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Based on observation of three units, review of medical records, and staff interviews, the facility failed to safeguard and uphold the rights of each patient in the facility.

A. This failure resulted in 44 of 44 bedrooms on units A1, A2, and A3 with observable ligature risks (toilets and bathroom doors) and 10 of 10 patients (Patient #8, 9, 10, 11, 12, 13, 14, 15, 16, and Patient #17) on suicide precautions being placed in bedrooms with adjacent bathrooms that had observable ligature risks. These anchor points could be used to attach material for the purpose of hanging or strangulation. Such actions have the potential to cause serious injury, impairment, or death.

B. This failure resulted in 4 of 4 seclusion rooms that had blind spots when providing one-on-one observation from outside the seclusion room door. In addition, the adjacent bathrooms to 4 of 4 seclusion rooms had observable ligature risks (toilets).


Cross reference: A0144

Based on interview and record review, the facility failed to document in its written notice to 1 of 1 patient (Patient #2) the date of completion.


Findings included:


Record review of "Patient Rights and Responsibilities," policy #1000.01, revised 1/1/2018 showed: "C. The Patient's Bill of Rights shall include ... the patient's right to: ... 24. Be advised of the hospital grievance process ... Notification of the grievance process includes: ... the results of the grievance and the grievance completion date."

Record review of "Patient Complaint and Grievance Process," policy #1000.09, revised 10/16/2017, showed: " ... C. The information provided to the patient includes: ... 5. Timeframes for review and resolution of grievance ... J. The patient will be provided with written notice of: ... 4. The date of completion of the complaint and grievance process."

In an interview with the patient advocate (Staff D) on 6/4/2019 at 2:00 PM, she stated that she does not include the date of completion in the correspondence to complainants.

Record review of the letter to patient #2 showed:
1) There was no date of completion within the body of the letter to Patient #2.
2) The letter to Patient #2 was not dated.

Based on observation, review of medical records, and staff interviews, the facility failed to ensure that patients received psychiatric care in a safe setting.

A. This failure resulted in 44 of 44 bedrooms on units A1, A2, and A3 with observable ligature risks (toilets and bathroom doors) and 10 of 10 patients (Patient #8, 9, 10, 11, 12, 13, 14, 15, 16, and Patient #17) on suicide precautions being placed in bedrooms with adjacent bathrooms that had observable ligature risks.

B. This failure resulted in 4 of 4 seclusion rooms that had blind spots when providing one-on-one observation from outside the seclusion room door.


Findings:


A. Ligature risks.

Based on observation, review of medical records, and staff interviews, the facility failed to ensure that patients received psychiatric care in a safe setting.

A. This failure resulted in 44 of 44 bedrooms on units A1, A2, and A3 with observable ligature risks (toilets and bathroom doors) and 10 of 10 patients (Patient #8, 9, 10, 11, 12, 13, 14, 15, 16, and Patient #17) on suicide precautions being placed in bedrooms with adjacent bathrooms that had observable ligature risks.

B. This failure resulted in 4 of 4 seclusion rooms that had blind spots when providing one-on-one observation from outside the seclusion room door.


Findings:

In an interview with Staff A on 6/4/2019 at 2:15 PM, he stated that patients are presented with a copy of the "Patient's Bill of Rights" at the time of admission.

Record review of the "Patient's Bill of Rights" [provided to patients at the time of admission] showed: "3. You have the right to a clean and humane environment in which you ae protected from harm ... 5. You have the right to be free from mistreatment, abuse, neglect, and exploitation ..."

Record review of "Rights and Responsibilities of the Patient" policy #1000.01, revised 1/1/2018, showed, "... All hospital staff, medical staff and contracted agancy staff performing patient care activities shall ovserve these patient rights ... care ... provided in a safe environment ..."


A. Ligature risks.

Observation of the bedrooms and bathrooms on Units A1, A2, and A3 on 6/4/2019 at 10:30 AM showed:

1) Toilets were not mounted flush to the wall and floor, creating a loopable hole between the toilet bowl and the wall that could be used as a tie off point for hanging or strangulation.

2) Though bathroom doors were cut at an angle across the top, an anchor point was identified on top of the door hinge that could be used as a tie off point for hanging or strangulation.

Observation of the bathroom in rooms 206 and 208 on 6/4/2019 at 10:30 AM showed Staff F was able to tie off on the bathroom doors with a sheet to create a means for hanging or strangulation.

In an interview with Staff F on 6/4/2019 at 10:45 AM, he stated:

1) The top of the hinge on the bathroom doors created an anchor point that could be used for hanging.

