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Based on observation, interview, document review and policy review the hospital failed to protect and promote patient rights. The hospital had multiple hanging risks throughout the facility that patients could use to kill themselves or others. The hospital routinely admits patients who are at risk for suicide/homicide. The hospital has a current census of 13.

The cumulative effect of the hospital's failure to ensure suicidal/homicidal patients receive care in a safe setting has the potential for all patients to harm or injure themselves or others.

Findings Include:

The hospital failed to ensure suicidal/homicidal patients receive care in a safe setting due to the presence of multiple hanging risks throughout the facility (Refer to A-0144).

Based on observation, interview, document review and policy review the hospital failed to ensure patients at risk for suicide or who have homicidal thoughts receive care in a safe setting due to multiple hanging risks throughout the facility.

Failure of the hospital to ensure care in a safe setting places all suicidal/homicidal patients at risk for injury or harm to self or others.

Findings Include:

Review of the Centers for Medicare & Medicaid Services (CMS) article titled, "Clarification of Ligature Risk Policy," dated 12/08/17 showed the care and safety of psychiatric patients and the staff that provide that care are our primary concern ...a ligature risk (point) is defined as anything which could be used to attach a cord, rope, or other material for the purpose of hanging or strangulation. Ligature points include shower rails, coat hooks, pipes, radiators, bedsteads, window and door frames, ceiling fixtures, handles, hinges and closures ...the focus for a ligature "resistant" or ligature "free" environment is primarily aimed at Psychiatric units/hospitals.

Review of the CMS memorandum titled, "Clarification of Ligature Risk Interpretive Guidelines," dated 04/19/19 showed "Patient Rights" (42 CFR 483.13(c)(2)) establishes the rights of all patients to receive care in a safe setting and is intended to provide protection for a patient's emotional health and safety as well as his or her physical safety ...in order to provide care in a safe setting, hospitals should identify patients who are at risk for intentionally harming themselves or others, identify environmental risks ...and provide environmental safety education and training ...guidelines are intended to provide increased direction, clarity and guidance regarding what constitutes a ligature risk and clarify the expectation that hospitals achieve a ligature "resistant" environment in psychiatric hospitals.

Review of the hospital's undated document titled, "Patient Rights," located in the admission packet showed patients have the right to receive care in a safe setting.

Review of the hospital's policy titled, "Patient Rights and Responsibilities," dated 05/05/21 showed the document is given and explained upon admission ...and annually thereafter.

Review of the hospital's policy titled, "Suicide Awareness, Screening and Assessment - Inpatient," dated 02/04/20 showed based on the level or risk identified ...a patient will immediately be placed on one of the following ...risk levels to mitigate potential for harm through implementation of corresponding interventions...a physician's order (based on clinical judgement and assessment) can add to or delete an intervention associated with a specific suicide risk level ...screening will be performed by nursing upon admission ...and on every patient ...each shift by the RN ...high risk one, 1:1 staffing within arm's reach of staff; high risk two, 1:1 staffing within arm's reach of staff or continuous observation (within line of sight of staff) based on discretion of the provider; moderate risk, 10 minute checks with documentation, and low risk, 15 minute checks with documentation of patient location.

Review of the hospital's environmental risk assessment and a risk mitigation report dated 2019 for (sink plumbing, shower handles, hinges on room doors, door handles, chairs, low-max bed (in handicap rooms and rooms 30 and 39 only one was seen on the tour), widows, light coverings outlets, sink handles, cords, DVD/TV cart, plexiglass covers over overhead lights, door knobs and closures, rails in day room, courtyard area, hall call lights, cords to CD players and clocks, fire extinguisher cabinet handles, mirrors in hallway, water fountain, exit signs, wing 4 exit door release bar, shower rod holders, vent in sunflower room, blinds, knobs for window blinds, smoke detectors, and shower curtains) showed an assessment of each area. The mitigation form showed a column for the internal process, device, scenario and location. An example of a mitigation is as follows: cords are in a public area that is monitored by camera in addition to other in person monitoring; many of the chairs that could be lifted and broke are in public areas therefore it would be more difficult to inflict harm with this item.

Review of the hospital's policies failed to show a policy for Ligature Risks.

The hospital has a current census of 13 patients. All 13 patients were listed at some level of risk for suicide.


Sample of Patients


Patient 1
Review of Patient 1's medical record showed she is a 33-year-old female, with a diagnosis of depression and suicidal thoughts with a plan to overdose on medications and was admitted to the inpatient hospital on 07/15/21 at 4:41 PM via private car with her family.

