HospitalInspections.org

Based on review of hospital records and staff interviews, it was determined that the hospital failed to comply with protecting and promoting each patient's rights as evidenced by:

Cross reference A-0144: Failure to ensure a patient bathrooms were free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk and other hazardous sharp object. The facility further failed to comply with the plan of correction and IJ process.

The egregious nature of this deficient practice and the failure of the facility to comply with the survey process by following their mitigation plan resulted in the facility's failure to meet the requirement for the Condition of Participation for Patient Rights and provide a safe environment for patients to protect them from harm.

Based on observation, review of documents and staff interviews, it was determined the Hospital failed to ensure a patient bedroom and bathroom was free from a condition or situation that may cause a patient or other individual to suffer physical injury by not ensuring that the area is free from ligature risk and health and safety concerns by having areas in which a patient could cut themselves. This deficient practice provides opportunities for patients to utilize these as tie off points, thus presenting a health and safety risk for patients that could result in self asphyxiation and death. Sharp mirrors can be used to inflict self-harm and result in patient death by exsanguination.

Findings include:

Policy titled "Patient Rights and Responsibilities" last revised April 4, 2022, revealed, "...8. Patients at ASH have the right to: a. Be safe in their surroundings..."

Observations during an on-site tour in the Palo Verde North and East Units on October 8, 2024, revealed patient bathrooms with sink faucets not flush with sink allowing for a tie-off point and mirrors with excessively sharp corners. A second tour on October 15, 2024, revealed Patient toilet tanks not flush creating tie-off points and patient bathroom grab bars not flush, on tiles at grout points not caulked, creating tie-off points.


Employee #3 and Employee #4 confirmed during a joint interview on October 8, 2024, that patient areas had not been maintained in a manner to decrease patient physical injury risk. Employee #3 and Employee #4 acknowledged the findings on tour on October 15, 2024.