HospitalInspections.org

The Condition of Participation for Patient Rights has not been met.

Based on a review of hospital documentation for ligature risk assessment, review of clinical records, tour, and interview with staff, the hospital failed to ensure that the identified hazards in the psychiatric environment were immediately corrected and/or that safety measures were implemented to ensure the patients were maintained in a safe environment.

Please see A144

1. Based on a review of hospital documentation for ligature risk assessment, tour and interview with staff, the hospital failed to ensure that the identified hazards in the psychiatric environment were immediately corrected and/or that safety measures were implemented to ensure the patients were maintained in a safe environment. The findings include the following:

Interview with the Regional Regulatory Representative, the Psychiatric Director of Nursing (DON) and Chief of Quality on 4/11/19 at 1:30 PM identified that a risk assessment had been completed in July 2018 for WS3, WS2 and LV2 and that the facility received the report in "the fall". The DON indicated that at that time the facility formed a committee to review the findings and determine what would be acted on, however no interventions were initiated (as of 4/11/19) to mitigate the ligature risks.

Review of the risk assessment findings and observations of multiple psychiatric units on 4/11/19 identified the following:

a. Tour of WS2, LV2 and WS3 psychiatric units on 4/11/19 during the period of 1:45 PM and 2:45 PM identified patient bathrooms contained toilets with exposed plumbing. WS3 and LV2 had four bathrooms with exposed piping, and WS2 had three toilets with exposed plumbing/piping that was not ligature resistant.

b. Tour of WS3 identified 5 hospital beds that were not of ligature resistant quality and the beds were accessible to all patients.

c. Tour of WS2 identified fourteen (14) hospital beds loopable surfaces that were not of ligature resistant quality.

d. Tour of the Fitkin Observational area had four (4) stretchers that were not of ligature resistant quality.

e. Tour of the communal kitchen area on LV2 identified an unlocked cabinet approximately 4 feet off the ground that contained a control valve for a fire hose station that was not ligature resistant.

f. Tour Winchester 1, WS3, WS2 and LV2 identified loopable furniture throughout the units.

g. Tour of Winchester 1, LV2 and WS2 identified that the TV's in the common areas had numerous cords approximately 16-24 inches long that were hanging down between the TV and the cable box.

h. Tour of Winchester 1 on 4/11/19 at 9:15 AM identified that the restraint stretcher with Velcro restraints attached to the stretcher was housed in an alcove of the hallway. Interview with the Patient Service Manager (PSM) on 4/11/19 at 10:00 AM indicated that the stretcher is there secondary to lack of storage areas.

i. Tour of all the inpatient psychiatric areas identified oval mirrors installed in the hallways with wall mounted metal brackets that are not breakaway. Winchester 1 had 8 mirrors, WS2 had 2 mirrors, Fitkin basement and WS3 all had 3 mirrors located in the hallway.

j. Tour of Winchester 1 identified patient accessible phone cords extending longer than 24 inches.

k. Tour of WS2 and LV2 identified toilet paper holders in the bathrooms that were not breakaway.

l. Tour of the Winchester 1 common room identified two sets of doors with hinges. Additionally the cabinet doors in the common room and a file cabinet had loopable handles and non-ligature resistant door handles.

m. Tour of the Winchester 1 common area identified a mounted coat rack that was hanging off the wall and accessible to patients.

n. Tour of the Psychiatric Emergency Department on 4/10/19 during the period of 1:00 PM to 3:00 PM identified three (3) workstations on wheels (WOW) with several long cords (greater that 36 inches) were stationed in the hallway accessible to patients. Observation identified several patients standing near or around the WOW's with no staff in attendance or in the adjoining area. Interview with the PSM indicated that staff are to be monitoring and near the WOW's.

Interview with the Regional Risk Representative on 4/11/19 at 1:30 PM indicated that the Winchester 1 (children's unit), the ED crisis unit and the ED observational area had not had Risk Assessments completed at the same time as the other psychiatric units and the assessment was just completed on 4/9/19.

Interview with the Regional Regulatory Representative and DON on 4/11/19 at 9:30 AM identified that a risk assessment had been completed in July 2018 for the two in-patient psychiatric units at the ST. Raphael Campus of the hospital and that the facility received the report in "the fall". The Regional Regulatory Representative indicated that when the results of the report were received, the facility formed a committee to review the findings and determine what would be acted on. A job description for an environmental rounds employee was developed and an environmental check list had been created. However no interventions such as mitigation of environmental hazards or initiation of environmental rounds were initiated between July 2018 and April 11, 2019 to mitigate the ligature risks.

Review of the ST. Raphael Campus risk assessment findings and observations of the two psychiatric units on 4/11/19 between 10:00 AM and 11:30 AM identified the following items that were not of ligature resistant quality or construction: Hospital beds used throughout the units and accessible to all patients, door hinges, lighting fixtures, mirrors, loopable furniture, window hardware, ceiling mounted camera, window locks, paper towel dispenser, and non-tamper resistant screws.

During a tour of the units, Unit Manager #110 was unable to readily identify if any patients had current or passive suicidal ideations. The Unit Manager sought out one availables pychiatrist who determined that none of his/her patients were actively or passively suicidal but could not speak to patients who were assigned to other psychiatrists.


2. Based on tour of a psychiatric unit, clinical record review, and interview with staff for 1 patient with suicidal ideation (Patient #50) the facility failed ensure that the patient was placed in a safe environment. The findings include the following:

Patient #50 was admitted on 3/31/19 with suicidal ideation. The suicide risk assessment dated 4/3/19 identified that the patient was at moderate risk. The patient was placed in a room with a hospital bed with loopable surfaces that was not of ligature resistant quality.