2) There were 44 bedrooms with adjacent bathrooms on units A1, A2, and A3.

3) None of the toilets in these 44 bathrooms were mounted flush to the wall and floor.

4) All of the bathroom doors in these 44 bathrooms had an anchor point on top of the door hinge.

5) The bathroom doors had been replaced with soft suicide prevention doors and the toilets were mounted flush to the wall and floor on unit C, a recently remodeled unit.

In an interview with Staff E on 6/4/2019 11:55 AM, he stated he has seen patients tie off on toilets in a suicide attempt.

In an interview with Staff C on 6/4/2019 at 11:00 AM, she stated there were 10 patients (Patient #8, 9, 10, 11, 12, 13, 14, 15, 16, and Patient #17) on units A1, A2, and A3 that were on suicide precautions.


Patient #8.

Record review of the Psychiatric Evaluation by Staff K (MD) dated 6/3/2019 at 9:58 showed command hallucinations telling him to kill himself.

Record review of the Physician Orders by Staff K (MD) dated 6/4/2019 at 10:27 showed suicide precautions. Patient #8 was in room #305/A.


Patient #9.

Record review of the Psychiatric Evaluation by Staff K (MD) dated 5/29/2019 at 5:26 PM showed voices commanding him to harm himself. He did not want to live.

Record review of the Physician Orders by Staff K (MD) dated 6/3/2019 at 11:35 AM showed suicide precautions. Patient #9 was in room #307/A.


Patient #10.

Record review of the Physician Progress Note by Staff X (NP) dated 5/30/2019 at 9:18 AM showed history of self-harm behaviors. He was unable to commit to safety.

Record review of the Physician Orders by Staff X (NP) dated 6/4/2019 at 10:51 showed suicide precautions. Patient #10 was in room #310/A.


Patient #11.

Record review of the Admission Orders by Staff Z (MD) dated 6/3/2019 [not timed] showed major depressive disorder, recurrent, with psychotic features. Suicide precautions were ordered. Patient #11 was in room #211/B.


Patient #12.

Record review of the Psychiatric Evaluation by Staff K (MD) dated 6/3/2019 at 10:11 AM showed voices commanding him to kill himself. He had attempted suicide the day prior to admission.

Record review of the Admission Orders by Staff K (MD) dated 6/4/2019 at 12:02 PM showed suicide precautions. Patient #9 was in room #212/A.


Patient #13.

Record review of the Admission Orders by Staff AA (MD) dated 6/4/2019 [not timed] showed schizoaffective disorder, depressed type, and suicide precautions. Patient #9 was in room #212/B.


Patient #14.

Record review of the Psychiatric Evaluation by Staff K (MD) dated 5/29/2019 at 4:00 PM showed suicidal ideation and a suspected suicide attempt with Xanaflex. She had written a suicide note.

Record review of Physician Orders by Staff K (MD) dated 6/3/2019 [not timed] showed suicide precautions. Patient #14 was in room 111/B.


Patient #15.

Record review of the Psychiatric Evaluation by Staff BB (MD) dated 5/28/2019 at 12:45 PM showed suicidal thoughts and severe psychosis and paranoia.

Review of Admission Orders by Staff J (MD) dated 5/27/2019 at 1:30 AM showed suicide precautions. Patient #15 was in room 111/A.


Patient #16.

Record review of Physician's Orders and Preliminary Plan of Care by Staff CC (MD) showed major depressive disorder, recurrent, severe and suicide precautions. Patient #16 was in room #112/B.


Patient #17.

Record review of Admission Orders by Staff DD (MD) dated 6/3/2019 at 3:42 PM showed a history of schizophrenia and suicide precautions. Patient #17 was in room 205/B.


Seclusion Rooms.

Observation of the seclusion rooms on units A2 and C showed:

1) Blind spots when providing one-on-one observation from outside the seclusion room door. When a staff member stood in the corner to the extreme left of the seclusion room door, the staff member could not be seen by the surveyor stationed outside the door looking through the window of the door.

2) The toilets in the bathrooms adjacent to the seclusion rooms were not mounted flush to the wall and floor. This created a loopable hole between the toilet bowl and the wall that could be used as a tie off point for hanging or strangulation.

In an interview with Staff A on 6/4/2019 at 11:15 AM, he stated there was a total of four seclusions rooms with these blind spots and toilets that were not mounted flush to the wall and floor. He also stated that the blind spots had been identified as an issue and psych-safe convex mirrors were going to be installed in one corner of the rooms.