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Based on observation and interview, the facility failed to meet the requirements for the Condition of Participation of Patient Rights, by not ensuring the patient's right to receive care in a safe setting. This was shown by:

1. Ligature risk hazards present in patient bathrooms;

2. Sharp, rusty metal bolts present in patient bathrooms, posing accidental or intentional injury hazards; and

3. Failure to develop and follow processes to identify and address these safety hazards in their facility-wide environmental risk assessment as well as during their daily room checks.


More specifically, the facility failed to:


1. Identify and remove ligature points in seven patient bathrooms inside patient bedrooms. They consisted of exposed plumbing pipes from the wall connecting to the toilets. These pipes had approximately two to three inches of exposed areas, creating large ligature points. The pipes measured approximately two inches in diameter and carried the water supply used to flush the toilets. When bed sheets were tied to these exposed areas, they were able to withstand the weight of an adult when pressure was applied;


2. Identify, mitigate, and monitor sharp, rusty, exposed bolts securing toilets to floors in six patient bathrooms where patients were currently residing. The bolts, present on of each side of the toilet, protruded directly upwards approximately ½ -1 ½ inches, creating an opportunity for accidental or self-harm injury;

Note-This same issue was cited during a previous survey ending on 2/14/23 when the facility was found not to be in substantial compliance-see Form CMS-2567.

3. Recognize gaps behind toilets as ligature risks, and the sharp, rusty exposed toilet bolts as injury hazards in their own environmental risk assessment. In addition, they failed to identify these hazards during their daily "Day Shift Safety & Security Rounds" and daily "Room Checks", both of which had formal checklists which staff were expected to complete.

(Cross reference Tag A-144)

Based on observation and interview, the facility failed to provide a safe environment for 25 of 46 current patients in the facility as shown by:

1. The presence of ligature risks in seven patient bathrooms (Rooms 1606, 1612, 1614, 1706, 1707, 1713, & 1714) where 14 patients were currently residing (Patient # B, C, E, F, H, K, M, O, P, Q, R, V, W, & Y). Four of these patients were on suicide precautions (Patient #s B, C, E, & F);

2. The presence of sharp, rusty, exposed bolts securing toilets to floors in six patient bathrooms in the patient rooms (Rooms 1602, 1609, 1612, 1613, 1615, & 1712) where 11 patients were currently residing (Patient # D, J, K, S, T, U, W, X, AA, CC, & DD). These bolts, present on of each side of the toilet, protruded upwards approximately ½ - 1 ½ inches. These hazards posed either accidental and/or self- harm injury risks to patients (puncture, cutting, infection), and;

3. Failure to identify and address ligature risks on toilets in patient bathrooms as well as rusty, sharp toilet bolts hazards in patient bathrooms in their own environmental risk assessment. In addition, these hazards were not identified and addressed in their own daily Day Shift Safety & Security Rounds or their daily Room Checks. The facility had created a policy-driven form (Day Shift Safety And Security Rounds") with a checklist that had either failed in effectiveness or was not adhered to.


Findings included:

Review of facility's policy titled "Room Checks", #EOC-20, effective 01/11/2016 showed that the purpose of the policy was to assure a safe patient environment by doing daily room checks for safety factors. These room checks are to be done by staff in each patient room, every day. A nursing staff member is to use a checklist as a guide, and any "broken" areas of rooms will be reported to EOC (Environment of Care) staff. In addition, EOC staff is responsible to ensure that the physical plant is safe, and any broken items are repaired;

Review of another facility policy titled "Safety Inspection Of All Areas", #EOC-28, effective 01/11/2016 showed that patient rooms are to be inspected on a monthly basis, nursing staff performs a "safety walk" daily on every shift and documents findings on a form called a Safety Round form, then reports unsafe issues to the EOC staff;

Record review of the facility form titled "Daily Shift Safety And Security Rounds" (as described in Policy #EOC-28 as Safety Round) showed that on 8/22/23, the sheet was filled out and signed by a Registered Nurse (RN) and a Mental Health Technician (MHT) on duty that day for both facility hallways. The form addressed doors for the facility's front, back, linen room, washer/dryer room, office, and refrigerator being locked; patient buckets (hygiene buckets) being locked; sprinkler head, exits, windows and passageways being unobstructed; a dining area check, and a "shower area" being checked. 'Shower Area' (which is adjacent to the toilets in patient bathrooms) was checked-off on the form as being acceptable with no issues observed.