Interview with the PSM on 4/11/19 at 2:30 PM indicated that suicidal ideation patients are placed randomly in rooms and patient beds is not a determination of patient placement.

The hospital submitted a plan of action on 4/11/19 that included immediate environmental safety rounds, staff education on environmental hazards, and identification of patients for suicidal ideation to ensure the appropriate level of observation was in place.

The Condition of Participation for Physical Environment has not been met.

Based on a review of hospital documentation for ligature risk assessment, tour and interview with staff, the hospital failed to ensure that the identified hazards in the psychiatric environment were immediately corrected and/or that safety measures were implemented to ensure the patients were maintained in a safe environment.

Please see A701

Based on a review of hospital documentation for ligature risk assessment, tour and interview with staff, the hospital failed to ensure that the identified hazards in the psychiatric environment were immediately corrected and/or that safety measures were implemented to ensure the patients were maintained in a safe environment. The findings include the following:

Interview with the Regional Regulatory Representative, the Psychiatric Director of Nursing (DON) and Chief of Quality on 4/11/19 at 1:30 PM identified that a risk assessment had been completed in July 2018 for WS3, WS2 and LV2 and that the facility received the report in "the fall". The DON indicated that at that time the facility formed a committee to review the findings and determine what would be acted on, however no interventions were initiated (as of 4/11/19) to mitigate the ligature risks.

Review of the risk assessment findings and observations of multiple psychiatric units on 4/11/19 identified the following:

a. Tour of WS2, LV2 and WS3 psychiatric units on 4/11/19 during the period of 1:45 PM and 2:45 PM identified patient bathrooms contained toilets with exposed plumbing. WS3 and LV2 had four bathrooms with exposed piping, and WS2 had three toilets with exposed plumbing/piping that was not ligature resistant.

b. Tour of WS3 identified 5 hospital beds with loopable surfaces that were not of ligature resistant quality and the beds were accessible to all patients.

c. Tour of WS2 identified fourteen (14) hospital beds with loopable surfaces that were not of ligature resistant quality.

d. Tour of the Fitkin Observational area had four (4) stretchers that were not of ligature resistant quality.

e. Tour of the communal kitchen area on LV2 identified an unlocked cabinet approximately 4 feet off the ground that contained a control valve for a fire hose station that was not ligature resistant.

f. Tour Winchester 1, WS3, WS2 and LV2 identified loopable furniture throughout the units.

g. Tour of Winchester 1, LV2 and WS2 identified that the TV's in the common areas had numerous cords approximately 16-24 inches long that were hanging down between the TV and the cable box.

h. Tour of Winchester 1 on 4/11/19 at 9:15 AM identified that the restraint stretcher with Velcro restraints attached to the stretcher was housed in an alcove of the hallway. Interview with the Patient Service Manager (PSM) on 4/11/19 at 10:00 AM indicated that the stretcher is there secondary to lack of storage areas.

i. Tour of all the inpatient psychiatric areas identified oval mirrors installed in the hallways with wall mounted metal brackets that are not breakaway. Winchester 1 had 8 mirrors, WS2 had 2 mirrors, Fitkin basement and WS3 all had 3 mirrors located in the hallway.

j. Tour of Winchester 1 identified patient accessible phone cords extending longer than 24 inches.

k. Tour of WS2 and LV2 identified toilet paper holders in the bathrooms that were not breakaway.

l. Tour of the Winchester 1 common room identified two sets of doors with hinges. Additionally the cabinet doors in the common room and a file cabinet had loopable handles and non-ligature resistant door handles.

m. Tour of the Winchester 1 common area identified a mounted coat rack that was hanging off the wall and accessible to patients.

n. Tour of the Psychiatric Emergency Department on 4/10/19 during the period of 1:00 PM to 3:00 PM identified three (3) workstations on wheels (WOW) with several long cords (greater that 36 inches) were stationed in the hallway accessible to patients. Observation identified several patients standing near or around the WOW's with no staff in attendance or in the adjoining area. Interview with the PSM indicated that staff are to be monitoring and near the WOW's.

Interview with the Regional Risk Representative on 4/11/19 at 1:30 PM indicated that the Winchester 1 (children's unit), the ED crisis unit and the ED observational area had not had Risk Assessments completed at the same time as the other psychiatric units and the assessment was just completed on 4/9/19.

Interview with the Regional Regulatory Representative and DON on 4/11/19 at 9:30 AM identified that a risk assessment had been completed in July 2018 for the two in-patient psychiatric units at the ST. Raphael Campus of the hospital and that the facility received the report in "the fall". The Regional Regulatory Representative indicated that when the results of the report were received, the facility formed a committee to review the findings and determine what would be acted on. A job description for an environmental rounds employee was developed and an environmental check list had been created. However no interventions such as mitigation of environmental hazards or initiation of environmental rounds were initiated between July 2018 and April 11, 2019 to mitigate the ligature risks.

Review of the ST. Raphael Campus risk assessment findings and observations of the two psychiatric units on 4/11/19 between 10:00 AM and 11:30 AM identified the following items that were not of ligature resistant quality or construction: Hospital beds used throughout the units and accessible to all patients, door hinges, lighting fixtures, mirrors, loopable furniture, window hardware, ceiling mounted camera, window locks, paper towel dispenser, and non-tamper resistant screws.

During a tour of the units, Unit Manager #110 was unable to readily identify if any patients had current or passive suicidal ideations. The Unit Manager sought out one available pychiatrist who determined that none of his/her patients were actively or passively suicidal but could not speak to patients who were assigned to other psychiatrists.

The hospital submitted a plan of action on 4/11/19 that included immediate environmental safety rounds, staff education on environmental hazards, and identification of patients for suicidal ideation to ensure the appropriate level of observation was in place.