Review of physician orders showed on 07/15/21 at 6:47 PM Patient 1 was assessed as moderate risk for suicide, and okayed to have a fan/radio. Her orders were updated on 07/16/21 at 1:19 PM to low risk for suicide. Patient 1 remains as low risk for suicide.

Review of nursing assessment dated 07/15/21 at 8:30 PM, Staff P, RN noted the patient stated that her depression is so bad that she took five hydroxyzine (treats anxiety, nausea, vomiting, and allergies) before her therapy appointment yesterday, they completed a safety plan and she went home. That night she took 10 Benadryl (for pain and itching) and eight Vistaril (for anxiety, nausea, vomiting and allergies). The next morning, she went back to her therapist who told her she would need to be admitted for inpatient care.

Review of psychosocial assessment dated 07/16/21 at 1:59 PM, Staff R, Licensed Specialist Clinical Social Worker (LSCSW) noted the patient stated, "I wanted to end my life," she has anxiety, psychotic symptoms, past suicide attempts, and an eating disorder.

Observation on 07/20/21 at 5:07 PM, Patient 1 had a small portable fan plugged into the wall, running at high speed, sitting on the mattress at the head of her bed. Patient 1 stated that she likes the fan on at night to help her sleep better. Staff N was asked by the surveyor if the fan was a ligature/safety risk and she stated it was but Patient 1 is on a low suicide risk level. Patient 1 had the fan in her room since admission when she was at moderate risk for suicide. Patient 1 had a bed, desk chair and bathroom sink in her room that failed to be ligature safe and could be used to hang herself.



Patient 2

Review of Patient 2's discharged medical record showed a 24-year-old male, with a diagnosis of depression and suicidal thoughts without a plan was admitted to the inpatient hospital on 04/19/21 at 11:04 AM.

Review of nursing assessment dated 04/19/21 at 11:45 AM, Staff I, RN noted the patient was anxious, cooperative, depressed, and alert and oriented. He was a referral due to increased stressors, drinking on duty, and suicidal ideation.

Review of physician orders showed on 04/19/21 at 12:21 PM Patient 2 was assessed as moderate risk for suicide and his status was updated on 04/19/21 at 4:56 PM to a low risk for suicide and remained that way until his discharge.

Review of the psychiatric assessment dated 04/19/21 at 2:50 PM, Staff S, Advanced Practice Registered Nurse (APRN) noted the patient stated, "I needed to (come here) before I did something stupid." The patient has had a past suicidal attempt holding a gun to his head, and his brother died by suicide. The patient reported he was a former gang member, and experienced physical, verbal and sexual abuse from his mother.

Review of the psychosocial assessment dated 04/19/21 at 3:30 PM, Staff R, LSCSW noted the patient refused to allow her to collaborate with his family, he has family history of suicide, he has anxiety, mania, physical and emotional abuse.

Observation of Patient 2's assigned room during his admission showed he had a bed, desk chair and bathroom sink in his room that failed to be ligature safe that could be used to hang himself.



Patient 3

Review of Patient 3's discharged medical record showed a 38-year-old female, with a diagnosis of attempted suicide (driving her car into the path of a semi-truck that was traveling at a highway speed) was admitted to the inpatient hospital on 05/15/21 at 7:14 PM.

Review of physician orders on 05/15/21 at 10:12 PM showed Patient 3 was moderate risk for suicide and on 05/18/21 at 4:29 PM she was updated as a low risk for suicide.

Review of the psychiatric assessment dated 05/16/21 at 10:15 AM, Staff O, MD noted the patient was brought by EMS after driving her car into the path of a semi-truck that was traveling at a highway speed. She was unrestrained, and airbags deployed, but the patient was not seriously injured. A long traffic jam ensued and reportedly the truck carrying hazardous material toppled and erupted. She is disappointed and angry it failed.

Review of the psychosocial assessment dated 05/17/21 at 11:19 AM, Staff K, LMSW noted the patient stated that this suicide attempt had been formulating since an attempt with alcohol and pills didn't work on 05/12/21. The patient had depression, anxiety, past suicide attempts, and substance abuse. The plan is for therapy, coordination with family, medication management, and working on a safety plan.

Observation of Patient 3's assigned room during her hospitalization showed she had a bed, desk chair and bathroom sink in her room that failed to be ligature safe that could be used to hang herself.



Tour of the Facility

During a tour on 07/19/21 at 4:34 PM, Staff I, RN showed the facility has one water fountain on the north wall of the common area with a water faucet that protrudes from the top making it a hanging risk and the water fountain has a large open space above and under the sink area making it a ligature point that would be easy to tie a cord around.

