HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure that patients received care in a safe setting. The deficient practice was evidenced by failing to ensure the physical environment was maintained in a manner to assure an acceptable level of safety and quality for geriatric psychiatric patients admitted for being a danger to self or others. Findings:

On 08/16/2021 at 10:15 a.m. an observation was made of the hospital's patient care area in the Geriatric Psychiatric Unit. The following ligature and safety risks were observed:

1) The unit's 12 patient beds were electric beds with cords. The patient beds were observed to be adjustable hospital-type beds with 4 closed side rails (2 - 1/4 rails per each side of the bed). The beds had headboards and footboards. The beds provided multiple potential ligature points.
2) Patients' bathrooms in rooms 714 and 717: Observed toilets in the patients' bathrooms with an opening between the toilet and the wall that provided a potential ligature point. The toilet seats were capable of being raised and also provided a ligature risk.

An interview was conducted with S3Director and S2SrDirector on 08/17/2021 at 10:30 a.m. that confirmed the above observations. They reported the unit was a geriatric psychiatric unit which admitted patients 65 years and older.