HospitalInspections.org

Based on observation and staff interview the hospital failed to ensure they maintained the physical environment of the behavior health unit (BHU) in a manner to provide care in a safe setting. The BHU had no current patients assessed at risk for suicide or harm to others, however, the BHU admits patients with diagnoses of dementia, psychosis, schizoaffective disorder, bipolar disorder, and suicidal ideations. This deficient practice placed patients admitted to the unit with suicidal risk or harm to others at risk for potential harm.


Findings include:


The professional standards of practice were identified as coming for these sources:

The Veteran's Health Administration (VHA) National Center for Patient Safety formed a national committee that developed The Environment of Care Checklist for the purpose of reducing environmental factors that contribute to inpatient suicides, suicide attempts, and other self-injurious behaviors. This initiative is consistent with current literature on prevention of suicidal behaviors (Suicide Prevention Strategies: A systematic review. The Journal of the American Medical Association, (JAMA), 2005, v 294, 2064-2074).

JAMA, published continuously since 1883, is an international peer-reviewed general medical journal published 48 times per year. JAMA is the most widely circulated medical journal in the world.

The VHA and JAMA have all established accepted standards of practice for psychiatric inpatient facilities in the United States.

The VHA committee developed the Mental Health Environment of Care Checklist (MHEOCC) with the goal to prospectively identify and eliminate environmental risks for inpatient suicide and suicide attempts. The following are some of the items included on the MHEOCC to reduce environmental risks for inpatient suicide:

-Furniture should be free of anchor points.

-Closet doors should be free of anchor points.

-Door handles should be free of anchor points.

-Pictures and wall hanging should be tamper resistant screws or anchors
.
-Vents should be secured to the wall or ceiling with tamper resistant screws or anchors.

-Ceilings should be constructed of solid materials.

-Electrical outlets should be protected and tamper resistant.

-Light fixtures should be flush mounted and tamper resistant.

-Hospital gowns should have no strings and fitted sheets should not have elastic.


- Observation of the BHU's 17 patient rooms and one dayroom on 3/10/15 between 9:15 am and 12:30 pm revealed the following;

Observation of each patient room revealed;

1) Patient room door handles have anchor points.
2) Patient room closets had two doors with C-handles that provide a looping/hanging
risk
3) Each patient room had two metal closet doors with C-handles that provide a
looping/hanging risk.
4) Patient rooms had five to seven uncovered electrical outlets
5) Each room had one to two beds with two rails on each bed, an unsecured electrical
cord greater than 12 inches.
6) Each room had one thermostat protruding from the wall
7) One light switch with non-tamper proof screws
8) One wall mounted hand sanitizer.
9) One to two wall mounted white boards
10) Call light with unsecured cord greater than 12 inches

Observation of the Dayhall room revealed;

1) One wall mounted picture with non- tamper proof screws
2) A sink with tall faucet
3) A wall mounted thermostat
4) One wall mounted hand sanitizer.

Observation of the BHU's South hallway and items observed on the unit revealed;

1) A dropped ceiling with 24 by 12 inch tiles
2) 12 wall mounted pictures with non-tamper proof screws
3) Seven electrical outlets easily accessible with non-tamper proof screws.
4) 11 sections of wall mounted side railing, of multiple length sections, open to allow
looping hazard.
5) Two wall mounted hand sanitizers.

Observation of the BHU's North hallway and items observed on the unit revealed;

1) A dropped ceiling with 24 by 12 inch tiles
2) A wall mounted picture with non-tamper proof screws.
3) One electrical outlet easily accessible with non-tamper proof screws.
4)13 sections of wall mounted side railing, of multiple length sections, open to allow
looping hazard.
5) Three wall mounted hand sanitizers
6) The blind area of the hallway contained a cabinet with four C-handles.
7) Exit door with three exposed hinges.

Registered Nurse (RN) staff D on 3/11/14 at 9:30am acknowledged the patient room door handles, closets with C-handles, uncovered electrical outlets, beds with two rails and unsecured electrical cord greater than 12 inches, thermostat protruding from the wall, light switch with non-tamper proof screws, wall mounted hand sanitizer, wall mounted white boards, and call light with unsecured cord greater than 12 inches.

Administrative Nursing staff B interviewed on 3/10/15 at 9:45am acknowledged the electrical outlets on the behavioral health unit (BHU) were the same as all the others throughout the hospital.

Maintenance staff C interviewed on 3/10/15 at 9:30am revealed the patient room windows were non-breakable glass and standard outlets.