HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting as evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality of care for geriatric psychiatric patients for ligature risks and safety risks.

Findings:
A hospital tour was conducted on 1:25 p.m. on 8/18/2014 with SF1Administrator and SF2DON. There were 8 double occupancy patient rooms located down a single hallway in view of the nurse's station. All rooms had a bathroom within the room with a toilet and a sink. All rooms had an outside window view and all rooms opened to the main hallway. The census on 8/18/2014 was 11 patients.

The following ligature risk and safety risk observations were made:
1) interior bathroom doors with open-ended door hinges (x3 on each door) for all 8 rooms (a,b,c,d,e,f,g, and h),
2) exposed plumbing/pipes behind the toilets with flanged flushing handles on the toilets for rooms (d and h),
3) flanged faucet handles on the bathroom sinks with exposed plumbing/pipes behind the
sinks for rooms (d and h).


In an interview on 8/18/2014 at 1:30 p.m. with the SF1Administrator and the SF2DON indicated that patient rooms would be locked when patients were in activities and that all patients would remain on 15 minute checks. SF1Administrator and SF2DON were made aware of the ligature risks and the safety risks for the open frame 1/4 bedrails in use in the patient rooms. The SF1Administrator stated that the facility had removed the bedrails from 2 of the 16 beds in the facility. The SF1Administrator had indicated that the hospital policy on Bedrail Use had been updated to include how the bedrails would be monitored for patient safety. The SF1Administrator and the SF2DON indicated that there were no patients at present on suicide risks and no patients were presently on 1:1 monitoring. SF1Administrator and the SF2DON further indicated that the admission criteria was 50 years and older. During the exit conference the SF1Administrator stated that the bedrails had been removed from 5 of the 16 beds in the facility.





30172

Based upon review of the plan of correction and administrative staff interview, the hospital failed to ensure a Psychologist was on staff to provide psychological services. Findings:

Review of the plan of correction from the survey conducted on 07/10/14 revealed the hospital was to procure a Psychologist to provide psychological services. Interview with SF1 Administrator on 08/19/14 at 2:30 p.m. revealed the hospital had not found a Psychologist to provide the services.




22538

Based upon review of 3 of 6 medical records and staff interviews, the hospital failed to ensure the Master Treatment Plan identified activity therapies based upon the assessment conducted by the Activity Therapist. This was evidenced by the SF3 Activity Therapist's failure to identify activity therapies on the Master Treatment Plan based upon the activity assessments for patients #F1, F4 and F6. Findings:

Review of the medical records for patients #F1, #F4, and #F6 revealed SF3 Activity Therapist conducted an initial activity assessment on each patient and identified specific activities for each patient. Review of the Master Treatment Plans for patients F1, F4 and F6 revealed the only clinical interventions identified were "activity therapy".

Interview with SF3 Activity Therapist on 08/19/14 at 3:00 p.m. revealed when asked about identifying the clinical interventions for the type of activities for each patient, SF3 Activity Therapist responded she was not aware the activities needed to be documented on the Master Treatment Plan.




22538