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Based on observation, policy/procedure review, documentation review, patient and staff interviews, the Psychiatric Unit staff failed to establish and then maintain systems that assured a safe and functional environment for patients with a psychiatric diagnosis. The acute psychiatric unit census was 19 in-patients in the child/ adolescent unit, 28 in-patients in the adult unit and 15 in-patients in the older adult unit.

Although the hospital was aware of conditions that posed a risk to patients with psychiatric diagnoses, some of whom may be suicidal, the hospital failed:
- To identify and remove or replace non-breakaway hardware from patient shower room, bathroom and closet doors;
- To maintain a safe environment for suicidal patients by failing to minimize risk factors available in patient bedrooms; and
- To maintain a safe environment for suicidal patients by failing to minimize other risk factors available in patient bathrooms and shower rooms.

(Refer to A144)

The cumulative effect of these systemic failures and deficient practices resulted in the facility's inability to ensure the safe care and monitoring of patients in a safe environment for patients with psychiatric diagnoses who may also be suicidal.

Based on observation, review of policy/procedures, associated documents, and psychiatric staff interviews, the hospital failed to establish and maintain a safe environment for 14 of 14 child/adolescent patient rooms, 18 of 18 adult patient rooms, and 9 of 9 older adult patient rooms on nursing units that treated patients with a psychiatric diagnosis. Lack of a safe environment was demonstrated by the following:

- The patient rooms contained 1 or more unprotected active electrical outlets. Unprotected active electrical outlets can provide a method for electrocution if attempting suicide. This results in an unsafe environment for patients in the child/adolescent, adult, and older adult psychiatric units who may at risk for suicide.
- All rooms contained a hand sink. Psychiatric administrative staff failed to identify, remove or replace faucets on these sinks that were not tamper-resistant or would breakaway when a force was applied. These faucets also had not been tested for breakaway capacity when an outside force wuold be applied. Faucets can provide a point of attachment for a hanging device that a patient can then tie the other end around a patient's neck as a method to attempt suicide. This resulted in an unsafe environment for patients in the psychiatric unit.
- Plumbing to sinks and toilets was not tamper-resistant or would breakaway. The plumbing had not been tested for breakaway capacity if an outside force would be applied. Exposed plumbing to sinks and toilets can provide a point of attachment for a hanging device that a patient can then tie the other end around their neck as a method to attempt suicide. This resulted in an unsafe environment for patients in the psychiatric unit.
- Closet and shower door hinges were visible on the child/adolescent psychiatric unit, and bathroom door hinges in the older adult psychiatric unit. Failure to conceal all door hinges could potentially result in patient deaths or other life-threatening conditions on a psychiatric unit.
- 18 of 18 electric beds in the older adult psychiatric unit had electical cords long emough to use by a patient with suicidal thoughts.

The psychiatric administrative staff identified a census of 19 child/adolescent patients, 28 adult patients, and 15 older adult patients in the 3 psychiatric units of the hospital.

Findings include:

1. Observations of psychiatric units on 9/20/11 revealed the following:

a. At 2:00 PM, a tour of the child/adolescent unit, with the Director of Behavioral Health and Staff B, Manager of Child Adolescent Behavioral Health, revealed:
- 14 of 14 patient rooms contained 1 or more unprotected active electrical outlets. Staff B verified the outlets were operational.
- 14 of 14 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be required before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant.
- 14 of 14 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified the plumbing to the sinks and toilets lacked testing regarding the amount of weight required for plumbing to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.
- Individual patient rooms all contained a closet door. Attaching the closet door to the door frame were 3 visible metal door hinges on 9 of 14 closet doors. Additional observation, at this time, revealed 2 shower doors with 3 visible door hinges, the shower doors opened outward into the hallway. When closed, the shower door hinges were visible only to the patient taking a shower. The door hinges extended approximately 1-inch from the doorframe. The door hinges provided a sufficient area for attachment of a hanging device and resulted in an unsafe patient environment.

b. At 3:20 PM, a tour of the adult unit, with the Director of the Behavioral Health and Staff D, Supervisor of the Adult Behavioral Health, revealed:
- 18 of 18 patient rooms contained 1 or more unprotected active electrical outlets. Staff D verified the outlets were operational.
- 18 of 18 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be required before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant.
- 18 of 18 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified that the plumbing to the sinks and toilets lacked testing regarding the amount of weight required to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.