The first day room showed a television mounted on the wall that failed to have a ligature safe covering over the glass. A patient could potentially break the glass and use it to harm themselves or others. The television cords and DVD cords were exposed and a patient could use them to hang themselves or wrap around another patient's neck. There were multiple chairs and small end tables that failed to be weighted. These chairs and tables could be used as weapons and thrown at staff, visitors and other patients. The shelves on each side of the fireplace were filled with books and games on a shelf unit that failed to be locked up. The shelving could be use as a hanging point.

The activity room showed a small portable plastic unit with drawers that could be used as a hanging point. There were two shelf units with puzzles and one table with a puzzle that was currently being worked on that could be used as hanging points. The patients were free to come into the activity room whenever they wanted. The wooden chairs and tables were not weighted and could be used as weapons and thrown at staff, visitors, and other patients.

There was a work room and medication room located behind the central desk both of which were opened with no staff present. The open medication door could potentially allow all patients, including suicidal patients access to medications.

In the large common area with the central desk, there is a large non-weighted table with eight non-weighted chairs around it and a small end table that could be used as weapons and thrown at staff, visitors, or other patients. On the east wall, there was a radio plugged in the wall with a cord that someone could use to hang themselves or wrap around another patient's neck; a plastic magazine holder, and small trash can that could easily be used as weapons and thrown at patients, staff, and visitors. The south wall had a large chalk board mounted to the wall which could be used as a hanging point.

There are three hallways that come off the central area. One hall has rooms numbered 30 - 39 which can have two beds per room, another hallway has beds numbered 40 - 49 that showed four of the 10 rooms are designed for handicap accessibility (40, 41, 48, and 49), and the other six rooms can have two beds. Each of the non-handicap rooms showed the sinks failed to be ligature safe as they had regular mounting for the on/off water spout, the beds were wooden framed that failed to be weighted and the slats could be used as a hanging point. The chairs for each desk area failed to be weighted and could be used as weapons and thrown at patients, visitors, and staff. Three of the four (40, 41, and 48) disability rooms had non-weighted chairs at the desks that could be used as weapons to throw at patients, staff, and visitors and one of the four rooms had a hospital bed that failed to be ligature safe and could be used as hanging point. The hand rails in each hallway failed to be ligature safe and a patient could wrap something around the rail and hang themselves.

The 40's hallway (south) showed two main hallway doors that failed to have ligature safe hinges at the top that could be used as a hanging point. The end of the hallway showed a door leading outside with a hinge at the top that failed to be ligature safe and could be used as a hanging point. The hallway had two small alcoves, one of which had 2 small unweighted tables that could be used as a weapon and thrown at staff, visitors, and other patients, and a television attached to the wall with the television and DVD player cords exposed which could be used to hang someone and the glass screen of the TV could be broken and used to hurt someone. The other alcove had a small end table that failed to be weighted and could be used as a weapon and thrown at staff, visitors, and other patients.


The 30's hallway (east) showed the main hallway doors and the outside exit door at the end of the hallway failed to have ligature safe hinges at the top which could be used as a hanging point. One alcove showed one non-weighted chair that could be used as a weapon and thrown at patient, staff, and visitors, and the second alcove showed a large old television (with glass front exposed - which could be broken and used as a weapon to hurt self or others) on a portable, moveable stand with the television/DVD cords exposed that could be used to hang someone. There was a non-weighted chair and small non-weighted side table that could be used as a weapon and thrown at patient, staff, and visitors.

The north hallway had a separate bathroom for patient use if they are in seclusion with a non-ligature safe toilet and sink which could be used as a hanging point.


During an interview on 07/20/21 at 8:31 AM, Staff C, Facilities Director stated that the last environmental risk assessment was completed in 2019 and the last walk through assessment of all patient rooms and common areas was completed 03/26/21. Staff C stated that they try to fix any items as soon as possible when they need repair. Staff H, MD, Medical Director stated that they mitigate the risk by continually assessing each patient for their suicide risk level to ensure patient safety. Staff D, Director of Inpatient Clinical Services stated that suicide checks are performed on each patient around the clock according to their risk level.

During an interview on 07/21/21 at 10:37 AM, Staff F, Risk Manager stated that the safety committee performs environment of care rounds twice a year in all patient care areas. He stated that these are in addition to the assessments performed by the maintenance department. Staff F stated that the safety guidelines are based on guidance from the Kansas Department of Health and Environment (KDHE), the Centers for Medicare and Medicaid Services (CMS), Joint Commission on Accreditation of Health Care Organizations (JCAHO), and Occupational and Safety Health Act (OSHA).