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Based on observation, interview and document review, the facility was found not in compliance with §485.623 Condition of Physical Plant and Environment, when the faciliy failed to ensure the environment was free of ligature risks on the Senior Care unit, the facility's inpatient geriatric psychiatric unit.

Findings include:

Refer to C222--The facility failed to maintain electrical, mechanical and patient care equipment in a manner to prevent ligature risk for all 9 patients who currently resided in the unit.

Based on observation, interview and record review, the facility failed to ensure the environment of the Distinct Part Unit (DPU) for geriatric Psychiatric Services, known as the Senior Care Unit, was free of ligature risks. This had the potential to affect all nine patients(P1, P2, P4, P5, P6, P7, P8, P9 and P10) who currently resided in the 10-bed unit.

Findings include:

According to CMS (Centers for Medicare and Medicaid Services) S&C (survey and certification) memo 18-06; 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, and radiators, bedsteads, window and door frames, ceiling fittings, handles, hinges and closures.

On 4/2/19, at 10:45 a.m. the Unit's program director, registered nurse (RN)-A, confirmed the unit consisted of a total of seven single rooms, (Rooms 30, 32, 33, 34, 35, 36 and 37) and two double rooms (Rooms 32 and 39.) RN-A stated room 30 was specifically used for patients, which required closer observation as the room was directly diagonally across from the nurses' station. RN-A stated when room 30 was used; one of the other beds would be taken out of service in order to maintain the 10-bed requirement. RN-A stated the behavioral health unit provided psychiatric care to patients 55 and older, and indicated their overall population was geriatric. RN-A stated most of their patients required physical assistance with activities of daily living (ADLs) in addition to psychiatric/behavioral health care. She stated the patient rooms were along a hallway around the corner of the nurses' station which was enclosed in safety glass with a half door. RN-A stated the hallways and rooms had real time video monitoring which was observed from the monitors at the nurses' station. Further, RN-A stated when motion was detected in one of the patient rooms, the video monitor would automatically turn on and staff were able to observe resident movement.

During a unit tour on 4/2/19, at 11:15 a.m. with RN-A, the following observations of ligature risk were identified and confirmed with RN-A:

Ligature risks in patient rooms 32 and 39 (which were set up identically) were as follows:
-a double room with two, standard mechanical hospital beds with a metal frame and bilateral side rails. The beds were affixed to the floor with metal brackets to prevent the bed from moving and the head of the bed and foot of the bed had been affixed with a safety strip to the bed frame to prevent the head and foot of the bed from moving up and down. The bathroom doors had continuous hinges and door closures that were non-weight bearing, however the bathroom faucets, paper towel holders and dispensers were all-standard and were not ligature proof. Further, the patient room door had exposed hinges internal to the room and a standard door handle.

Ligature risks in patient rooms 30, 32, 33, 34, 35, 36, 37, (which were set up identically) were as follows:
-each room had a single standard mechanical hospital bed with a metal frame and bilateral side rails. The beds were affixed to the floor with metal brackets to prevent the bed from moving and the head of the bed and foot of the bed had been affixed with a safety strip to the bed frame to prevent the head and foot of the bed from moving up and down. The bathroom doors had continuous hinges and door closures that were non-weight bearing, however the bathroom faucets, paper towel holders and dispensers were all-standard and were not ligature proof. Further, the patient room door had exposed hinges internal to the room and a standard door handle.

On 4/2/19, at 12:10 p.m. RN-A confirmed the aforementioned points were potential ligature risks however, stated she felt the risk for ligature with their patient population was minimal. RN-A stated the unit had processes in place to identify patients at risk for self-harm and/or suicide which began with the unit's pre-screening process.

On 4/2/19, at 2:00 p.m. the intake coordinator, RN-B, stated her primary role was completing patient intakes and pre-screening processes. RN-B stated she routinely assessed each potential patient's risk of self-harm and/or suicide and often times would not accept those patients. RN-B stated due to the typical acuity level of their inpatients (ADL and behavioral) needs, she felt the unit was not typically appropriate for a patient with suicide and self-harm risk. She stated she could not recall when/or if they had provided services for a patient identified at risk for self-harm/suicide within the last few years.

On 4/2/19 at 4:06 p.m., a follow up interview was conducted with RN-A. RN-A confirmed the unit had not completed a ligature risk assessment and confirmed there were no current processes in place to fix the aforementioned ligature risks. RN-A stated she felt the ligature risk guidelines did not apply to a geriatric inpatient unit, and stated the nursing staff routinely assessed patients' behavioral needs and implemented monitoring/supervision interventions as needed. RN-A stated all patients were on routine every 15-minute checks (observations) and that the frequency of checks would increase based upon need, up to 1:1 supervision.

Review of the facility's behavioral health unit policy, Precautions Monitoring reviewed 11/18, indicated the purpose of the policy was to: describe the process of assessing an individual's suicide, homicide, or elopement risk and subsequent degree of supervision. The policy revealed all individuals admitted to the program were assessed for their degree of risk behavior during the admission assessment process. The policy indicated, the admitting nurse would assess the patient for suicide risk, degree of agitation, and subsequent potential for violence to self or others. The policy listed a description of precaution levels which included:
-15 minute checks, patient under supervision of staff every 15 minutes and documented every 15 minutes.
-constant visual, patient to remain visible to assigned staff member at all times and placed in a room close to the nurses station. Patient behavior documented every 15 minutes and would be discontinued by a physician.
-within arm's reach, patient is assigned a staff member who remains in the immediate vicinity of the patient and placed in a room close to the nurses' station. The patients' physician and treatment team to determine possible transfer needs of the patient and document behaviors every 15 minutes.

Review of the facility's 11/18 policy Patient Safety, identified it was the purpose of the policy to provide general guidelines for maintaining a safe environment. The policy revealed safety guidelines in effect during times on the unit were to provide a safe environment for patients, staff and visitors. The guidelines were listed as follows:
-a potential search of patients, staff and visitors may be done in certain circumstances.
-doors to enter and exit the unit remained locked at all times
-all patients were treated as high risk for falls.
The policy lacked any indication of potential ligature risk.