in rooms 143 and 145 leave a pathway to the inside foam rendering the area non-cleanable with the potential for cross contamination.

-Registered Nurse staff SS interviewed on 1/20/15 between 3:15 and 4:20 acknowledged the rust on bed springs, torn vinyl on wheelchairs and the torn mattress covers. Staff SS indicated they were unaware if these had been reported to management.

-Managing and Preventing Symptoms (MAPS) A2 unit observed on 1/20/15 between 4:20pm and 5:15pm revealed a bed in room 144 with rusted springs.

-Observation on Continuing Care (CCP) B1 unit on 1/22/15 at 9:30am revealed a patient treatment room examination table with vinyl upholstery had a torn corner exposing the threaded backing approximately three inches by three inches. A chair in the treatment room had a tear in the vinyl covering on the chairs back support exposing the threaded backing approximately two inches by two inches. The torn vinyl leave a pathway to the inside foam rendering the area non-cleanable with the potential for cross contamination. A metal waste basket in the treatment room had rust on the metal lid and foot pedal mechanism that opened the trash can. Rust is visible therefore it cannot be cleaned.

- Stepping Stones Program (SSP) B2 unit observed on 1/12/15 between 1:55pm to 4:47pm and 1/13/15 between 2:10pm to 3:00pm revealed a metal step stool with chipped paint, a metal trash can rusted around the bottom and lid. Torn vinyl with foam exposed on the arm rests of a wheel chair. The torn vinyl rendered the areas non-cleanable with the potential for cross contamination.

-Registered Nurse Specialist (Unit Manager) RR interviewed on 1/14/15 between 1:55pm to 4:47pm acknowledged the rusted step stool and trash can and the torn vinyl on wheelchairs.

- Crisis Stabilization Program (CSP) East Biddle unit observed on 1/14/15 between 5:10pm and 6:00pm and 1/15/15 between 8:10am to 12:00pm revealed rusted bed springs in rooms, 203, 207, 209, 211, 213, 216, 230, 228, and 262. Torn and cracked vinyl on two wheel chairs with foam exposed on arm rest and seats. One wheel chair had tape covering the entire arm rest. The torn and cracked vinyl rendered the areas non-cleanable with the potential for cross contamination.

-Registered Nurse Specialist (Unit Manager) RR interviewed on 1/15/15 between 8:10 to 12:00pm acknowledged the rusted bed springs and torn and cracked wheelchairs. Staff RR indicated they have ordered new beds.

-Healthy Options, Plans, and Experiences (HOPE) unit C2 building observed on 1/21/15 at 9:00am revealed three folded linen bags on the floor, MHT staff GG picked the linen bags up off the floor and place them on the clean linen cart located near the nurses' station. Dirty items placed on the clean linen have the potential for cross contamination and the potential spread of infection.

-Staff GG interviewed on 1/21/15 at 9:00 am revealed the folded linens located on the floor next to the clean linen cart were the dirty linen bags.

Based on document review, staff interview, and medical record review, the hospital failed to discharge patients when they transferred to another hospital for further care and/or treatment for 4 of 4 transferred patient's medical records reviewed (patient #'s 9, 13, 21, and 27). The hospital's failure to discharge patients when they are transferred to another facility for further care or treatment has the potential to affect all patients transferred to other facilities and places these patients at risk for inadequate care, assessment, and evaluation.


Findings include:


- The Hospital's policies/procedures titled "Discharge to a Hospital (Psychiatric and/or Medical", reviewed on 1/13/15 at 3:15pm directed, "...patients who are transferred form Osawatomie State Hospital (OSH) and admitted to a medical hospital should be reviewed for discharge from OSH...Following the transfer, the attending physician will contact the physician at the medical hospital for an update about the expected treatment and length of stay at the medical hospital...after consulting with the physician at the medical hospital and it is affirmed the patient has been admitted for care and treatment of a physical issue, the OSH physician will initiate the discharge process for the patient...IDT (interdisciplinary team) will summarize the above information to the Medical Director prior to making a decision regarding discharge."


- The Hospital's policies/procedures titled "Emergency Medical Transfer to Outside Healthcare Facility" reviewed on 1/13/15 at 10:00am directed, "...Patient Admitted to Inpatient Bed at Outside Healthcare Facility...The following business day after the initial transfer and daily thereafter...Physician and RNs contact the healthcare facility to inquire about the patient's status...Social workers contact the healthcare facility, when applicable, Phone conversations may be completed with the entire IDT...Document all information in the Patient Care System (electronic medical record)...request the healthcare facility to provide hospital records when the patient is returned..."



-Patient # 9's medical record reviewed on 1/12/15 and 1/13/15 revealed an admitting date of 4/16/14 with psychiatric diagnoses of Schizophrenia and Psychotic Disorder and a medical diagnosis of hypothermia. Patient #9's medical record revealed a transfer to an acute care hospital (hospital A) on 12/11/15 for an exacerbation of hypothermia. Patient #9's medical record remained open and patient #9 returned from hospital A on 12/19/14 (eight days later). Patient #9's medical record lacked evidence of discharge after the patient transferred to another facility.


-Patient #13's medical record reviewed on 1/14/15 revealed an admitting date of 10/29/14 with a diagnosis of Schizoaffective Disorder, Bipolar type. The medical record revealed Patient #13 transferred to an inpatient psychiatric hospital (hospital C) on 12/3/14 for further care and treatment. Patient #13's medical record remained open and patient #13 returned to the above-named hospital on 1/6/15 (thirty four days later). The medical record lacked evidence of discharge after the patient transferred to another facility.


-Patient # 21's medical record reviewed on 1/12/15 revealed an admitting date of 10/31/14 and a diagnosis of Schizophrenia. The medical record revealed Patient # 21 transferred to a psychiatric facility on 1/9/15 for further care and treatment. Patient # 2's medical record remained open and the patient remained on the unit census as of 1/21/15 (12 days later). The medical record lacked evidence of discharge after the patient transferred to another facility.


- Patient #28's closed medical record reviewed on 1/21/15 revealed an admitting date of 12/21/14 with diagnosis of paranoid schizophrenia. The medical record revealed patient #28 transferred to an acute care hospital on 12/28/14 for further care and treatment. Patient #28's medical record remained open and patient #28 returned to the above-named hospital on 12/30/14 (two days later). The medical record lacked evidence of discharge after the patient transferred to another facility.



Staff S, LSMSW interviewed on 1/13/15 at 3:05pm explained when the hospital transfers a patient to another hospital the patient's medical record will remain on the unit and the patient remains listed on the patient census but designated as on leave. When the patient is transferred back to the hospital, the unit uses the same chart, does a medication reconciliation, new preliminary orders, head to toe assessment, reviews the same treatment plan the patient had before being transferred to another hospital, and then revises the treatment plan when the Interdisciplinary Team meets.