c. Observation of the older adult unit on 9/21/11 at 8:35 AM, with the Director of Behavioral Health and Staff C, Manager of Older Adult Unit, revealed:
- 9 of 9 patient rooms contained 1 or more unprotected active electrical outlets. Staff C verified the outlets were operational.
- 9 of 9 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be requred before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant
- 9 of 9 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified the plumbing to the sinks and toilets lacked testing regarding the amount of weight required to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.
- 3 metal hinges attaching the bathroom doors to the doorframes in 9 of 9 patient rooms.
- 9 patient rooms each room contained 2 electric beds. The hand controls for raising and lowering 15 of 18 electric beds were located in the handrails at the head of the beds. The hand controls could be used by patients while in or lying under the bed. Operation of the hand controls while under the bed could allow a patient to wedge him or herself under the bed and lower the bed onto their body allowing the bed to crush the patient resulting in a successful suicide attempt. Additional observation revealed the length of the electrical cords was 6 feet 6 inches, which is long enough to use as a hanging device to enable a patient to commit suicide. The hand controls for 3 of 18 beds were on a 4 foot cord and could be moved to any location in or under the bed. The cord lengths were sufficient to use as a hanging device and the beds could be used to crush the patients completing successful suicide attempts. During an interview on 9/21/11 at 8:35 AM, Staff C verified the older adult patients were not supervised constantly while in their assigned rooms. Staff C agreed the electric beds established an unsafe environment for patients.


2. Review of hospital policies and procedures found hospital staff had developed or implemented no policies and procedures that ensured the safety of child/adolescent, adult and older adult patients on the nursing units that treated patients with a psychiatric diagnosis:
- From the active electric outlets,
- That established breakaway points for the exposed plumbing in the patient rooms,
- That established guidelines for enclosing hinges in patient rooms and shower rooms, or .
- That ensured the safety of the older adult patients by establishing guidelines for the length of electrical cords or the safe use of the electrical beds.


3. Review of policy and procedure titled "Suicidal Patient Management Protocol", revised 7/09, found it stated in part, "General Suicide Precautions (SP): Initiated if physician and/or nursing staff access the patient to be potentially suicidal. Involves knowing the general whereabouts of the patient at all times with specific checks being made every 15 minutes ... "

Interviews with staff on the psychiatric units on 9/20/11 revealed the following information:

a. At 2:00 PM, Staff B verified the child/adolescent patients were not supervised constantly while in their assigned rooms. Staff B identified 17 patients currently on suicide precautions.

b. At 3:20 PM, Staff D verified the child/adolescent patients were not supervised constantly while in their assigned rooms. Staff D identified 17 patients currently on suicide precautions.

c. During an interview on 9/21/11 at 8:35 AM, Staff C verified the child/adolescent patients were not supervised constantly while in their assigned rooms. Staff C identified 7 patients currently on suicide precautions.

d. Staff B and D agreed the visible hinges produced an unsafe environment.


4. Review of the hospital document titled "Behavioral Health Area Corrections Risk", last updated 9/2011, revealed a consulting firm identified the above concern areas along with many other risk areas. This consulting firm identified the areas of concern initially in 2007. Although many of the areas of risk were corrected, observations and interviews revealed hospital hospital failed to correct the areas of risk stated above.


5. During an interview on 9/22/11 at 11:45 AM, the Director of Facility Planning and Operations stated the areas identified by the surveyors and the consulting firm were not corrected at the time of the survey.


6. During an interview on 9/22/11 at 8:15 AM, the Safety Program manager and Vice President of operations said the areas of risk identified by the surveyors and the consluting firm were not corrected at time of the survey.

Based on observation, review of policy/procedures, associated documents, and psychiatric staff interviews, the hospital failed to establish and maintain a safe environment for 14 of 14 child/adolescent patient rooms, 18 of 18 adult patient rooms, and 9 of 9 older adult patient rooms on nursing units that treated patients with a psychiatric diagnosis. Lack of a safe environment was demonstrated by the following:

- The patient rooms contained 1 or more unprotected active electrical outlets. Unprotected active electrical outlets can provide a method for electrocution if attempting suicide. This results in an unsafe environment for patients in the child/adolescent, adult, and older adult psychiatric units who may at risk for suicide.
- All rooms contained a hand sink. Psychiatric administrative staff failed to identify, remove or replace faucets on these sinks that were not tamper-resistant or would breakaway when a force was applied. These faucets also had not been tested for breakaway capacity when an outside force wuold be applied. Faucets can provide a point of attachment for a hanging device that a patient can then tie the other end around a patient's neck as a method to attempt suicide. This resulted in an unsafe environment for patients in the psychiatric unit.
- Plumbing to sinks and toilets was not tamper-resistant or would breakaway. The plumbing had not been tested for breakaway capacity if an outside force would be applied. Exposed plumbing to sinks and toilets can provide a point of attachment for a hanging device that a patient can then tie the other end around their neck as a method to attempt suicide. This resulted in an unsafe environment for patients in the psychiatric unit.
- Closet and shower door hinges were visible on the child/adolescent psychiatric unit, and bathroom door hinges in the older adult psychiatric unit. Failure to conceal all door hinges could potentially result in patient deaths or other life-threatening conditions on a psychiatric unit.
- 18 of 18 electric beds in the older adult psychiatric unit had electical cords long emough to use by a patient with suicidal thoughts.

The psychiatric administrative staff identified a census of 19 child/adolescent patients, 28 adult patients, and 15 older adult patients in the 3 psychiatric units of the hospital.

Findings include:

1. Observations of psychiatric units on 9/20/11 revealed the following:

a. At 2:00 PM, a tour of the child/adolescent unit, with the Director of Behavioral Health and Staff B, Manager of Child Adolescent Behavioral Health, revealed:
- 14 of 14 patient rooms contained 1 or more unprotected active electrical outlets. Staff B verified the outlets were operational.
- 14 of 14 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be required before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant.
- 14 of 14 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified the plumbing to the sinks and toilets lacked testing regarding the amount of weight required for plumbing to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.
- Individual patient rooms all contained a closet door. Attaching the closet door to the door frame were 3 visible metal door hinges on 9 of 14 closet doors. Additional observation, at this time, revealed 2 shower doors with 3 visible door hinges, the shower doors opened outward into the hallway. When closed, the shower door hinges were visible only to the patient taking a shower. The door hinges extended approximately 1-inch from the doorframe. The door hinges provided a sufficient area for attachment of a hanging device and resulted in an unsafe patient environment.

b. At 3:20 PM, a tour of the adult unit, with the Director of the Behavioral Health and Staff D, Supervisor of the Adult Behavioral Health, revealed:
- 18 of 18 patient rooms contained 1 or more unprotected active electrical outlets. Staff D verified the outlets were operational.
- 18 of 18 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be required before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant.
- 18 of 18 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified that the plumbing to the sinks and toilets lacked testing regarding the amount of weight required to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.

c. Observation of the older adult unit on 9/21/11 at 8:35 AM, with the Director of Behavioral Health and Staff C, Manager of Older Adult Unit, revealed:
- 9 of 9 patient rooms contained 1 or more unprotected active electrical outlets. Staff C verified the outlets were operational.
- 9 of 9 patient rooms that contained standard sinks and faucets. The sink/faucet combinations were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The Director of Behavioral Health verified that the faucets lacked testing regarding the amount of weight that would be requred before the faucet would break away from the sink, and lacked knowledge of the faucets being tamper resistant
- 9 of 9 patient rooms that contained standard sinks and toilets. The sinks and toilets were similar to the types found in the common home and labeled with the name of a familiar manufacturer. The sink plumbing was 18 inches from the floor, and the toilet plumbing was 3 feet from the floor. The Director of Behavioral Health verified the plumbing to the sinks and toilets lacked testing regarding the amount of weight required to break away from the sink/toilet, and lacked knowledge of the plumbing being tamper resistant.
- 3 metal hinges attaching the bathroom doors to the doorframes in 9 of 9 patient rooms.
- 9 patient rooms each room contained 2 electric beds. The hand controls for raising and lowering 15 of 18 electric beds were located in the handrails at the head of the beds. The hand controls could be used by patients while in or lying under the bed. Operation of the hand controls while under the bed could allow a patient to wedge him or herself under the bed and lower the bed onto their body allowing the bed to crush the patient resulting in a successful suicide attempt. Additional observation revealed the length of the electrical cords was 6 feet 6 inches, which is long enough to use as a hanging device to enable a patient to commit suicide. The hand controls for 3 of 18 beds were on a 4 foot cord and could be moved to any location in or under the bed. The cord lengths were sufficient to use as a hanging device and the beds could be used to crush the patients completing successful suicide attempts. During an interview on 9/21/11 at 8:35 AM, Staff C verified the older adult patients were not supervised constantly while in their assigned rooms. Staff C agreed the electric beds established an unsafe environment for patients.


2. Review of hospital policies and procedures found hospital staff had developed or implemented no policies and procedures that ensured the safety of child/adolescent, adult an