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Based on record review, observation and interview, the hospital failed to ensure patients' rights were enforced and to provide a safe patient care environment based on the patients' needs for three of three current patients (Patient #8, #9, #21) who had access to furnishings and objects potentially hazardous to the patients.

Cross refer to A 0144.

Based on interview, record review, and observation, the hospital failed to ensure the rights of 3 of 3 patients (Patients #8, #9, #21) to receive care in a safe patient care environment.

1) Patient #9 was admitted with suicidal thoughts and a specific plan. The patient told staff she felt hopeless and was serious. Patient #9 was placed on routine staff safety checks. Patient #9's room with a metal bar bed had the potential for ligature. The room was far from the nurses' station. Patient #9 was not moved to a room closer to the nurses' desk until after surveyor observation.

2) Patient #8 was admitted with expressive suicidal thoughts and no reason to live. Less than 24 hours before surveyor observation, Patient #8 was noted to be in severe clinical depression. The patient was placed in a room with several opportunities for ligature including a metal bed with side rails and two devices with long electrical cords. Patient #8's room was at the very end of the "long" hallway at the farthest distance away from the nurses' station.

3) Two-third of the hospital's dining room chairs had legs of uneven length which made them unstable. One of the chairs was assigned to Patient #21 who had experienced a fall at the hospital earlier and was assessed to be at a high risk for falls.

Findings included:


1) Patient #9 was surveyor interviewed on 05/25/16 at 1445 and stated she was depressed and thought it was "hopeless" after she had suffered a debilitating stroke, was in pain, and planned to take "...the whole bottle of Lisinopril [blood pressure medication]." Patient #9 stated she was very sad and angry about losing her independence due to the stroke.

Observations on 05/25/16 at 1450 reflected the patient was in a metal bed with multiple individual bars potentially usable for ligature. She was covered by a white bed sheet. Her room was approximately 75 steps (approximately 60 yards) away from the nurses' station.

Patient #9's Pre-Admission Exam dated 05/23/16 at 1750 reflected the patient had suicidal ideation.

Nursing Assessment dated 05/23/16 at 1900 reflected Patient #9 was noted to be of high risk for suicide. The patient verbalized the plan to use a knife or take all of her blood pressure medications in a glass of water. Patient #9 was asked about her intent to act on suicidal thoughts and responded, "If I have the opportunity I will...I am very serious..."

Admission Orders dated 05/23/16 at 1900 reflected Patient #9 was placed on 15-minute level of observation for suicide.

Patient #9's Physician Psychiatric Evaluation dated 05/24/16 reflected the patient had been admitted because "...she wanted to die...had a pretty good idea how to kill herself...reports she does not want to have another stroke, reports...hopelessness ...helplessness..."

Practitioner Psychiatric Progress Notes dated 05/25/16 reflected Patient #9 had suicidal ideation "intermittently."

Personnel #4 stated on 05/26/16 at 1430 that actively suicidal patients were placed on one-to-one staff observation and moved close to the nurses' station.

Nursing Progress Notes dated 05/26/16 at 2100 (approximately 30 hours after initial surveyor observation) reflected the patient was moved "...to be closer to the nurses' station."

2) Patient #8's MOT (Memorandum of Transfer) Physician Note dated 05/23/16 at 2245 reflected the patient had "expressive suicidal thoughts" and had planned to "blow...[her] head off...no reason to live..."

Patient #8's admission nursing assessment dated 05/24/16 at 0129 reflected the patient's "high" level of suicidal ideation. Patient #8 stated she had been depressed for five years.

Patient #8's diagnostic interview dated 05/25/16 at 1316 reflected the patient had severe clinical depression and had thoughts that "she would be better off dead...unable to verbalize examples of coping skills..."

Observations on 05/26/16 at 1130 reflected Patient #8's bed had a remote control device with a curly electrical cord of at least three feet length. Personnel #3 acknowledged the cord. The patient's metal bed and its two sets of side rails had individual bars with multiple spaces potentially usable for ligature.

Observations in Patient #8's room on 05/26/16 at around 1130 reflected a second bed with individual metal bars and a corded weight sensor device. Personnel #3 stated at that time that the cord was "longer than a foot" and requested that Personnel #27 shorten the cord with a zip tie.

Personnel #4 stated on 05/26/16 at 14:30 that all 36 beds on the unit were metal beds. Personnel #4 stated that actively suicidal patients were placed on one-to-one staff observation and longer cords in patients' rooms were "zip tied."


3) On 05/26/16 at 1256 Patient #21 was observed in the dining room seated on a chair with legs of uneven length. The difference in length caused the chair to move when Patient #21 attempted to stand up and transfer to his wheel-chair. The patient became unsteady.

Patient #21's Fall Risk Assessments dated 05/19/16, 05/20/16, 05/21/16, 05/22/16, 05/23/16, 05/24/16, 05/25/16, and 05/26/16 reflected the patient was assessed to be at a high or the highest fall risk.

Practitioner Order dated 05/19/16 at 1644 reflected that Patient #21 had experienced a fall. Nursing was to check the patient for neurological changes.

Observations in the hospital's dining room on 05/26/16 at approximately 1400 reflected 14 out of 21 chairs were unsteady due to legs of uneven length.

Leadership Environmental Rounds documentation dated 05/26/16 at 0645 did not reflect any furniture repair needs.

During an interview on 05/26/16 at 1405 Personnel #3 denied the unsteady chairs in the dining room were identified as a fall risk.

Governing Board Meeting Minutes dated 04/29/16 did not address environmental factors in their fall prevention discussion.

Quality Council Meeting minutes dated 05/19/16 reflected a discussion of fall prevention interventions. They did not include potential risks associated with unstable dining room chairs.

Based on interview and record review, the facility failed to ensure a Registered Nurse evaluated and/or assessed 1 of 3 patients (Patient #1) who sustained a fall.

Findings included:

Patient #1's Psychiatric Evaluation dated 05/12/16 reflected, "80 year old female with...history of arthritis, falls, lumbar pain...presenting from nursing home...due to increased aggression..."

The progress notes (nursing) dated 05/14/16 timed at 0730 reflected, "Patient very agitated...was told in report patient fell yesterday (05/13/16 at 0300) on bottom...witnessed fall...continue to monitor."

The progress notes (nursing) dated 05/13/16 revealed no documentation and/or assessment/evaluation when Patient #1 sustained a fall.

On 05/25/16 at 1350 Personnel #3 was interviewed. Personnel #3 was asked to review Patient #1's medical record. Personnel #3 stated she could not find any initial nursing assessment or documentation which addressed the fall Patient #1 sustained on 05/13/16 at 0300.

The policy and procedure entitled, "Assessment/Reassessment" with a revision date of 07/2015 reflected, " Each patient is reassessed as necessary...or change in their condition..."

Based on observation and interview, the hospital failed to post conspicuously in the administrative lobby likely to be noticed by prospective patients a sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor and post information indicating whether or not the hospital participates in the Medicaid program under a State plan approved under Title XIX.

Findings included:

Observation on 05/26/16 at 1510 reflected there was no sign in the hospital's administrative lobby specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women in labor and information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX.

Personnel #3 acknowledged the findings on 05/26/16 at 1510 and verbalized the intent to post the EMTALA signage.