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LICKING MEMORIAL HOSPITAL
PHYSICAL ENVIRONMENT
Tag No.: A0700
Based on observation, interview, and documentation review the facility failed to ensure sprinkler heads located in the inpatient mental health facility were ligature resistant (A701), corridor doors were designed to resist the passage of smoke as per NFPA 101, and the generator remote annunciator panel was located in a regular work station during operating hours as per NFPA 110 (A710). The cumulative effects of these systemic practices resulted in the facility's inability to ensure the safety of patients.
MAINTENANCE OF PHYSICAL PLANT
Tag No.: A0701
Based on observation and staff interview the facility failed to ensure sprinkler heads located in the inpatient mental health facility were ligature resistant. This has the potential to affect all patients with suicidal ideation's in the facility. The inpatient mental health census was 3.
Findings include:
Tour of the inpatient mental health unit on 02/07/18 revealed cover plates over the sprinkler head. After the removal of the cover plate by maintenance staff, in a patient bathroom, the sprinkler head was observed to not be ligature resistant. No special tools were used to remove the sprinkler head cover and the cover could be accessed while standing on the ground.
A request was made for documentation to confirm testing of ligature resistance on 02/07/18 at 10:15 AM from Staff B.
Interview with Staff A on 02/08/18 at 10:45 AM revealed that after contacting the supplier of the sprinkler heads in the inpatient mental health facility the facility does not have documentation to support that the sprinler head breaks away after a certain amount of weight is applied.
LIFE SAFETY FROM FIRE
Tag No.: A0710
Based on observation, interview, and documentation review, the facility failed to meet the requirements for life safety, specifically, the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association. This had the potential to affect all patients receiving services from the facility. The inpatient mental health census was 3.
Findings include:
1. Please see K363 for findings related to failure to ensure corridor doors were designed to resist the passage of smoke.
2. Please see K916 for findings related to the failure to ensure the generator remote annunciator panel was located in a regular work location manned during operating hours.