HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure the patient's right to a safe, hazard-free environment on 2 of 2 patient units ( Units 2 & 3).

Both units contained widespread safety risks that included: non-ligature resistant door handles, door hinges, faucets, and toilets.

Findings include:

Bathroom hazards: faucets and toilets:
*Unit 3:

Interview on 12-30-15 at 2:15 p.m. with Unit Supervisor # 3 he stated there was a total of eleven (11) patient rooms with two (2) beds each.

All of the rooms (except one) had a connecting shared bathroom in between 2 bedrooms. Unit Supervisor # 3 said the bathrooms were kept locked and could only be opened by staff members with a key.

He went on to say patients were allowed 15 minutes in the bathroom to take a shower. If a patient was on 1:1 monitoring, they would not be left alone in the shower.
Observation at this time of all Unit 3 patient bathrooms revealed:

11 of 11 bathrooms had non-ligature resistant faucets and toilets.

Unit Supervisor # 3 acknowledged the faucets and toilets could pose a ligature risk. He went on to say the last suicide attempt on this unit was over a year ago, and it was more of "of an acting out" than a serious attempt.

*Unit 2:
Observation on 12-30-15 at 3:00 p.m. of Unit 2 revealed the same shared /connecting bathroom set up as unit 3. Observation of all patient bathroom with Unit supervisor # 7 revealed:

11 of 11 bathrooms had non-ligature resistant faucets and toilets.

Unit 2 supervisor # 7 acknowledged the faucets and toilets could pose a ligature risk. He said he had not " thought of these as a safety risk before."

Room Door Hinges and Door Handles:

*Unit 3:

Observation on 12-30-15 at 2:15 p.m. with Unit Supervisor # 3 revealed :

11 of 11 patient room doors had non-ligature resistant door hinges.
9 of 11 patient room doors had non-ligature resistant door handles.

Interview at time of observation, Unit Supervisor # 2 stated patient's bedroom doors were most always kept open. There were times when a patient might request the bedroom door be partially closed for privacy during shower time. Unit supervisor # 2 acknowledged this could pose a safety hazard.

He went on to say there were two(2) current patients on "modified" suicide precautions (SP) : Patients # 5 and # 6.

Patient # 5 : SP modification was she was allowed to go out on the patio.

Patient # 6: SP modification was she was allowed to attend school.

Unit Supervisor # 2 stated patients in suicide precautions were not necessarily placed on 1:1 monitoring. Level of supervision was individualized based on on-going patient assessment.

Review of the physician orders for Patient 5 & 6 revealed each was ordered a Level of Supervision (LOS) of 3.

Review of facility policy titled "Levels of Supervision & Precaution Monitoring," dated 3/2013, read: "...LOS 3:...Expectations of supervision include:...5. The client is to be supervised in the restroom and be checked at least every 15 minutes or more frequently if behaviors warrant.."

*Unit 2:

Observation on 12-30-15 at 3:00 p.m. of Unit 2 along with the unit supervisor revealed:

11 of 11 patient room doors had non-ligature resistant door hinges.

9 of 11 patient room doors had non-ligature resistant door handles.

Unit 2 supervisor # 7 acknowledged the hinges and door handles could pose a ligature risk. He went on to say currently there were no patients on suicide precautions on Unit 2.

Interview on 12-30-15 at 3:00 p.m. with Quality Management Coordinator # 2, she stated that daily environmental rounds were made by staff to observe for hazards and safety issues. She stated she was not aware of the hinges and faucets being identified as a ligature risk in the past.

Review of facility form titled " Daily Environment of Care Assessment," read: This assessment is to be completed once per day...the purpose of the daily environment of care assessment is to ensure the unit is safe, clean, and in good repair...by identifying actual or potential...conditions or items that may cause injury to a client OR items that a client may use to HURT THEMSELVES ( facility capitalization)..." The facility had a form for staff to use for these inspections. At the top of the form it read: " Notes regarding specific issues to be addressed: Check all client bedrooms and bathrooms ..for items/conditions.. .that a client could use to hurt themselves...At a minimum the following items are inspected:...sink faucets...doors...door knobs...".

Review of facility "Patient Bill of Rights" (p.3) : "Basic Rights for All Patients" read: "...3. You have the right to a clean and humane environment in which you are protected from harm..."