The staff filling out the form did not address the ligature risks on the toilets or the unsafe rusty bolts.

*Note: The same issue with sharp rusty bolts was previously cited when the facility was found to not be in substantial compliance from a survey earlier this year-See Form CMS-2567, survey ending 2/14/23.

During the survey, the facility also presented a checklist form titled "Room Checks" which was addressed by their policy #EOC-20. One of the items on the list included the entry "Bathrooms neat and clean. No contraband, no linen left in shower". However, these forms were blank and not completed by staff.

Observation of facility's two hallways containing the patient bedrooms on 8/22/23 at 11:30 am with House Supervisor-Staff #H, showed there were a total of 14 patient rooms on the 1600's hallway and 14 patient rooms on the 1700's hallway.

Seven bathrooms in patient bedrooms (Rooms 1606, 1612, 1614, 1706, 1707, 1713, & 1714) were found to have the following present:

Exposed steel plumbing pipes coming from the wall and connecting to the toilet bowls, measuring approximately two inches in diameter. There were open gaps of these pipes present, exposing approximately two to three inches of pipe, creating strong ligature points.

In each of the seven bathrooms with Staff #H present, a bed sheet was able to be tied around the pipes, then draped-over the bathroom's closely adjacent sink from one side to the other (with the sheet falling in between the sink's faucet and the wall, preventing it from slipping forward), leaving approximately three feet of sheet left available to wrap around a person's neck, which was then demonstrated. When the end of the sheet was pulled downwards using Staff H's body weight, the knots on the pipes held strongly in each instance.

In interviews at the time of findings in each of the seven rooms, Staff #H stated the exposed plumbing pipes were all ligature risk hazards and a patient could use this for hanging and strangulation/asphyxiation.

Record review of facility's list of patients currently on Suicide Precautions showed there were a total of 16 patients on these precautions, four of which were housed in the rooms with the ligature risks (Patient #C in Room 1606, Patient #F in Room 1707, Patient #E in Room 1713, and Patient #B in Room 1714).

Continued observation during the same time of the ligature risk findings inside patient bathrooms, also showed following:

In six patient bathrooms, there were sharp, rusty bolts approximately ½-1 ½ inches in height, protruding upwards, one on each side of the toilets, which were used to secure them to the floor.

The following rooms contained hazardous bolts: Rooms 1602, 1609, 1612, 1613, 1615, & 1712. There were 11 patients currently residing in these rooms: Patient # D, J, K, S, T, U, W, X, AA, CC, & DD.

These bolts posed safety hazards for accidental or self-harm injury by puncturing or cutting. They were also an infection risk (bacterial-including tetanus, gut microbes, etc).

In an interview with Staff #H at the time of these findings, he acknowledged these bolts had the potential for injury and stated he was not aware they existed.

In an interview on 8/22/23 at 2:00 pm, Plant Operations Director-Staff #6 stated that the facility rooms were checked every day by various staff for safety hazards and added there were forms that the facility staff are supposed to use as checklists to identify safety hazards for patients. When presented with the findings of the ligature risks on the toilet plumbing and the sharp, rusty toilet bolts, he stated these were not things that were recognized before as safety risks.

Based on record review and interview the facility failed to maintain a medical record that is properly completed for 1 of 1 patient # A with a facial injury.

Patient #A's Medical Progress note by Nurse Practitioner # 16 dated 8/6/23 at 11:15 read: Fall/skin tear-fall precaution/ wound care, apply TAO (triple antibiotic ointment) and open to air.

Patient #A's Medical Progress note by Nurse Practitioner # 14 dated 8/7/23 at 18:34 read Blood pressure on low side. Denies pain. Reported un-witnessed fall incident yesterday. Obtained small skin tear on right upper eyelid. No signs/ symptoms of infection.

Patient #A's Medical Progress note by Nurse Practitioner # 14 dated 8/9/23 at 16:22 read: Forehead swelling reported by nurse. Patient denies any acute injuries or fall States that "this happened when I fell a few days ago. It has been there." Patient expresses no grimacing or signs of pain, mental status, and vital signs at baseline. Patient denies headache, nausea, vomiting, dizziness.

Patient #A's medical record did not contain any descriptive documentation of skin/wound condition after the reported fall. The record is lacking measurements of the skin tear, swelling, or bruising while hospitalized.

Interview on 08/23/2023 at 2:15 pm facility staff ID #17 confirmed the above findings.